management of ectopic pregnancy

prepared byprepared byM.Sadhana Reddy M.Sadhana Reddy

Definition:Definition:

An ectopic pregnancy, or eccysis, is a complication of An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants outside pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are pregnancies are not viable. Furthermore, they are dangerous for the mother, since internal haemorrhage dangerous for the mother, since internal haemorrhage is a life-threatening complicatiois a life-threatening complication. n.

Classification:Classification:

Tubal pregnancyTubal pregnancy Nontubal ectopic pregnancyNontubal ectopic pregnancy Heterotopic pregnancyHeterotopic pregnancy Persistent ectopic pregnancyPersistent ectopic pregnancy Pregnancy of unknown locationPregnancy of unknown location

The vast majority of ectopic pregnancies implant in The vast majority of ectopic pregnancies implant in

the Fallopian tubethe Fallopian tube. .

Nontubal ectopic pregnancyNontubal ectopic pregnancy

Two percent of ectopic pregnancies occur in Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. the ovary, cervix, or are intraabdominal.

Heterotopic pregnancyHeterotopic pregnancy

In rare cases of ectopic pregnancy, there may In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus be two fertilized eggs, one outside the uterus and the other inside. This is called a and the other inside. This is called a  heterotopic pregnancy. heterotopic pregnancy.

Persistent ectopic pregnancyPersistent ectopic pregnancy

A persistent ectopic pregnancy refers to the A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a continuation of trophoplastic growth after a surgical intervention to remove an ectopic surgical intervention to remove an ectopic pregnancy. pregnancy.

For this reason hCG levels may have to be For this reason hCG levels may have to be monitored after removal of an ectopic monitored after removal of an ectopic pregnancy to assure their decline, pregnancy to assure their decline, also methotrexate can be given at the time of also methotrexate can be given at the time of surgery prophylactically.surgery prophylactically.

Pregnancy of unknown locationPregnancy of unknown location

Pregnancy of unknown location (PUL) is the Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a term used for a pregnancy where there is a positive pregnancy test but no pregnancy has positive pregnancy test but no pregnancy has been visualized using transvaginal been visualized using transvaginal ultrasonographyultrasonography

  Between 30 and 47% of women with Between 30 and 47% of women with pregnancy of unknown location are ultimately pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine diagnosed with an ongoing intrauterine pregnancypregnancy

Signs and symptoms:Signs and symptoms:

Early signs includeEarly signs include 1.Vaginal bleeding1.Vaginal bleeding 2. Abdominal pain2. Abdominal pain

3. Less common features of ectopic 3. Less common features of ectopic pregnancy nausea, vomiting and diarrhoea.pregnancy nausea, vomiting and diarrhoea.

4. Heavy bleeding4. Heavy bleeding

Risk Factor for Ectopic PregnancyRisk Factor for Ectopic Pregnancy

Previous PID – chalamydia infectionPrevious PID – chalamydia infection Previous ectopic pregnancyPrevious ectopic pregnancy Tubal ligationTubal ligation Previous tubal surgeryPrevious tubal surgery Intrauterine device (IUD)Intrauterine device (IUD) Prolonged infertilityProlonged infertility Diethylstilbestrol (DES) exposure Diethylstilbestrol (DES) exposure Multiple sexual partnersMultiple sexual partners smoking smoking

Clinical Finding: Variable - Early diagnosisVariable - Early diagnosis

- location of the implantation- location of the implantation - Whether rupture has occurred- Whether rupture has occurred

Classic symptom trait with unruptured ectopic Classic symptom trait with unruptured ectopic pregnancy:pregnancy:

Amenorrhoea, abdominal pain, abnromal Amenorrhoea, abdominal pain, abnromal vagina bleedingvagina bleeding

Classic signs – adnexal or cervical Classic signs – adnexal or cervical motion motion

tenderness.tenderness. With ruptured ectopic pregnancy, finding parallel With ruptured ectopic pregnancy, finding parallel

with the degree of internal bleeding and with the degree of internal bleeding and hypovolemia – abdominal guarding and rigidity, hypovolemia – abdominal guarding and rigidity, shoulder pain and fainting attacks and shock.shoulder pain and fainting attacks and shock.

DiagnosisDiagnosis Transvaginal ultrasonographyTransvaginal ultrasonography: it has : it has

a sensitivity of at least 90% for ectopic a sensitivity of at least 90% for ectopic pregnancy. The diagnostic ultrasonographic pregnancy. The diagnostic ultrasonographic finding in ectopic pregnancy is an adnexal finding in ectopic pregnancy is an adnexal mass that moves separately from the ovary.mass that moves separately from the ovary.

Ultrasonography and β-hCGUltrasonography and β-hCG Where no intrauterine pregnancy is seen on Where no intrauterine pregnancy is seen on

ultrasound, measuring β-human chorionic ultrasound, measuring β-human chorionic gonadotropin (β-hCG) levels may aid in the gonadotropin (β-hCG) levels may aid in the diagnosis. The ration is that a low β-hCG level diagnosis. The ration is that a low β-hCG level may indicate that the pregnancy is intrauterine may indicate that the pregnancy is intrauterine but yet too small to be visible on but yet too small to be visible on ultrasonography. ultrasonography.

