management of ectopic pregnancy 2

8/12/2019 Management of Ectopic Pregnancy 2

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DIAGNOSIS & MANAGEMENT OF ECTOPICPREGNANCY

JOURNAL CLUB-01/06/2005


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DIAGNOSIS

In recent years, inspite of an increase in theincidence of ectopic pregnancy there has been afall in the case fatality rate.- Due to the widespread introduction ofdiagnostic tests & an increased awareness ofthe serious nature of this disease.

This has resulted in early diagnosis andeffective treatment.Now the rate of tubal rupture is as low as 20%.


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METHODS OF EARLY

DIAGNOSISImmunoassay utilising monoclonal antibodies to betaHCGUltrasound scanning Abdominal & Vaginal includingColour DopplerLaparoscopySerum progesterone estimation alone is not helpful

A combination of these methodsmay have to be employed.


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METHODS OF EARLY DIAGNOSIS

TVS can visualise a gestational sac as early as4-5 weeks .

During this time the lowest serum beta HCG is2000 IU/Lt.When beta HCG level is greater than this &there is an empty uterine cavity on TVS ectopic

pregnancy can be suspected.In such a situation, when the value of beta HCGdoes not double in 48 hours ?ECTOPIC.

At 4-5 weeks -


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The USG features of ectopic pregnancy after 5weeks can be any of the following-

1. Demonstration of the gestational sac with or without alive embryo (Begels sign) - The GS appears as an intactwell defined tubal ring by 6 weeks when it measures 5mm in diameter.

2. Afterwards it can be seen as a complete sonolucent sacwith the yolk sac and the embryonic pole with orwithout heart activity inside.


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Poorly defined tubal ring / containingechogenic structure & fluid or blood in POD. Ruptured ectopic with fluid in the POD and an

empty uterus. In Colour Doppler, the vascular colour in a

characteristic placental shape, the so-calledfire pattern, can be seen outside the uterine

cavity while the uterine cavity is cold in respectto blood flow

The USG features of ectopic pregnancy after 5weeks can be any of the following-


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MANAGEMENT

Depends on the stage of the disease andthe condition of the patient at diagnosis.

Options-Surgery Laparoscopy / LaparotomyMedical Administration of drugs systemically

Expectant Observation


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MANAGEMENT OF ACUTE

ECTOPIC PREGNANCYHospitalisation

Resuscitation -Treatment of shockLie flat with the leg end raised

AnalgesicsBlood transfusion


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MANAGEMENT OF ACUTE

ECTOPIC PREGNANCYLaparotomy should be done at theearliest.

Salpingectomy is the definitivetreatment.No benefit from removing Ovary along with

the tubeIf blood is not available, auto-transfusion can be done.


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MANAGEMENT OF CHRONIC

ECTOPIC PREGNANCYINVESTIGATIONS-Laboratory/Chemical test

Serial quantitative beta HCG level by RIASerum progesterone level (


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MANAGEMENT OF UNRUPTURED

ECTOPIC PREGNANCY

SURGICALMEDICAL TREATMENTEXPECTANT MANAGEMENT

OPTIONS: -


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SURGICAL TREATMENT OF

ECTOPIC PREGNANCYCarried out either by Laparoscopy / Laparotomy.The procedures are: -

Salpingectomy / Cornual resection / ExcisionConservative surgery (in cases of Infertility &desire for pregnancy)

Linear salpingostomy

Linear salpingotomySegmental resection and anastomosisMilking of the tube


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SURGICAL TREATMENT OF

ECTOPIC PREGNANCYLAPAROTOMY?

VS.LAPAROSCOPY?

SALPINGECTOMY?VS

SALPINGOSTOMY / SALPINGOTOMY?

The debate goes on


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COMPARING LAPAROTOMY Vs LAPAROSCOPY

Ltomy Lscopy Hospital cost More? Less?

Post operative adhesions More LessRisk of future ectopic Same SameFuture fertility Same Same

Experience of Surgeon Trained SpecialInstruments General Special


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SALPINGECTOMYVS

SALPINGOSTOMY / SALPINGOTOMY

All tubal pregnancies can be treated by partialor total Salpingectomy

Salpingostomy / Salpingotomy is onlyindicated when:1. The patient desires to conserve her fertility2. Patient is haemodinamically stable

3. Tubal pregnancy is accessible4. Unruptured and < 5Cm. In size5. Contralateral tube is absent or damaged


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The choice of surgical treatment does notinfluence the post treatment fertility, but priorhistory of infertility is associated with a markedreduction in fertility after treatmentMaking the choice a scoring system (based onthe patients previous gynaecological history

and the appearance of the pelvic organs)

to decide between

salpingostomy / salpingotomy and salpingectomy.

