Ectopic Pregnancy

Danielle E,et.al, Ectopic Pregnancy-

From SurgicalEmergency to Medical Management.
The Journal of the American Association of Gynecologic Laparoscopists.
2004 Feb;11(1):109-118
James Johnston Walker,MD, Ectopic pregnancy.
Clinical Obstetrics and Gynecology.2007 Mar;50(1) 88-89
Mohamed Raheem.el al,Ectopic preganacy.
The Middle East Journal of emergency medicine.2005 Mar ;5(1)
Epidemiology

• A 2006 WHO analysis of cause maternal

morbidity, pooled data from multiple
geographic areas, the rate of death from
ectopic pregnancy was 4.9%(0.4%-4.7%)
 Epidemiology
With TVS and high sensitivity of hCG level,
1970; more than 80%can be diagnosed before rupture,
35.5/10,000 result in decline in the mortality rate

2000;
2.6/10,000
Epidemiology
• Traditionally, rate of EP is around 1/100
pregnancies but over recent decades
there has been rising ,associated with …
– Greater prevalence of STD
– Increase TS and reversal procedure
– Delay childbearing
– ART
– More successful clinical detection
 Epidemiology
• The risk for developing ectopic pregnancy
– Black and other minority race (RR1.6),
relate to socioeconomic factor
– Advance maternal age
– Impede the migration of conceptus
• Anatomical defect
• Hormonal factor
• Pathologic factor
Presentation
• Usually present between GA 6-10wk
• Main presenting feature are abdominal pain
(69.3%) and vaginal bleeding(45.3%)
• Earlier diagnosis is important to allow
intervention that will reduce morbidity and
maximize further fertility
Presentation
• Hx and PE do not reliably diagnosis
to exclude EP,
(9% no pain ,36% lack of adnexal tenderness)
• The present of risk factors should
increase suspicion
• Tubal rupture is rarely sudden due to
invasion of trophoblast , relative slow
progress
Diagnosis
• Serum hCG level
– Diagnostic pregnancy
• as early as 10 days following ovulation
– Identifying abnormal pregnancy
• Less than a 66% ↑ hCG levels during 48hr
• 15% of normal pregnancies would fall in the
ectopic category, and 13% of the ectopic
pregnancies would be missed.
– Monitoring the resolution
Diagnosis
• Progesterone
– The usefulness is limited because
significant number of tests fall in the
intermediate range (5-25 ng/ml)
Diagnosis

• TVS
– TVS combine hCG level has improve the
diagnostic accuracy
– At hCG 1500 IU/L ,IUP should be seen
– Heterotrophic pregnancy more common with the
increased use ARTs
(up to 1% of IVF versus
1/3,800 naturally conceived pregnancies)
Suspected ectopic (UPT positive)

Clinical assessment Haemodynamically

compromised

Stable
Laparotomy
TVS

IUP Empty Uterus Empty uterus

With adnexal mass/free fluid
 Empty uterus Empty uterus with
adnexal mass/free fluid

Serum hCG <1500 Serum hCG >1500 Laparoscopy

Repeat 48h later Rise by less than 66%

if stable Or condition worsens

66% or more rise

Repeat scan in 1 wk
Unless condition changes
Treatment
• Surgical option
– Salpingotomy VS salpingectomy
– Laparotomy VS Laparoscopy
• Nonsurgical treatment
– Expectant management
– Metrotrexate
• Combined medical-surgical treatment
Surgical option
• In the past, laparotomy with salpingectomy
was standard
• Recently, a more conservative surgical
approach to unruptured ectopic pregnancy
has been advocated to preserve tubal
function.
Surgical option
• Salpingectomy VS Salpingotomy
– No RCT that specific compare
laparoscopic salpingectomy and
salpingotomy and the effects on
subsequence fertility.
– Reviews of observational studies show
no evidence that there is an increase in
the rate of subsequence IUP
Surgical option
• Salpingectomy VS Salpingotomy
– Some studies show that the IUP rate were
similar, other demonstrate a trend toward
improved subsequence IUP rates with
conservative surgery
– All studies suggest a trend towards an
increased repeat ectopic rate with
salpingotomy compares with salpingectomy
Surgical option
• Salpingectomy VS Salpingotomy
– Recent cohort studies suggesting that the
future success has more to do with
underlying pathology than the surgery
undertaken
 Surgical option

• Salpingectomy VS Salpingotomy
– If two or more of these prognostic factors ,
Hx of salpingitis / ectopic pregnancy/ tubal surgery,
or presence of adhesions on the contralateral tube,
were present, the chances of a subsequent
ectopic exceeded the chances of a
successful pregnancy.
 Surgical option
• Salpingectomy VS Salpingotomy
– Salpingectomy is the treatment of choice
if the fallopian tube is extensively diseased
or damaged as there is high risk of
recurrent EP
– Salpingotomy is therapeutic option in an
attempt to maintain fertility.
Surgical option
• Salpingectomy VS Salpingotomy
– Because of the risk of persistent trophoblast
after salpingotomy ,close follow up is
required with regular hCG assessment
– This results in short term cost of
salpingotomy being greater ,however if
need for assisted conception would make
salpingotomy more cost-effective.
Surgical option

• Persistent trophoblast
– This is mostly a problem after salpingotomy
– Incidence around 8%
– More likely if the preoperative serum hCG
are above 3000 IU/L
– There are insufficient data to recommended
the correct definition and units needs to
develop their criteria
Surgical option

