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Early pregnancy complications- Early pregnancy complications- Ectopic pregnancy Ectopic pregnancy Kapila GunawardanaMS,FRCOG Kapila GunawardanaMS,FRCOG B

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  • Early pregnancy complications- Ectopic pregnancyKapila GunawardanaMS,FRCOGBreakthrough bleeding Bleeding While on hormones

  • `MiscarriagesEctopic pregnancyGestational Trophoblastic disease

  • Ectopic pregnancyIntroductionEctopic pregnancy represent approximately 2% of all pregnancies. The risk of heterotopic pregnancy is approximately 1 in 10,000 to 1 in 30,000. However risk may increase up to 1 in 100 in infertility clinics.

  • Definition.

    Any pregnancy implanted outside the uterine cavity.

  • 5The First TrimesterImplantation in uterine wallFig. 2Cleavage and blastocyst formationcleavage implantationplacentation embryogenesis

  • Patho-physiology

    Fertilization of the ovum occurs in the ampulary part of the fallopian tube. As the zygote divides , it becomes first a morula and then a blastocyst, normally arriving in the uterine cavity and beginning implantation on day 6th after the fertlization. Anything that delays or impedes tubal transport may allow implantation to begin while the blasocyst is still in the tube or it can get dislodge out of the fimbrial end in to the peritoneal cavity.

  • Risk actorsIt is strongly associated with conditions that cause alterations to the normal mechanism of fallopian tubal transport. It has been postulated more damage that occurs to the fallopian tube , higher the risk of ectopic pregnancy.InfectionSurgery (Tubal and non tubal pelvic surgery) congenital anomaliesTumorsPast history of ectopicAn IUCD( relative increase)

  • Locations of the ectopic pregnancyFallopian tube (95%) Ampula(12%) Fimbriya(11%) Cornua(2.4%)Ovarian (3.2%)Abdominal(1.3%)Cervical(
  • PresentationClassic triad Abdominal pain Amenorrhea Abnormal vaginal bleeding Examination Tachycardia, hypotension Cervical excitation Adnexal tenderness Palpable mass Unremarkable

  • DiagnosisHistory, Examination & InvestigationsInvestigations a) Transvaginal Ultrasound b)Serum beta HCG levels c) Combination of above two have Sensitivity & specificity of 90- 100% d) Laparoscopy

  • Diagnosis cont..IUP rules out an ectopic pregnancy except the rare possibility of hetertopic pregnancyAt POA of 5.5 weeks first maker of an IUP is a gestational sac with a double echogenic rings around the sacYork sac appears at 5-6w and disappear at 10wEmbryo pole and cardiac activity first seen at 5-6wsPsuedo sac may be seen

  • Diagnosis cont..What is a Psuedo sac ?Collection of fluid with in the endometrial cavityUsually located centrally where as gestational sac is away from the centre.This is due to desidual bleeding in the endometriumThis can be mistaken for an IUP

  • Diagnosis cont..Serum Beta HCG levels and the TVS findingsWhen Beta HCG level is > 6500mIU it is possible to see the IUP via abdominal scanWhen Beta HCG level is 1500- 2500mIU it is possible to see the IUP via TVS and if we cannot see IUP at this point, it is strongly suggestive of an ectopic. An exception would be early Multiple pregnancy

  • Diagnosis cont..Predictive values of Serum Beta HCGIn normal pregnancy the doubling time of the Beta HCG would be 2 days. Usually after 48h there will be an increase of 60% in normal pregnancy.A rise lower than this is highly likely of an abnormal pregnancy including an ectopic. However , normal rise donot rule out ectopic pregnancy as well.

  • Diagnosis cont..When there is no conclusive evidence of TVS and beta HCG levels ( specially HCG levels are in the normal pregnancy level ) to diagnose an ectopic pregnancy , it is advisable to do a diagnostic curettage to see the histology.Continue with serial TVS and Beta HCG levels . If levels are declining can follow up conservatively. If rising or remains the same better to treat with Metho- trexateSerum Progesterone levels > 25ng/ml is consistence of IUP.
  • TreatmentOptions

    ExpectantSurgical a) Laparotomy b)LaparoscopyMedical

  • Treatment contTreatment will depend on Stability of the patientAgeFertility wishesPatient wishesAvailable facilitiesSkills of the attending doctor

  • Treatment cont..Surgical optionsIf the patient is unstable immediate surgery via laparotomy or laparoscopy.When medical treatment is failed or undesirable.If the size of the ectopic is >5cm or live fetus seenRefusal of the patient for medical or expectant management.

  • Treatment contSurgical optionsPre operative assessment be carried outPreoperative i.v fluid be commenced via a wide bore canula An urgent blood investigation be sent (FBC) Pre operative counseling and reassurance be doneAppropriate surgical technique will be decided often in the operative suite (Salingostomy versus Salpingectomy)

  • Treatment contSalpingectomy vs salpingotomy

    SalpingostomyWishes to preserve fertilityContralaterar tube is un healthyPatients desire to retain the tube{{SalpingectomyRecurrent ectopic in the same tubeSeverly damage tubeUncotrolled bleedingHeterotopic pregnancyLack of desire to have further fertilityPersistent ectopic after salpingostomy or expectant management

  • How do we do salpingostomy?Make the incision on the antimesentric borderIncision will be made at the point of maximal distensionRemove the products of conception by hydrodesectionAvoid excessive handlingAvoid excessive cautery at the siteFollow up with TVS and BetaHCG weekly is recommendedSome have recommended prophylactic methotrexate

  • Persistent ectopic or trophoblastsOne of the hazards of conservative managementThe risk is about 2-20%This is common with an inexperienced operatorsIf the Beta HCG is rising, it is recommended to go ahead with salpingectomyIf the Beta HCG is plateaus, methotrexate is ecomended

  • Treatment contMedical optionCriteria for medical treatmentAbsolute indications a) Haemodynamicaly stable without active bleeding or signs of haemoperitoneum b) Desire for future fertility c) Non laparoscopic diagnosis d) Follow up can be done reliably e) Anesthesia posses risk f) No contra indication for methotrexate g) Unruptured mass < 3.5cm i) No fetal cardiac activity

  • Treatment contMedical optionMethotrexate has been the most successful drug of choice.Methotrexate is a folinic acid antagonist interfering with the synthesis of DNATwo regimens have been described a) Multiple doses + citrovorum rescue b) Single dose+ citrovorum rescue

  • Treatment contMedical optionMultiple dose regimenMethotrexate 1mg/kg/im EODCitrovorum rescue factor 0.1mg/kg EODThis be continued until there is a 15% decline in the level of HCG

  • Treatment contMedical optionSingle dose regimenDay 0 HCG +or D&CDay 1 HCG,FBC,LFT& Methotrexate 50mg/sqmDay 4 HCGDay 7 HCG

  • Treatment contMedical option{{Predictor of successBeta HCG levels10002000-49995000-9999>10,000

    Success rate98%87%87%68%

  • Treatment contMedical optionSurveillanceDay 1 HCGDay 4 HCG level can plteau or rise and abdominal painDay 7 HCG level With the Successful treatment there will be .15% decline of HCG from day 4-day 7Then weekly HCG levels are measured until HCG levels are
  • Expectant managementIf the serum Beta HCG levels are
  • Long term follow upAdvise to avoid pregnancy for the next 3mHysterosalphingogram after 3mIn case if she misses her periods to see an obstetrician for confirmation of the pregnancy and its location