Gynecology 5th year, 7th lecture (Dr. Muhabat Salih Saeid)

ECTOPIC PREGNANCY

Dr Muhabat Salih Saeid

MRCOG LONDON UK

WHEN A WOMAN PRESENTS WITH AN EARLY PREGNANCYhellip Ask yourself two questionshellip

Where is this pregnancy

Is it viable

WHERE IS THIS PREGNANCY

In a woman with an early pregnancy you must determine if the pregnancy is intrauterine or an ectopic because her life could depend on it

Ectopic Pregnancy 1048708 Pregnancy anywhere outside uterine cavity 1048708 Fallopian tube most common location 1048708 Second leading cause of maternal mortalityRisk Factors 1048708 Pelvic inflammatory disease Age Previous Ectopic Previous tubal ligationSymptoms 1048708 Abdominal pain vaginal bleeding syncope amenorrhea 1048708 Occurs 5-8 weeks after last menstrual period

ECTOPIC PREGNANCY 95 are in the fallopian tube (70 ampulla 12 isthmus 11 fimbria 2 interstitialcornual) Ovarian occurs about 3 of the time abdominal 1 of the time cervical lt1 of the time

Seeber 2006

HOW TO YOU DETERMINE LOCATION OF THE PREGNANCY First determine dating by LMP Then perform ultrasound If you can see location of the pregnancy

you are done If you cannothellipit becomes more

complicatedhellip

EARLY PREGNANCY WITH UNKNOWN LOCATION Check a serum BHCG If it is above the discriminatory zone

(DZ)mdash(this is different at every hospital) an intrauterine pregnancy should be seen

Then do an ultrasound to see if you see the pregnancy

EARLY PREGNANCY WITH UNKNOWN LOCATION If BHCGgtDZ and pregnancy seen in the

uterus you are done If BHCGgtDZ and no pregnancy seen in

the uterus it is an ectopic until proven otherwise

EARLY PREGNANCY WITH UNKNOWN LOCATION If BHCGlt DZ and you do not see the

pregnancy on the ultrasound consider your patienthellip

Is shehellipUnstable or stableHave pain Have risk factors for ectopicYour differential diagnosis is intrauterine

pregnancy just too small to see on ultrasound vs ectopic

EARLY PREGNANCY WITH UNKNOWN LOCATIONbull Generally BHCG will double in 48 hoursbull If the patient is stable you can have her

return in 48 hours for repeat BHCGbull If is doubling appropriately likely normal

intrauterine pregnancy and can order ultrasound when gtDZ

bull If not doubling appropriately consider treatment for ectopic (methotrexate or surgery)

USS FINDINGS Empty uterus Adnexal mass

+- FHRRing of blood flow on dopplerTenderness on probe pressure over mass

Free fluid especially POD TV scan ideally if available

ECTOPIC WITH FHR

Tubal Ectopic Pregnancy

Ectopic Pregnancy Management-determine hemodynamic stability Medical Methotrexate-unruptured small no cardiac activity compliant patient Surgical Laparoscopy

bull Salpingostomybull Salpingectomy

Laparotomy

Medical therapy Medical therapy involving methotrexate

The patient must be hemodynamically stable

no signs or symptoms of active bleeding or hemoperitoneum

she must be reliable compliant and able to return for follow-up

size of the gestation which should not exceed 35 cm at its greatest dimension on ultrasound (US) measurement

She should not have any contraindications to the use of methotrexate

Contraindications to Methotrexate

A bhCG level of greater than 15000 IUL fetal cardiac activity and free fluid in the cul-de-sac on US (presumably representing tubal rupture) documented hypersensitivity to methotrexate breastfeedingimmunodeficiencyalcoholismalcoholic liver disease or any liver diseaseblood dyscrasiasleukopeniathrombocytopeniaanemia active pulmonary diseasepeptic ulcer diseaserenal hepatic or hematologic dysfunction

Surgical therapy

Laparoscopy has become the recommended approach in most cases

Laparotomy is usually reserved for patients

who are hemodynamically unstable

patients with cornual ectopic pregnancies

for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is difficult (eg secondary to the presence of multiple dense adhesions obesity or massive hemoperitoneum)

Total salpingectomy is the procedure of choice In a patient who has completed childbearing and no longer desires fertility in a patient with a history of an ectopic pregnancy in the same tube in a patient with severely damaged tubes

Expectant management

Candidates for successful expectant management are asymptomatic and have no evidence of rupture or hemodynamic instability Furthermore they should portray objective evidence of resolution such as declining bhCG levels They must be fully compliant and must be willing to accept the potential risks of tubal rupture

Ectopic Pregnancy- Unusual Variants Heterotopic Pregnancy Simultaneous IUP and

ectopic gestations Rare- 1 in 30000 pregnancies

Abdominal Pregnancy-can occur anywhere in peritoneal cavity (1 in 3000)

Cervical Pregnancy (1 in 10000) May need hysterectomy

Ovarian Pregnancy (1 in 7000) Oophorectomy usually required

Prognosis for Subsequent Fertility

Overall subsequent pregnancy rate is 60 other 40 are infertile

One-third of pregnancies after an ectopic pregnancy are another ectopic pregnancy one-sixth are spontaneous abortions

Only 33 of women with ectopic pregnancy will have a subsequent live birth

Ectopic pregnancy

When a woman presents with an early pregnancyhellip


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Ectopic Pregnancy

How to you determine location of the pregnancy

Early pregnancy with unknown location

Early pregnancy with unknown location (2)



USS findings

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Ectopic with FHR

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WHEN A WOMAN PRESENTS WITH AN EARLY PREGNANCYhellip Ask yourself two questionshellip


Is it viable





Seeber 2006



complicatedhellip


















ECTOPIC WITH FHR




Laparotomy









Surgical therapy


















Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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Seeber 2006



complicatedhellip


















ECTOPIC WITH FHR




Laparotomy









Surgical therapy


















Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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complicatedhellip


















ECTOPIC WITH FHR




Laparotomy









Surgical therapy


















Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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ECTOPIC WITH FHR




Laparotomy









Surgical therapy


















Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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Laparotomy









Surgical therapy


















Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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Surgical therapy


















Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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Ectopic pregnancy



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Ectopic Pregnancy






USS findings

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Ectopic with FHR

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Gynecology 5th year, 7th lecture (Dr. Muhabat Salih Saeid)

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Transcript of Gynecology 5th year, 7th lecture (Dr. Muhabat Salih Saeid)