ECTOPI

C
PREGNANCY
 Ectopic pregnancy
Definition:

An ectopic pregnancy, or eccysis , is a complication of pregnancy

Occurs when the site of implantation is outside of the womb (uterine cavity)
either in the tubes,ovaries or abdominal cavity, With rare exceptions,
ectopic pregnancies are not viable, Pregnancy can even occur in both the
womb and the tube at the same time (heterotopic pregnancy).

Classification:

1- tubal pregnancy:
The vast majority of ectopic pregnancies 95-98 % implant in the
Fallopian tube, among these:

80% in the ampulla

10% in isthmus
5 % in fimbria
2% interstitial
2% in a
rudimentary
 Why?
The reason for the increase in ectopic pregnancy during this time
period is not entirely clear, but it was thought that the increase of
risk factors were responsible for a significant portion of the
increased number of cases of ectopic pregnancy.
Tubal pregnancy
 Diagnosis
1.hormonal assay

Serum β-hCG
Urine pregnancy tests are positive in only 50-60% of ectopic.
Detection of β-hCG in the serum by ELISA or radioimmunoassay
are more sensitive and can detect very early pregnancy about 10
days after fertilization i.e. before the missed period.
If the test is negative (generally less than 5 IU/L), normal and
abnormal pregnancy including ectopic are excluded.
If the test is positive , and doubles every 36-48 hour till reaching
1500 IU/L which is The threshold of discrimination for
intrauterine pregnancy, this indicates a normal intrauterine
pregnancy,
An abnormal rise in blood β-hCG levels may indicate an
ectopic pregnancy and ultrasonography is indicated.
 Diagnosis
Progesterone
The second most common hormone after hCG in
pregnancy is progesterone.
Generally, a progesterone concentration of greater than 25 ng/mL
is highly correlated with a normal intrauterine pregnancy while a
concentration of less than 5 ng/mL is highly correlated with an
abnormal and nonviable pregnancy
 Diagnosis
2-Ultrasound
In general, a positive β-hCG test with empty uterus by sonar adnexial
mass indicates ectopic pregnancy.

Discriminatory hCG zones:

Diagnosis of ectopic pregnancy is made if there is:
An empty uterine cavity by abdominal sonography with b -hCG
value
above 6000 mIU/ml.
An empty uterine cavity by vaginal sonography with b -hCG
value above 2000 mIU/ml.
Ultrasound
 Diagnosis
3-Culdocentesis
in this test, a needle is inserted into the space at the top of the vagina,
behind
the uterus and in front of the rectum to aspirate fluid and
Determines if there is blood in the space behind the uterus
If non-clotting blood is aspirated from the Douglas pouch ,
intraperitoneal haemorrhage is diagnosed. But if not, ectopic
pregnancy cannot be excluded.
 Diagnosis
4-laparoscopy or laparotomy can also be performed to visually confirm an
ectopic pregnancy. Often if a tubal abortion or tubal rupture has
occurred.
Laparoscopy: an endoscope is inserted through a small incision in the
woman’s abdomen
This allows you to see the fallopian tubes and other organs
This takes place in an operating room with anaesthesia
DIFFERENTIAL
DIAGNOSIS
INCASE OF CHRONIC (SUB
ACUTE) ECTOPIC:

1. Pelvic abscess
2. Pyosalpinx
3. Subserous uterine fibroid
4. Salpingintis
5. Retroverted gravid uterus
6. Appendicular lump
TREATMENT OPTIONS
1.EXPECTANT MANAGEMENT.
2.MEDICAL MANAGEMENT.
3.SURGICAL MANAGEMENT.
1
EXPECTANT
MANAGEME
NT
• Criteria for selection
– asymptomatic women no evidence
of rupture or hemodynamic
instability
– less than 100 ml fluid in the pouch
of Douglas
– hCG less than 1000 iu/l at
initial presentation
– Adnexal mass less than 3cm
– they should 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.
 MONITORING
– I n i ti a l f o l l o w up
• twice we e k l y with s e r i a l
hCGm easurem ents
• w e e k l y b y t r a n s v a g i n a l exa m i n a ti o n s
– B y t h e fi r s t w e e k
• d r o p in HCG l e v e l
• A d n e x a l m a s s si ze
– O t h e r w i s e r e a s s e s s t h e o p ti o n s
(Medical/Surgical)
– I f t h e f a l l o f HCG & r e d u c ti o n in si ze
of
a d n e x a l m a s s s a ti s f a t o r y
• w e e k l y hCG a n d t r a n s v a g i n a l u l t r a s o u n d
• 45–70% o f p re g n a n c i e s o f u n k n o w n
l o c a ti o n r e s o l v e s p o n t a n e o u s l y w i t h
e x p e c t a n t m a n a ge m e nt
• Ec to p i c p r e g n a n c y w a s s u b s e q u e n t l y
d i a g n o s e d in 14–28% o f c a s e s o f
p r e g n a n c y o f u n k n o w n l o c a ti o n
• I n t e r v e n ti o n h a s been s h o w n t o be
r e q u i r e d in 23–29% o f cases.
MEDICAL
MANAGEMENT

2
CRITERIA for MEDICAL
MANAGEMENT
• Selecti on criteria:
-hemodynamically stable
-Serum B-HCG should be less than 3000IU/L
- Tu b a l d i a m e t e r s h o u l d b e l e s s t h a n 4 c m
w i t h o u t a ny fe t a l c a r d i a c a c ti v i t y .
- t h e re s h o u l d b e n o i n t ra - a b d o m i n a l
hemorrhage
SYSTEMIC • Methotrexate

• injections of prostaglandins,
potassium chloride OR
LOCALLY hyperosmolar glucose OR
local methotrexate
 METHOTREXATE
• Methotrexate – a drug that destroys actively growing tissues such as the
placental tissues ,is used as an injection in selected cases to avoid surgery (in
non ruptured ectopic)
• Side effects include abdominal pain for 3 – 7 days in 50% of cases and
mild symptoms of nausea, mouth dryness and soreness and diarrhoea,
– Methotrexate-Intramuscular
– Dose calculated from body surface area
– Usual dose ranges between 75-95 mg
– HCG checked on day 4 & day 7
• If fall is less than 15 % consider second dose of methotrexate

 Anti-D should also be given if required

 Rest up to one hour after the injection.
 Check for any local reaction.
 OUTCOME
– 90% successful treatment with single dose
regime.
– Recurrent ectopic pregnancy rate 10 –
20%.
– Tubal patency approximately 80%.
– 14 % of medical management second dose of
methotrexate
– 75% would experience abdominal pain-
separation pain. This usually occurs between
day 3-7
– 10% would finally require surgical
management
3
SURGICAL
Indications for surgical treatment
• The patient is not a suitable candidate for
medical therapy.
• Medical therapy has failed.
• Cases where B-HCG levels are not decreasing
despite medical therapy.
• The patient is hemodynamically unstable and
needs immediate treatment.
SURGICAL OPTIONS:
The procedure can be done either by
laparoscopically or by laparotomy.

Conservative:
1. Salpingostomy.
2. Salpingotomy.
3. Fimbrial Expression.

Extirpative:
4. Salpingectomy.
5. Segmental ressection.
 Anti D
• Non sensitized women who are rhesus
negative with a confirmed or suspected
ectopic pregnancy should receive anti-D
immunoglobulin.
• In accordance with RCOG Guideline it is
recommended that anti-D immunoglobulin at a
dose of 250 IU (50 micrograms) be given to all
non sensitized women who are rhesus negative
and who have an ectopic pregnancy.
 ADVICE
• Not using IUCD
• Not using progesterone only pills
• Treatment for any PID
• Follow up by HCG that should disappear after 1
month
• Do HSG after 40 day to see patency of the tube
• Use barrier method of contraception
• Timing of pregnancy, visit specialist in any
missed period
THANK
YOU