ECTOPIC PREGNANCY
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Transcript of ECTOPIC PREGNANCY
ECTOPIC PREGNANCYDanforth’s Obstetrics and GynecologyTenth edition
Ectopic pregnancy, the implantation of a fertilized ovum outside of the endometrial cavity
a leading cause of life-threatening first-trimester morbidity
IncidencePathogenesis•Sites of implantation
Etiology and Risk Factors
•Tubal Damage and Infection
•Salpingitis Isthmica Nodosa
•Diethylstilbestrol
•Cigarette Smoking
•Contraception:IUDTubal ligationOCPBarrier contraception
Risk Factor Odds Ratioa
High riskTubal surgery 21.0Tubal ligation 9.3Previous ectopic pregnancy 8.3
In utero exposure to DES 5.6Use of IUD 4.2–45.0Tubal pathology 3.8–21.0Assisted reproduction 4.0Moderate riskIinfertility 2.5–21.0Previous genital infections 2.5–3.7Multiple sexual partners 2.1Salpingitis isthmica nodosa 1.5Low riskPrevious pelvic infection 0.9–3.8Cigarette smoking 2.3–2.5Vaginal douching 1.1–3.1First intercourse <18 y 1.6
Clinical Manifestations•Symptoms:abdominal or pelvic pain
vaginal bleeding or spotting a positive pregnancy test(mensturation delay)
•Signs:Abdominal
tendernessrebound tendernesscervical motion tenderness
tender adnexal mass
Diagnosis:Ectopic pregnancy can be diagnosed as early as 4.5 weeks gestation
•serial measurements of B-hCG
•ultrasonography
•uterine sampling via manual vacuum extraction or curettage
•serum progesterone levels
•Human Chorionic Gonadotropin ( B -hCG)
The B-hCG, produced by trophoblastic cells in normal pregnancy, has long been accepted to rise at least 66% and up to twofold every 2 daysEight-five percent of abnormal pregnancies, whether intrauterine or ectopic, have impaired B-hCG production with an abnormal rate of B-hCG rise
•Sonographytransvaginal ultrasonography reliably detects intrauterine gestations when the B-hCG levels are between 1,500 and 2,500 mIU/mLDiagnosis of an ectopic pregnancy can be made with 100% sensitivity but with low specificity (15% to 20%) if an extrauterine gestational sac containing a yolk sac or embryo is identifiedSome sonographic images, such as the pseudogestational sac, may mislead even an experienced examiner to falsely diagnose a gestational sacUltrasonography should be used to document the presence or absence of
an intrauterine pregnancy when the B-hCG levels have risen above the designated discriminatory cutoff zone
•ProgesteroneAlthough progesterone levels are higher in intrauterine pregnancies than in ectopic pregnancies, there is no established cutoff to use to discriminate between these two entities
a low progesterone level of less than 5 ng/mL can rule out a normal pregnancy with almost 100% accuracy but does not differentiate whether that pregnancy is an abnormal one in the uterus or at an ectopic site
•Uterine Evacuationnecessary when a transvaginal ultrasonogram and a rising or plateauing B-hCG level below the cutoff value are not sufficient for diagnosis
Treatment for Ectopic Pregnancy•Medical Management:
Methotrexate therapy
The folic acid antagonist, methotrexate, inhibits de novo synthesis of purines and pyrimidines, interfering with DNA synthesis and cell multiplication
1-unruptured ectopic pregnancy measuring less than or equal to 4 cm by ultrasonography
2-Hemodynamically stable3-B-HCG<10,0004-Exist of FHRMethotrexate treatment regimens include:
methotrexate directly impairs trophoblastic production of hCG with a secondary decrement of corpus luteum progestin secretion
the multiple dose, single dose,two-dose protocol
Methotrexate by Direct Injection
bone marrow suppression, hepatotoxicity, stomatitis, pulmonary fibrosis, alopecia, and photosensitivity
Side Effects
Fortunately, the side effects reported with methotrexate used to treat ectopic pregnancy have mostly been minor
Direct Injection of Cytotoxic Agents
Prostaglandins, hyperosmolar glucose, potassium chloride, and saline by direct injection have been tried as therapeutic alternatives to methotrexate
•Surgical TreatmentRuptured Ectopic Pregnancylaparotomy or laparoscopy with salpingectomy is the first choice for rupture
Stable Ectopic Pregnancy
If methotrexate is contraindicated, laparoscopic salpingostomy is the first surgical choicePersistent Ectopic Pregnancy Following Salpingostomy:drop of <50% from the preoperative level of B-HCG on postoperative day 1
prophylactic methotrexate administration is recommended
Other methodssegmental excision followed by intraoperative or delayed microsurgical anastomosis
Manual fimbrial expression
oEctopic Pregnancy and Assisted Reproductive Technology•Incidence•Location•Tubal Pathology•Ovulation Induction
Rare Types of Ectopic Pregnancy
•Abdominal PregnancyIncidenceClinical manifestations Diagnosistreatment
• Ovarian Pregnancy•Cornual Pregnancy•Cervical Pregnancy•Heterotopic Pregnancy
Summary PointsIn most circumstances, ectopic pregnancy can be diagnosed before symptoms develop and treated definitively with few complications.Quantitative B-hCG testing, ultrasonography, and curettage allow early diagnosis of ectopic pregnancy and use of medical therapy as the initial therapy option.Conservative surgical therapy and medical therapy for ectopic pregnancy are comparable in terms of success rates and subsequent fertility. Medical therapy is the preferred choice because of the freedom from surgical complications and lower cost.Surgery is the treatment of choice for hemorrhage, medical failures, neglected cases, and when medical therapy is contraindicated.Multiple-dose methotrexate is preferable to single-dose methotrexate, direct injection, or tubal cannulation and is the first choice for unruptured, uncomplicated ectopic pregnancy.Laparoscopic salpingostomy or salpingectomy is favored for cases of intra-abdominal hemorrhage, medical failure, neglected cases, and complex cases when medical therapy is contraindicated