Ectopic PregnancyBy

Dr. Umtal BatoolPGR – 1, Unit 3

Definition

“It is defined as implantation of fertilized ovum at a site other than uterine endometrium”

Etiology

Delay in the ovum transport.

Risk Factors

•Previous history of tubal pregnancy

•Previous tubal surgery

•PID

•Termination of pregnancy

•IUCD Use

•Assisted Conception

•Smoking

•DES

•Salpingitis

Pathophysiology“Abnormality in either tubal morphology or function”

•Damage to tubal mucosa

•Dysfunction of myoelectrical activity

•Dysfunction of cilia

Incidence11.1% in 1000 pregnancies in UK

2%12% 80%

5%

1.4%

0.2%

0.2%

Progression of Tubal Pregnancy•Ruptured•Unruptured•Abortion•Involution•Tubal Mole

Timing of RuptureDepends upon location & duration of gestation

Arias Stella Phenomenon

DiagnosisDiagnosis is made upon

•History

•Examination

•Complete Workup

On History Classical alarming triad

•Amenorrhea

•Abd Pain

•Abnormal Uterine Bleeding

On Examination Hemodynamically StableHemodynamically Unstable

On P/A

•Generalized Tenderness

•Localized Tenderness

•Rebound Tenderness

Cullen’s Sign

On PVInconclusive

Types of Presentation

•Acute

•Sub acute

Investigations•Biochemical•Radio Imaging•Diagnostic Laparoscopy•Culdo centesis

Biochemical•Beta HCG•Serum Progesterone

Beta HCG

•Secreted by syncitiotrophoblast

Normal Doubling Time

•2.2 days

Normal Half Life

•32 – 37hrs

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”

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

USG•TVS •Abdominal•Doppler•3D

Normal IUP Sign

Double decidual sac sign

Pseudo Sac

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.

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

DisadvantageMorbidity

•Need of MX•Need of surgery

Mortality • Rupture

Medical Management

•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)

Methotrexate

• GIT• Skin and Hair • Renal Toxicity• Myelo Suppression

Side Effects

• Initial BHCG < 3000 iu / L•Adnexal mass < 2cm•Absent FCA

Criteria of Patient Selection

Pre Requisite Investigations for MTX

• Systemic• Local

Routes

• CBC and platelets • LFT’s & RFT’s

• Single standard dose protocol• Multiple fixed dose protocol

Routes

Mifepristone & MTX Combination

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

Surgical

• Hemodynamic condition of patient.• Size and location of pregnancy• Expense of surgery• Availability of instruments

Selection Criteria

• Laparoscopy• Laparotomy

Conservative Surgery SalpingotomyRadical Salpingectomy

Laparoscopy

Laparoscopic salpingtomy

• Retention of troproblastic tissue and need if MTX

Disadvantages

Considered primary Rx of tubal Ectopic if contra lateral tube damage is there and patient wants to retain fertility.

Salpingectomy

•Ruptured tubal pregnancy•Recurrent Ectopic pregnancy•Prev. n/o sterilization & reversal.•Prev. tubal surgery for infertility.•Pre existing tubal damage.

Indications

•Radical•Partial

Fertility after Ectopic Pregnancy• IUP Rate 50% – 70%• Recurrent Ectopic 6% - 16 %

Abdominal Ectopic Pregnancy

Ovarian Ectopic Pregnancy

Cornual / Interstitial Ectopic Pregnancy

PT +ve + Suspected Eptopic

TVS

IUP Ectopic seen USG inconclusive

StableUnstable

SurgicalExpectant Medical Surgical

Follow up

BHCG BHCG

Serial BHCGTill 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

PT +ve + Suspected Ectopic

TVS

Stable Unstable

OPD Management BHCG Levels

PUL

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

Thank You Very Much