• Persistent trophoblast
– Suggested criteria for starting the
treatment are if hCG level fail to fall below
65% at 48hr postop or hCG level is
greater than 10% at 10days postop.
– If diagnosed, MTX 50mg/m2 is preferable
to repeat surgical procedure
Surgical option
• Laparotomy VS Laparoscopy
– In case where is rupture of tube and
hemodynamically unstable ,laparotomy is
preferred
– The decision on approach should be made
by clinical state and skill of operator
Surgical option
• Laparotomy VS Laparoscopy
– Laparotomy is also associated with lower
subsequent pregnancy rate but this may be
due to the relative severity of cases
– In the small number of RCT, there is no
difference in tubal patency and
subsequence IUP but developed
significantly less adhesions trend toward
lower EP if laparoscopy was used.
Surgical option
• Laparoscopy
– Main benefits
• shorter operation times
• Less intraoperative blood loss
• Shorter hospital stays
• Lower anesgesic requirement
• Shorter convalescence
Surgical option
• In the surgical management, one must consider
the patient’s desire for further childbearing.
• The couple is fully informed of the possibility of
laparotomy with salpingectomy or more extirpative
surgery.
• Even if neither tube can be saved, effort to
preserve the uterus and at least one ovary to keep
alive with the use of the IVF
Nonsurgical treatment
• Expectant management
– Many EPs will resolve spontaneously
– The range of success in observational
studies is 44%-69%
Nonsurgical treatment
• Expectant management
– The success depend on the USG
appearance and the level of hCG level
• Adnexal mass ≤4 cm.
• Absence of a GS
• Free fluid <100ml
• hCG < 1000 IU/L and by fall at least 15% in first
24hr ;most predictive factor
But no cut-off value has been found below which
expectant management is uniformly safe
Nonsurgical treatment
• Expectant management
– Need serial hCG measurements twice a
week and weekly TVS to ensure resolution,
(marked by a rapidly decrease hCG to less than 50% of
initial level and reduction in size of mass by 7day)
– Thereafter ,weekly hCG and TVS should be
carried out until serum levels are less than
20 IU/L
Nonsurgical treatment
• Expectant management
– Should be counseled about the importance
of compliance with follow-up and should
have easy access to hospital
– However, tubal patency rates have been
reported to be the same with either
expectant or salpingotomy
Nonsurgical treatment
• Metrotrexate
– Folic antagonist, has been used for over
20years
– Aimed at patients before ectopic ruptures
and who hemodynamically stable
Nonsurgical treatment
• Metrotrexate
– Metroxate can be successful at
• small GS(<4cm) ,
• lower serum hCG (<3000 IU/L)
• absence of blood in the peritoneal cavity and
absent fetal heart activity.
– High failure rate if progesterone>10ng/mL
or hCG >5000IU/L or presence cardiac
activity or yolk sac are seen
Nonsurgical treatment
• Metrotrexate
– Abdominal pain is common (75%) and some
need to admit if rupture is suspected
– Should be advises to avoid SI ,maintain
ample fluid intake during treatment and
need to understand treatment and potential
problem
– Contraception 3 mo after MTX has been
given
Nonsurgical treatment
• Metrotrexate
– Benefit of single dose MTX is associate cost
saving due to outpatient management
– However in RCT, cost saving were only
seen when hCG below 1500 IU/L due to
increased need for further treatment and
prolong follow-up
Nonsurgical treatment
• Metrotrexate
– In a multicenter RCT found that patients
treated with MTX had more limitations in
physical and social functioning, worse
health perceptions, less energy, more pain,
more physical symptoms a worse overall
quality of life, than surgically treated
patients
Nonsurgical treatment
• Metrotrexate
– Systemic methotrexate therapy is
contraindicated
• hemodynamically unstable
• have signs of bone marrow depression
• liver or renal dysfunction,
• evidenced by leukopenia and/or
thrombocytopenia,
Nonsurgical treatment
• Metrotrexate
– Work up prior to therapy should include
CBC, LFT,BUN/Cr and coagulation
– S/E of MTX are rare and usually mild and
include: nausea, vomiting, diarrhea,
stomatitis, reversible alopecia, neutropenia,
and pneumonitis.in high risk patient
Combined medical-surgical therapy

• Local injection of MTX into the ectopic under

USG or laparoscopy
• Although the local levels are high, the
circulating levels of MTX are not decreased.
• In fact they are the same as if injected IM,
as one would expect given the rapid systemic
absorption of the antimetabolite.
Combined medical-surgical therapy

• Laparoscopic salpingotomy VS
Laparoscopic local MTX injection
– Equally effective and with balanced
advantages/disadvantages
– Local MTX injection
• shorter operation time
• less need for surgical expertise
– The salpingotomy
• shorter hospitalization
• reduced risk of persistent trophoblastic activity
Combined medical-surgical therapy

• Prophylactic MTX has been successfully

used to reduce the risk of persistent ectopic
pregnancy following the salpingotomy,
– MTX1mg/kg IM, the rate was reduced from
14.5% to 1.9% in the study Group
– MTX 1 mg/kg, in the affected tube,reduced
from 15.8% to 0% in the treatment group.
Combined medical-surgical therapy

• Heterotopic pregnancies
– Laparoscopic removal of the eccyesis had
previously been the standard treatment
– A less invasive and safer is the local injection of
KCl or hyperosmolar glucose directly into the
ectopic GS
– MTX should not be used since its systemic
absorption would endanger the IUP
 Comparison between treatment methods

Pregnancy rate Recurrent EP

Expectant
80%-88% 4.2%-5%
management

66% 10%
Medical
treatment starting hCG levels < 3000IU/L ,
the results are comparable with laparoscopic surgery

65% within a year

10-15%
over 80% in the long term
Surgical
treatment outcome in the next pregnancy is as much to do with
underlying pathology as the therapeutic option chosen.