The fall in serum hCG over 48 hours may be The fall in serum hCG over 48 hours may be measured as the hCG ratio, which is calculated measured as the hCG ratio, which is calculated as: as:  hCGratio= hCGat 48h/ hCGat 0h hCGratio= hCGat 48h/ hCGat 0h

Laparoscopy: for identifying an unruptured Laparoscopy: for identifying an unruptured tubal pregnancy which is producing tubal pregnancy which is producing equivocal symptoms and for exclude equivocal symptoms and for exclude salpingitis and bleeding from small ovarian salpingitis and bleeding from small ovarian cyst.cyst.-- For operative treatment using For operative treatment using minimally invasive methods.minimally invasive methods.

Treatment:Treatment: If haemorrhage and shock presentIf haemorrhage and shock present

Restore blood volume by the transfusion of red cells Restore blood volume by the transfusion of red cells or volume expanderor volume expander

Proceed with LaparotomyProceed with Laparotomy The earlier diagnosis of tubal pregnancy has The earlier diagnosis of tubal pregnancy has

allowed a more conservative approach to allowed a more conservative approach to management where the tube is less damage.management where the tube is less damage.

Pregnancy removed from the tube by laparoscopy Pregnancy removed from the tube by laparoscopy (salpingostomy) hopefully retaining tubal function.(salpingostomy) hopefully retaining tubal function.

Trophoblast destroyed by chemotherapeutic agent Trophoblast destroyed by chemotherapeutic agent such as methotrexatesuch as methotrexate

Medical ManagmentMedical Managment Methotrexate 1 mg/kg body weightMethotrexate 1 mg/kg body weight

Indications:Indications: Haemodynamically stable, no active bleeding Haemodynamically stable, no active bleeding

minimal bleeding and no painminimal bleeding and no pain

No contra indication to methotrexateNo contra indication to methotrexate

Able to return for follow up for several weeksAble to return for follow up for several weeks

Non laparoscopic diagnosis of ectopic pregnancyNon laparoscopic diagnosis of ectopic pregnancy

General anaesthesia poses a significant riskGeneral anaesthesia poses a significant risk

Unruptured adenexal mass < 4cm in size by scanUnruptured adenexal mass < 4cm in size by scan

HCG does not exceed 5000 IU/LHCG does not exceed 5000 IU/L Contraindications:Contraindications:

BreastfeedingBreastfeeding Immunodeficiency / active infectionImmunodeficiency / active infection Chronic liver diseaseChronic liver disease Active pulmonary diseaseActive pulmonary disease Active peptic ulcer or colitisActive peptic ulcer or colitis Blood disorderBlood disorder Hepatic, Renal or Haematological Hepatic, Renal or Haematological

dysfunctiondysfunction

Side Effects:Side Effects: Nausea & VomitingNausea & Vomiting

Diarrhorea, abdominal painDiarrhorea, abdominal pain

Photosensitivity skin reactionPhotosensitivity skin reaction

Impaired liver function, Impaired liver function,

PneumoniaPneumonia

Severe neutropeniaSevere neutropenia

Reversible alopeciaReversible alopecia

Treatment EffectsTreatment Effects:: Abdominal pain (2/3 of patient)Abdominal pain (2/3 of patient) HCG during first 3 days of treatmentHCG during first 3 days of treatment Vaginal bleedingVaginal bleeding

Signs and Treatment failureSigns and Treatment failure Significantly worsening abdominal pain, regardless Significantly worsening abdominal pain, regardless

of change in serum HCG of change in serum HCG Level of HCG do not decline by at least 15% Level of HCG do not decline by at least 15%

between Day 4 & 7 post treatmentbetween Day 4 & 7 post treatment or plateauing HCG level after first week of or plateauing HCG level after first week of

treatmenttreatment

SURGICAL MANAGEMENT:SURGICAL MANAGEMENT:

Laparoscopy approach – Laparoscopy approach – incise the affected incise the affected Fallopian and remove only the pregnancy Fallopian and remove only the pregnancy (salpingostomy) (salpingostomy)

remove the affected tube with the pregnancy remove the affected tube with the pregnancy (salpingectomy).(salpingectomy).

1. Positive pregnancy test

Lower abdominal pain +Minimal Vaginal bleeding

Asymptomatic with factorsfor ectopic pregnancy

Risk factorsPrevious ectopic pregnancyPrevious PIDTubal surgeryTubal pathology (PID, endometriosisInfertility, ovarian stimulationSterilization failurePrevious abdominal surgeryDES exposure in uteroMultiple sexual partners

2. History + clinical examination

MANAGEMENT OF ECTOPIC PREGNANCY

Regular cycle, i.e. >6 wks. gestation,

Arrange TV ultrasound

irregular cycle,Measure serum hCG

If hCG <100 (?early Intrauterine/? Ectopic pregnancy

If Hcg >1000, susept

Ectopic pregnancy

3. Empty uterus + serum hCG > 1000

Meet criteria for Methorexate treatment

Does not meet criteria for methotrexate treatment

Use methotrexateprotocol

Laproscopic /salpingotomy/Salpingectomy ?Proceed to

laparotomy OR Laparotomy if haemodynamically unstable