SALPINGECTOMYVS

SALPINGOSTOMY / SALPINGOTOMY


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It is carried out by laparoscopic scissorsand diathermy or Endo-loop.

After passing a loop of No.1 catgut overthe ectopic pregnancy the stitch istightened and then the tubal pregnancy is

cut distal to the loop stitch.The excised tissue is removed by piecemeal or in a tissue removal bag.

LAPAROSCOPIC SALPINGECTOMY


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The tubal pregnancy is thenevacuated by suction irrigation.

Haemostasis of the trophoblasticbed is ensured.The tubal incision is left open.

LAPAROSCOPIC SALPINGOTOMY


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PERSISTENT ECTOPICPREGNANCY (PEP)

This is a complication of salpingotomy /salpingostomy when residual trophoblastcontinues to survive .Diagnosis is made because of a raisedpostoperative serum HCGIf untreated, can cause life threateninghaemorrhage


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PERSISTENT ECTOPICPREGNANCY (PEP)

TREATMENT is by-

Reoperation and further evacuation /Salpingectomy Administration of IM / oral Methtrexate

in a single dose of 50 mg/m2


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MEDICAL TREATMENT WITHMETHOTREXATE

Earlier, mostly used for early resolution ofplacental tissue in abdominal pregnancy.Now used for tubal pregnancy as well .Mechanism of action- Interferes with the DNAsynthesis by inhibiting the synthesis of

pyrimidines trophoblastic cell death.

Auto enzymes and maternal tissues then absorb

the trophoblast.


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Ectopic pregnancy size should be < 3.5 cm.

Can be given IV/IM/OralRecent concept is to give Methtrexate IM ina single dose of 50mg/m2

If serum HCG does not fall to 15% within4-7 days, then a second dose ofMethtrexate is given and resolution

confirmed by HCG estimation


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Advantages Minimal Hospitalisation.

Quick recovery 90% success if cases are properly selected

Disadvantages-Side effects like GI & SkinMonitoring is essential- Total blood count, LFTrenal profile & serum HCG once weekly till it

becomes negative


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EXPECTANT TREATMENT

Tubal Pregnancies are known to Abort /

ResolveToday only selected cases are managedexpectantly, screened and identified by

high resolution ultrasound scanner andmonitored by serial serum HCG assay


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EXPECTANT TREATMENT

Identification criteria (Ylostalo et al , 1993)-Diameter of ectopic pregnancy


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EXPECTANT TREATMENT

Spontaneous resolution - in 72%; 28%will need laparoscopic salpingostomyIn spontaneous resolution, it may take4-67 days (mean 20 days) for the serumHCG to return to non pregnant level.

The percentage fall in serum HCG byday 7 is a good indicator . Warning: - Tubal pregnancies have beenknown to rupture even when Serum HCGlevels are low.


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SUMMARY - KEY POINTS

Incidence of ectopic pregnancy is rising while maternal mortality from it is falling

Early diagnosis is the key to less invasive treatment

The choice today is Laparoscopic treatment of unruptured ectopic pregnancy

The trend is towards conservative treatment

Careful monitoring and proper counselling of patients is mandatory

Ruptured ectopics should be unusual with compliant patients and appropriate medicalcare


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Summary:

Single dose methotrexate is best used for those are

asymptomatic, whose -hCG is < 5000 mIU/mL,

have tubal size < 3 cm, have no fetal cardiac

activity on ultrasonography, and will come in to be

followed closely. It cannot be used if there is a

heterotopic pregnancy .
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Summary:

Despite low and declining -hCGlevels,tubal rupture can still occurwith methotrexate treatment.

with severe pelvic pain, monitoring ofvital signs and haematocrit can helpdifferentiate between tubal abortion and tubal rupture .
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Summary:

Most common side effects ofmethotrexate are :(1) stomatitis, (2) conjunctivitis,(3) mild abdominal pain of shortduration.

Rare side effects include dermatitis andpleuritis.


