Ectopic pregnancy
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representation of every detail of ectopic pregnancy from incidence to management
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Ectopic pregnancy
- 2. Ectopic Pregnancy By Dr. Umtal Batool PGR – 1, Unit 3
- 3. Definition “It is defined as implantation of fertilized ovum at a site other than uterine endometrium” Etiology Delay in the ovum transport.
- 4. Risk Factors •Previous history of tubal pregnancy •Previous tubal surgery •PID •Termination of pregnancy •IUCD Use •Assisted Conception •Smoking •DES •Salpingitis
- 5. Pathophysiology “Abnormality in either tubal morphology or function” •Damage to tubal mucosa •Dysfunction of myoelectrical activity •Dysfunction of cilia Incidence 11.1% in 1000 pregnancies in UK
- 6. 2% 12% 80% 5% 1.4% 0.2% 0.2%
- 7. Progression of Tubal Pregnancy •Ruptured •Unruptured •Abortion •Involution •Tubal Mole Timing of Rupture Depends upon location & duration of gestation
- 9. Diagnosis Diagnosis is made upon •History •Examination •Complete Workup On History Classical alarming triad •Amenorrhea •Abd Pain •Abnormal Uterine Bleeding
- 10. On Examination Hemodynamically Stable Hemodynamically Unstable On P/A •Generalized Tenderness •Localized Tenderness •Rebound Tenderness Cullen’s Sign
- 11. On PV Inconclusive Types of Presentation •Acute •Sub acute
- 12. Investigations •Biochemical •Radio Imaging •Diagnostic Laparoscopy •Culdo centesis
- 13. Biochemical •Beta HCG •Serum Progesterone Beta HCG •Secreted by syncitiotrophoblast Normal Doubling Time •2.2 days Normal Half Life •32 – 37hrs
- 14. RCOG Says “An increase in BETA HCG of < 66% over 48hrs means ectopic pregnancy” ACOG Says “An increase in BETA HCG of < 53% over 48hrs means ectopic pregnancy”
- 15. Serum Progesterone •C21 Compound •Useful in diagnosis and management of pregnancy of unknown location Progesterone Levels >60 nmol / L Viable IUP <20 nmol / L Failing PUL
- 16. USG •TVS •Abdominal •Doppler •3D Normal IUP Sign Double decidual sac sign
- 19. Pseudo Sac
- 20. Management •Expectant •Medical •Surgical Expectant Management •ACOG: “If initial HCG level < 200 mu/ml. 88% Ectopic resolve spontaneously.” •Carefully selected patients desire to retain fertility.
- 21. Criteria •Clinically stable asymptomatic woman. •B HCG conc <1000-2000 1U/L •Haemo peritoneum of < 50- 100 ml •Adnexal mass of < 2cm •Absent FCA or fetal parts Disadvantage Morbidity •Need of MX •Need of surgery Mortality • Rupture
- 22. Medical Management Methotrexate •Offered to the patient desiring to retain fertility in presence of contralateral tube damage. •Antimetabolite Folic Acid Antagonist (Inhibits DNA synthesis in rapidly dividing cells) Side Effects • GIT • Skin and Hair • Renal Toxicity • Myelo Suppression Criteria of Patient Selection • Initial BHCG < 3000 iu / L •Adnexal mass < 2cm •Absent FCA
- 23. Pre Requisite Investigations for MTX • CBC and platelets • LFT’s & RFT’s Routes • Systemic • Local Routes • Single standard dose protocol • Multiple fixed dose protocol Mifepristone & MTX Combination
- 24. Day Single Dose Multiple Dose 1 HCG Conc. MTX 50 mg/m2 body surface area i/m HCG Conc. MTX 1mg/kg body wt i/m 2 Folinic acid .1mg/kg body wt po 3 HCG Conc If <15% ↓ from day 1-3, Give MTX 1mg/kg i/m If ≥ 15% decline from day 1-3, begin weekly HCG 4 HCG protocols vary Folinic acid .1mg/kg body wt po 5 HCG Conc If <15% ↓ from day 3-5, Give MTX 1mg/kg i/m If ≥ 15% ↓from day 3-5, ,begin weekly HCG 6 Folinic acid .1mg/kg body wt po 7 HCG Conc If <15% ↓ HCG from day 4-7 Or <25% ↓ HCG from day 1-7 Additional dose of MTX 50mg/m2 i/m If ≥ 15% ↓from day 4-7 If ≥ 25% ↓from day 1-7 Draw HCG conc. Weekly until HCG is undetectable. HCG Conc If <15% ↓ from day 5-7, Give MTX 1mg/kg i/m If ≥ 15% ↓from day 5-7, ,begin weekly HCG 8 Folinic acid .1mg/kg body wt po 14 HCG Conc If <15% ↓ hcg from day 7-14 Additional dose of MTX 50mg/m2 i/m If ≥ 15% ↓ from day 7 - 14 check HCG weekly untill undetectable HCG Conc If <15% ↓ hcg from day 7-14 Additional dose of MTX 1mg/kg i/m If ≥ 15% ↓ from day 7 - 14 check HCG weekly untill undetectable 15 Folinic acid .1mg/kg body wt po 21-28 If 3 doses given and there is 15% decline from day 21-28 proceed with laparoscopic surgery If 5 doses have been given and there is< 15% decline from day 14-21 proceed with laparoscopic surgery
- 25. Surgical • Laparoscopy • Laparotomy Selection Criteria • Hemodynamic condition of patient. • Size and location of pregnancy • Expense of surgery • Availability of instruments Conservative Surgery Salpingotomy Radical Salpingectomy
- 26. Laparoscopy
- 27. Laparoscopic salpingtomy Considered primary Rx of tubal Ectopic if contra lateral tube damage is there and patient wants to retain fertility. Disadvantages • Retention of troproblastic tissue and need if MTX
- 28. Salpingectomy •Radical •Partial Indications •Ruptured tubal pregnancy •Recurrent Ectopic pregnancy •Prev. n/o sterilization & reversal. •Prev. tubal surgery for infertility. •Pre existing tubal damage.
- 32. Fertility after Ectopic Pregnancy • IUP Rate 50% – 70% • Recurrent Ectopic 6% - 16 % Abdominal Ectopic Pregnancy
- 34. Cornual / Interstitial Ectopic Pregnancy
- 35. PT +ve + Suspected Eptopic TVS IUP Ectopic seen USG inconclusive Stable Unstable Surgical Expectant Medical Surgical Follow up BHCG BHCG Serial BHCG Till 20iu / L > 15 Fall of BHCG on Day 4 - 7 < 15 Fall of BHCG on Day 4 - 7 BHCG on Day 4 - 7 Repeat BHCG serially Consider 2nd dose Surgical Management
- 36. PT +ve + Suspected Ectopic TVS PUL Stable Unstable OPD Management BHCG Levels Inpatient Management >66% Inc in BHCG in 48hrs < 66% Inc in BHCG in 48hrs >15% dec in BHCG in 48hrs or < 15% dec in BHCG in 48hrs IUP Seen Ectopic Seen + Stable Patient Rescan after one week IUP Confirmed Ectopic Confirmed PUL Rescan for Viability Manage as indicated Repeat BHCG Failing PUL Repeat BHCG Serial BHCG till < 20 iu / L
- 37. Thank You Very Much