Ectopic Pregnancy

Ectopic Pregnancy Dr.Najwa.B.Eljabu Arab & Libyan Board Msc reproductive and Maternal sciences Glasgow University

Definition Ectopic pregnancy is implantation occurring outside the uterine cavity. Either implanted outside the uterus (fallopian tube, ovary and abdominal cavity) or in abnormal position within the uterus (cornua, cervix). Combined tubal and uterine (Heterotopic) pregnancies are uncommon) It is a major cause of maternal mortality in the first trimester.

Overview • Incidence Increasing (16/1000 Pregnancies in UK) • 95-98% tubal • 50% ampulla • 20% isthmus • 12% fimbrial • 10% interstitial • Mortality Decreasing With Better Detection • Surgical and Medical Treatment Available • Recurrence Rate ~ 10-15%

Risk Factors • Maternal age • Number of sexual partners • Cigarette smoking • Previous Ectopic Pregnancy • PID (Gonorrhea, Chlamydia) • Tubal Surgery or pelvic surgery • Infertility and infertility treatment • ICUD • IVF

Sites • Ampulla (50%) • Isthmus (20%) • Cornua (< 2%) • Ovary (< 2%) • Abdomen (< 2%) • Cervix (< 2%)

Simultaneous intrauterine and ectopic pregnancies (heterotopics) occur in 1/3000 to 1/30000 pregnancies

Symptoms • Amenorrhea (typically 6-8 weeks) • Abdominal Pain • Vaginal Bleeding (small amount) • Syncope • Pelvic Mass • Shoulder tip pain

15% of the cases present acutely with abdominal pain, amenorrhea and haemodynamic compromise • In most cases the history will be more chronic • Arias-stella reaction

Evaluation and Diagnosis • History and Physical Exam • Blood investigations (CBC, blood group) • Serial Quantitative HCG • Ultrasound • Laparoscopy

Evaluation and Diagnosis • Clinical: • O/E: look for signs of intra-peritoneal hemorrhage • Abdominal tenderness(95%) • Peritonism • Abdominal distension • Pain on movement of the cervix (cervical excitation (50%) • Adnexal mass (63%) • Cervix ----closed

Serial B-HCG • HCG Levels Double Every 48 Hrs • 66% Rise / 48 Hrs Consistent With Ectopic • Single Determination Not Helpful • Best If Done Within Same Laboratory • At HCG of 1000 IU/L gestational sac of an intrauterine pregnancy should be detected by US

Ultrasound • May or May Not Be Helpful • Discriminatory Zone: TV: 1500-2000 mIU/ml TA: 6500 mIU/ml • +IUP: Generally Excludes Ectopic • Free fluids in POD • Adnexal mass

Treatment • Observation • Laparoscopy • Laparotomy • Medical • MTX • Hyperosmolar Glucose • PG

Observation • Many Tubal Pregnancies Abort • Needs simple follow up • Criteria for selection of patients • Serial HCG levels and US

Management of acute hemorrhage • Urgent hospital assessment • Resuscitation • Intravenous access and two large cannula • Start IVF (colloid) • Send for blood group, CBC and cross match • Serum BHCG • Transfer to theater • Anti D should be given to all RH negative women

Laparoscopy • Allows Diagnosis and Treatment • Lower post op morbidity and quicker recovery • Salpingotomy • Salpingectomy (Total / Partial) • Cornual Resection • Minimally Invasive, Unlike Laparotomy • Few Contraindications: Unstable Patient (Possibly)

Mini-laparotomy • Salpingectomy • Salpingotomy • Needed in acute intra-peritoneal haemorrhage-------for immediate ligation of the bleeding point

Medical treatment Suitable patients are: • Haemodynamically stable • serum BHCG less than 10000IU/L • no extrauterine fetal heart by US • compliant patient

Methotrexate • Toxic to Trophoblast Cells • Minimal Side Effects • May Preserve Fertility in Cases of Cervical Pregnancy • Requires Compliant Patient, Time • Pain Not Uncommon • BHCG May Rise Initially

Persistent Trophoblast • Most Often after Salpingostomy • Laparoscopic • Minilap • Most Easily Treated With MTX

Outcomes • 15% Repeat Ectopic Rate • 60-70% intra-uterine pregnancy after single ectopic

Summary • Ectopic Pregnancy is a Common, Treatable Problem • Sensitive Assays Allow Early Detection • Surgical and Medical Options Exist • Ruptured Ectopics should be Unusual with Compliant Patients and Appropriate Medical Care

Thanks

Ectopic Pregnancy