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Summary:Surgery is done only if transvaginal ultrasonographyshows an ectopic pregnancy .

Laparoscopic surgery has been found to besuperior to laparotomy and can treat most patients.

Persistent ectopic pregnancy refers to thecontinued growth of trophoblastic tissue aftersurgery.Special attention should be given to the pr oximalportion du ring surgery and the ectopicpregnancy should be flushed out with suctionirrigation.
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Summary:

Expectant management is done whenectopic pregnancy is suspected, but

transvaginal ultrasonography does not showan ectopic pregnancy. The patient is followedwith weekly ultrasonography and weekly-hCG measurements until the level is < 10

mIU/mL. All pregnant women who are Rh-negativeshould receive Rh immunoglobulin.


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PROPOSED EVIDENCE-BASED ALGORITHM

Suspectcd ectopic pregnancy

Haemodynamically stable

TVS

IUP Empty Ux Ad.mass < 3.5cmNo FHBNo FF

Empty Ux Ad.mass>3.5cmFHB +FF +

Suitablesurgery

Serum -hCG

5000 iu/l


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5ng/ml

Repeat

hCG after 48hours

< 50% increase

Colour Doppler

Ectopic pregnancy

Methotrexate

> 50% increase

TVS forviability



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2000 -5000 iu/l

D 1 MTX50mg/sqm

D 5 Repeat hCG

> 15 % decrease

Yes No

Repeat hCGWeekly until< 10iu/l

2nd dose MTX

YES NO

Repeat hCGWeekly until< 10 iu/l

Surgery/3 rd dose MTX

D 9 Repeat hCG

> 15 % decrease

PROPOSED EVIDENCE-

BASED ALGORITHM


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>5000 iu/l

Suitable surgery



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RCOG GUIDELINE 21

MAY 2004

A laparoscopic approach to the surgicalmanagement of tubal pregnancy, in thehaemodynamicallystable patient, is preferable to an openapproach.


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Management of tubal pregnancy in thepresence of haemodynamic instability shouldbe by the most expedient method. In most cases this will belaparotomy.

RCOG GUIDELINE 21

MAY 2004


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In the presence of a healthycontralateral tube there is noclear evidence thatsalpingotomy should be used in preference to

salpingectomy.

RCOG GUIDELINE 21

MAY 2004


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Laparoscopic salpingotomy should beconsidered as the primary treatment whenmanaging tubal pregnancy in the presence of contralateral tubal

disease and the desire for future fertility.

RCOG GUIDELINE 21

MAY 2004


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Medical therapy should be offered tosuitable women, and units should havetreatment and follow-upprotocols for the use of methotrexate in the

treatment of ectopic pregnancy.

RCOG GUIDELINE 21

MAY 2004


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Women most suitable formethotrexate therapy are those witha serum hCG below 3000 iu/l, and minimal symptoms.

RCOG GUIDELINE 21

MAY 2004


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Outpatient medical therapy withsingle-dose methotrexate isassociated with a saving intreatment costs.

RCOG GUIDELINE 21

MAY 2004


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Expectant management is an option for

clinically stable women with minimalsymptoms and a pregnancy of unknown location.

RCOG GUIDELINE 21

MAY 2004


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Expectant management is anoption for clinically stable

asymptomatic women with anultrasound diagnosis of ectopic pregnancyand a decreasing serum hCG,initially less thanserum 1000 iu/l.

RCOG GUIDELINE 21

MAY 2004


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When salpingotomy is used for themanagement of tubal pregnancy,protocols should be in place for the identification and treatment ofwomen with persistent

trophoblast.

RCOG GUIDELINE 21

MAY 2004


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Clinicians undertaking the surgicalmanagement of ectopic pregnancy musthave received appropriate training. Laparoscopic surgery requiresappropriate equipment and trainedtheatre staff.

RCOG GUIDELINE 21

MAY 2004


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RCOG GUIDELINE 21

MAY 2004Nonsensitised women who are

rhesus negative with aconfirmed or suspected ectopicpregnancyshould receive anti-D

immunoglobulin.


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Women should be carefully advised,whenever possible, of the advantagesand disadvantages associated with each approach used forthe treatment of ectopic pregnancy. Theyshould participate

fully in the selection of the mostappropriate treatment.

RCOG GUIDELINE 21

MAY 2004


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management of ectopic pregnancy 2

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