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Ectopic Pregnancy

Ectopic Pregnancy. Dr. Yasir Katib MBBS, FRCSC, Perinatologist. Introduction. Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity

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Ectopic Pregnancy

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  1. Ectopic Pregnancy Dr. Yasir Katib MBBS, FRCSC, Perinatologist

  2. Introduction • Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity • The most common extra-uterine location is the fallopian tube, which accounts for 98%

  3. Types of EP

  4. Sites of EP Heterotopic Pregnancies: 1 in 30 000

  5. Epidemiology • 2nd leading cause of overall maternal mortality in US • Leading cause of pregnancy-related deaths during T-1 • 1-2% of all diagnosed pregnancies

  6. Epidemiology • Incidence is  •  incidence of salpingitis d/t chlamydia or other STI • Improved diagnostic techniques •  age • Blacks >non-whites>whites • Most occur in multigravid women • > 50% in women with  3 pregnancies • 10-15% in nulligravid women

  7. Mortality • Causes 15% of maternal deaths • Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion • Cause of death due • blood loss (80%)I • infection (3%) • anesthesia (2%) • Interstitial & abdominal 5X > risk of death than other sites

  8. Of Historical Note……. • 1693 • 1st documentation of unruptured ectopic • 1752 • Infertility linked to EP • mid 19th century • Path reports stressed pelvic inflammation as cause of EP • 1800s • 30 abd operations in (5 women survived) • If not treated, 1 out of 3 survived (better!)

  9. Risk Factors for EP • Definite (high risk) • Previous EP • Any tubal surgery or sterilization procedure • In-utero DES exposure 

  10. Risk Factors for EP • Probable (modrate risk) • PID • Infertility • “Superovulating agents” • Pergonal, Clomiphene citrate • Multiple sexual partners  • Smoking

  11. Risk Factors for EP • Uncertain Association (low risk) • IUCD • Vaginal douching  • Maternal age (extremes) • Use of reproductive techniques • In vitro fertilization • Gamete intrafallopian transfer • Embryo transfer

  12. Classic TRIAD of EP • Delayed menses • Irregular vaginal bleeding • Abdominal pain Most commonly NOT encountered

  13. Symptoms of Ectopic Pregnancy

  14. Signs of EP * 20% of masses occur on the side opposite the EP.

  15. Differential Diagnosis • Complication of IUP • Abortion • Early pregnancy plus uterine fibroid or ovarian tumour • Conditions causing acute abd pain • Torsion of ovarian tumour, FT, or subserous pedunculated fibroid • Salpino-oophoritis • Pelvic pain with an IUCD in situ • Appendicitis

  16. Differential Dx – cont’d • Conditions causing hemoperitoneum • Ruptured corpus luteum • Ruptured follicular cyst • Ruptured endometriotic cyst • Conditions simulating a pelvic hematocele • Retroverted gravid uterus • Pelvic or tubo-ovarian abcess

  17. Management of EP • Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50% • 20% of EP occur as surgical emergencies • Delay is justified only to correct shock

  18. Acute Management of EP • Remember your ABCs • Oxygen • Large bore IV(s)  crystalloids • Blood • Labs • CBC, coagulation studies, T & C • -hCG

  19. Usefulness of Quantitaive -hCG • Assessment of pregnancy viability • Serial rise usually indicates a normal pregnancy • Correlation with ultrasonography • With titers > 1500 IU/L, TVUS should ID an IUP • With multiple gestation, a gestational sac will not be apparent until titer rises a little higher • Assessment of treatment results • Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD

  20. The Importance of TVUS • Documentation of an intrauterine sac • A viable IUP should be identified when -hCG > 1500 IU/ml • Adnexal mass • An EP > 2 cm should be identified • Adnexal cardiac activity • Detectable when -hCG is ~ 15 000 – 20 000

  21. U/S – Is it EP or miscarriage?

  22. Surgical Management of EP • Radical • Salpingectomy with/out oophorectomy • Conservative • Salpingotomy • Salpingostomy or segmental resection  does not  repeat EP rate • fimbrial evacuation (traumatizes the endosalphinx & is assoc with  rate of recurrent EP (24%) compared withsalpingectomy

  23. Medical Management of EPMethotrexate (MTX) • 1st used in Japan in 1982 • Antimetabolite that interferes with dihydrofolate reductase • Considered for low -hCG • Success rate 67%-94% • Indications • Hemodynamically stable pt • good F/U • Recurrent EP following Sx intervention

  24. Methotrexate – cont’d • Contraindications • Evidence of rupture • Serum -hCG > 5 000 IU/L (varies) • FH detected on U/S • Adnexal mass> 3.5 cm on U/S • Unreliable pt • F/U unavailable • Laparoscopy required to make dx • Solid adnexal masses (germ cell tumour) • Free fluid > 30ml

  25. Methotrexate Protocol • Exclude contraindications as well as • No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST,ALT, urea, Cr, CBC) • Informed consent • 5% risk of hematoperitoneum 2° to rupture of EP following MTX • MTX 50mg/m² body surface area (~1mg/kg) given IV or IM

  26. Methotrexate Protocol – cont’d • Pt F/U • repeat serum quantitative -hCG in 3-4 days, 7days, then weekly until < 10 IU/L • If > day-4 level at day-7  repeat MTX • If -hCG fails to fall by at least 25%/week at any time repeat dose • U/S not required routinely • Pt should avoid • Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)

  27. Methotrexate Protocol – cont’d • What to expect • Majority experience some degree of abd pain (occurs in ~ 50% at day-6) • Shedding of a decidual cast • Moderate vaginal bleeding • Side effects (usually at higher doses) • Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx

  28. Expectant Mx of EP • Anticipates spontaneous regression of EP • Occurs in ~ 57% • Symptoms, HCG titers, & U/S findings followed • Risk of tubal rupture is 10% if HCG levels < 1000 • Criteria include • Sonographic diameter < 3cm • Initial -hCG < 1 000 IU/ml, no  in 2-day period, subsequent levels  • asymptomatic

  29. Future Fertility following EP • Subsequent conception rate is ~ 60% • Incidence of recurrent EP is 15% • Other factors influencing include: • Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis • No difference b/t laparoscopy vs laparotomy

  30. Prevention of EP • Treat salpingitis early & correctly • MTX management lowers rate of subsequent EP • Risk of EP is  with all methods of contraception, except progesterone containing IUCDs • Remember Rh Sensitization • Rhogam for the Rh-neg woman

  31. The End

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