Ectopic pregnancy

Ectopic pregnancy

1. Ectopic pregnancy Mohammad Yahya tailakh 5 th year medical student University of Jordan

2. DEFINITION “Any pregnancy where the fertilized ovum gets implanted & develops in a site other than normal uterine cavity”. Ectopic pregnancy is accounted for 2% of all pregnancies, and is the most common cause of maternal death during the first trimester (usually week 6-8 of pregnancy ) It represents a serious hazard to a woman’s health and reproductive potential, requiring prompt recognition and early aggressive intervention.

3. Sites: 1-Fallopian tubes in 95% of the cases -Ampulla ( most common site ) which is the widest part ( 5-6 cm) -Isthmus -Fimbria 2- Uterine Cornua or uterine horns . Which is the meeting point of the uterus and the fallopian tubes. This site of ectopic pregnancy is the most dangerous of all due to the high risk of rupture. This case needs around 10 weeks to appear. 3- Cervical Implantation ( 0.2%) 4- Ovarian Implantation (0.2%) 5- Abdominal Implantation (2%) This type may reach term.

4. Risk factors 1-The most important risk factor is previous history of ectopic pregnancy. ( 30% risk of recurrence) 2-Pelvic inflammatory disease (PID) and STD infections Any Assisted Reproductive techniques (ART) for eg , IVF History of any pelvic or tubal surgeryHistory of any pelvic or tubal surgery Contraceptive methods like Intrauterine device (IUD) . Smoking. Any congenital malformations of the tubes or the uterus

5. Signs and symptoms The classic clinical triad of ectopic pregnancy is as follows: Abdominal pain Amenorrhea Vaginal bleeding Unfortunately, only about 50% of patients present with all 3 symptoms.

6. Patients may present with other symptoms common to early pregnancy ( eg , nausea, breast fullness). The following symptoms have also been reported: Painful fetal movements (in the case of advanced abdominal pregnancy) Dizziness or weakness Fever Flulike symptoms Vomiting Syncope Cardiac arrest

7. The presence of the following signs suggests a surgical emergency: Abdominal rigidity Involuntary guarding Severe tenderness Evidence of hypovolemic shock ( eg , orthostatic blood pressure changes, tachycardia)

8. Findings on pelvic examination may include the following: The uterus may be slightly enlarged and soft Uterine or cervical motion tenderness may suggest peritoneal inflammation An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary Uterine contents may be present in the vagina, due to shedding of endometrial lining stimulated by an ectopic pregnancy

9. INVESTIGATIONS: Serum β- HCG levels In a normal pregnancy, the β- HCG level doubles every 48-72 hours until it reaches 10,000-20,000mIU/ mL. In ectopic pregnancies, β- HCG levels usually increase less. Mean serum β- HCG levels are lower in ectopic pregnancies than in healthy pregnancies. No single serum β- HCG level is diagnostic of an ectopic pregnancy. Serial serum β- HCG levels are necessary to differentiate between normal and abnormal pregnancies and to monitor resolution of ectopic pregnancy once therapy has been initiated.

10. *Progesterone level - greater than 20 micrograms/ml indicates good pregnancy and less than 5 micrograms/ml is a bad indicator ( ectopic or abortion) Anything in between 5-20 microgram/ml is a grey zone and not indicative. - Ultrasound imaging : it is usually inconclusive but the U/S findings suggestive of ectopic preg ; - ABSENT intrauterine sac and the presence of ectopic sac - complex adnexal mass -Free fluid in cul de sac ( ruptured ectopic pregnancy) VALUES of discriminatory beta HCG: On ABDOMINAL U/S  6,000-6,500 m IU/ml On Transvaginal U/S 1,500-1,800 m IU/ml

11. Arias-Stella reaction (ASR) This finding may provide initial histologic "clue" of ectopic pregnancy

12. Differential diagnosis: Differential diagnosis of first trimester bleeding : -Ectopic pregnancy -Recent Abortion -Molar pregnancy the symptomatic picture of ectopic pregnancy: Appendicitis, salpingitis, ruptured corpus luteum…

13. Management: The method of management depends greatly on the hemodynamic stability of the patient, so the vital signs indicates instability (hypotension) or decreased level of consciousness or life threatening bleeding Laparotomy is indicated. observation: Indicated when: the patient is stable without any significant bleeding or pain/ the site of implantation is the tube/ size of gestational sac< 4 cm , FALLING beta HCG levels .

14. Medical management (METHOTREXATE): If the patient is stable, no IUP ,gestational sac < 3.5 cm and no FHA, but suffering of significant pain or bleeding, METHOTREXATE is the drug of choice . MTX is an antimetabolite (folate antagonist). Usually, it is given as a single shot at a dose of 50 mg/m2 IM. Then Beta HCG is followed after 3-7 days a drop in the levels of beta HCG of about 15% indicates successful treatment. Beta HCG levels should be followed up till levels are 0-5. If serum levels were in plateau or the drop was less than 15%, a second dose of MTX should be given after 2 weeks. However if the level increased or if the patient became symptomatic, Surgery is indicated .

15. Surgical Management : It is indicated if the patient was hemodynamically unstable (laparotomy) or failure of medical treatment, or if FHA is present, or gestational sac size is > 4cm. If the patient is stable, but has one of these indications, laparoscopy is done. Salpingectomy ; removal of the tube.  no need for follow up of beta HCG levels. Salpingostomy ; Incision on the antimesentric portion of the tube is made, then after removal of products of conception, the tube is sutured.  Used for unruptured distal tube ectopic preg . Salpingotomy : The same procedure as salpingostomy however the incision is not sutured and is left to heal by secondary intention. In Salpingostomy and salpingiotomy , beta HCG levels should be followed up as in medical treatment. ( till levels are 0-5 )

16. Contraindications of Methotrexate: -Unstable patient Beta HCG levels > 5,000 -Fetal heart activity or any intrauterine pregnancy evidence -free fluid in cul de sac ( indicating ruptured ectopic preg . ) -Active Peptic ulcer disease -Active pulmonary/ renal/ hepatic disease -Breast feeding - MTX sensitivity - Moderate/severe Anemia/ Thrombocytopenia / Leukopenia -Leukemia Note: Do not use MTX with NSAID, since this combination may potentiate nephrotoxicity

17. Thank you