Ectopic pregnancy Ectopic pregnancy

Dr.F Mostajeran MD

Ectopic pregnancy remains

Leading cause life/hreatening F- Trimester (morbidity)

Medical therapy method terexate as standard first line

therop.

Surgery

Hemorrhage?

Medical failures

Neglected cases

Medical contraindicated

Incidence E.PIncidence E.P

Unprecedented sexual liberties.

↑Ascertainment E.P

↑ART

Leading cause maternal death U.S 5-6% all

M. death

PathogenesisPathogenesis

• Ability tube transport gametes embryos

• Clinical picture site E.P

• Most common site Tub 98-3%

• Ampoule – isthmus – fimbrial cornual.

• Rarely abdominal – ovarian – cervical.

• Proliferating trophoblast

• Tubale wall

• Growth may extend luminal mucosa.

• Muscularis- serosa full thickness blood vessels

• Distorts tube stretches serosa → pain bleeding

takes phase.

• 80% embryo degenerates.

• 50% often clinically silent.

• Tubal abortion self limited.

Risk factors Needs aggressive monitoring pregnancy

immediately after first missed menses High risk

• Tubal surgery (21) • Risk factors• Tubal ligation • Tubal Epithelial damage.• Previous E.P (6-8)• I U D , Morning after pill • A R T

• Moderate risk

• Infertility

• P I D

• Multiple sexual partners

• Salpingitis

Low risk

• Cigarette

• Vaginal douching first intercourse <18

• Signs and symptoms

• Many E.P never produce symptoms rather

• Timely diagnosed and treated (H.R)

• If diagnosis → delayed → classic triad.

• Amenorrhea , irregular V.B , lower ab- pain.

• Sudden sever ab pain 90-100% symptomatic patient.

• Pain radiating shoulder.

• Syncope shock → hemoperitaneum.( up to 20%)

• Most common signs ab EX

• 90% tenderness ,rebound tenderness in 70%.

• P.EX nonspecific.

• 2⁄3 C-motion tenderness .

• Adnexal mass 50%.

• Diagnosis

• Diag as early as 4.5 WK.

• Visualization is frequently not possible.

• Traditional laparoscopic visualization rarely necessary.

• Routine diagnostic Tests.

• Serial 3HCG.

• U.S

• Progesterone levels.

• U - curettage.

Treatment for E.PTreatment for E.P• Medical management .• Methotrexate therapy. • Folic acid antagonist • DNA synthesis and cell multiplication.• Single dose 50 mg/m2

• Blunts HCG increment (7)• Drop progesterone, 17 × hydroxy progesterone prior to

abortion• Hemodiamically stable. • E.P unruptured less 4cm• Eligible for methatrexate therapy.

Multiple-dose: tailored weight-E.P responsiveness.

• Comparing multiple-dose-laparoscopic salpingostomy.

• Patent fallopian tubes.

• Subsequent IU pregnancy.

• Repeat E.P comparable .

Single dose:

• Resent metaanalysis 26 studies.

• Based on clinical evidence presently available.

• Routine use methotrexate single dose IM not as

• Effective as multiple dose (tubal rupture↑)

• Indication for systemic M-dose methotrexate

• No rupture

• Tubal size ≤4cm

• HCG ≤ 10,000

• Positive F.H heartbeat proceed with caution.

Methotrexate by direct injection Methotrexate by direct injection

• Methotrexate E. gestational sac TVS.• Resolution within 2 weeks• Higher concentrations site of implantation.• Less systemic distribution drug• 75.1% successfully treated • Subsequent p–tubal patency (laparoscopic-

systemic Mehta)• Subsequent – P, recurrent E.P

Methotrexate failureMethotrexate failure

Pain is sever and persistent (>12h 4-12

3-7 after start therapy)

Falling HCT

Orthostatic hypotension.

Side effectsSide effects• High dose

• Bone marrow supp

• Hepatotoxicity

• Stomatitis

• Pulmonary fibrosis

• Alopecia

• Photosensitivity

• Infrequent in E.P therapy

Surgical TreatmentSurgical Treatment

• 1884 E.P laparotomy salpingectom.

• 1953 salpingostomy

• Manual fimbrial expression

• Segmental resection.

• Ruptured E.P

• Laparoscopy – laparotomy – salpingectomy.

• Inpatients hypovolemic shock.

• Surgery is choice.

Stable E.P

• If methotrexate contraindicated.

• Laparoscopic salpigostomy first surgical choice.

• Salpingectomy

Laparoscopy

Laparotomy

Expectant managementExpectant management

• E.P may resolve spontaneously

• 67.2% E.P resolved without surgery (over treats)

• Falling 3HCC under 1000 fallowed with

conservative expectant management

• With low initial and falling HCG

Rare types of E.P

• Abdominal pregnancy

• 1⁄8000 birth prognosis poor

• M.M 5.1⁄1000 7.7 higher than other E.P

• (Higher due to delay in diagnosis)

Primary - SecondaryPrimary - Secondary• Symptoms → normal for pregnancy to sever if time

permits• Abdominal pain intra abdominal hemorrhage shock• Primary rare usually abort• Secondary (reimplantation → abortion ,rupture)• U.S choice empty uterus • If fetus near viability → hospitalization• Adequate blood, bowel preparation• Placenta removed unless major vessels, vital organ

methotrexate

Ovarian pregnancyOvarian pregnancy• Most common form abdominal pregnancy • less than 3% of E.P• Clinical finding similar tubal E.P• ab-pain ,V.B Amenorrhea• 30% hemodynamic instability → rupture• Usually young multiparous cause • Treatment → systectomy, wedge resection

or oophorectomy

Cornual pregnancy

or interstitial pregnancy

• 4.7% E.P 2.2% M. mortality

• Most frequent symptom menstrual aberration

• Abdominal pain V.B, shock → rapture uterine(9-12nk)

• Risk factor previous salpingectomy

• Repeat U.S with Doppler flow studies → early diagnosis

• Cornual resection lapa - resection systemic methatraxate

local

Cervical pregnancyCervical pregnancy1⁄12000Most common risk factor D.C Previous CS IVF• Symptom most common V.B painless • C.EP usually diagnosis incidentally during routine U.S

or at time surgery for abortion• Cervix enlarged- globular, distended it appears

cyanotic hyperemic soft• Diagnosis – US, MRI , GSOC below C.OS, • Metha, U. Artery embolization, hysterectomy

Heterotopic pregnancyHeterotopic pregnancy

• E.P + intrauterine pregnancy 1⁄6778

• Most causes diagnosed after sign symptoms

develop admitted for emergency surgery

• Lower abdominal pain serial 3HCG not helpful