ECTOPIC PREGNANCY.pptx risk factors , symptoms and signs, type, investigation ,diagnosis and management

An ectopic pregnancy is any pregnancy implanted outside of uterine cavity.

1. ECTOPIC PREGNANCY Presented by Dr. SANA MUNAWAR PGR OBS AND GYNAE UNIT 3

2. WHAT IS ECTOPIC PREGNANCY? An ectopic pregnancy is any pregnancy implanted outside of the endometrial cavity. 

3. RISK FACTORS Risk factors for ectopic pregnancy include : Tubal damage following surgery or infection Smoking History of pelvic inflammatory diseases History of endometriosis History of ectopic pregnancy H/O assisted conceptions However, the majority of women with an ectopic pregnancy have no identifiable risk factor.

4. SYMPTOMS OF ECTOPIC PREGNANCY Symptoms of ectopic pregnancy include: Common symptoms: abdominal or pelvic pain amenorrhoea or missed period vaginal bleeding with or without clots

5. O ther reported symptoms: breast tenderness gastrointestinal symptoms dizziness, fainting or syncope shoulder tip pain urinary symptoms passage of tissue rectal pressure or pain on defecation

6. SIGNS OF ECTOPIC PREGNANCY Ectopic pregnancy can present with a variety of signs on examination more common signs: pelvic tenderness adnexal tenderness abdominal tenderness

7. Other reported signs: cervical motion tenderness rebound tenderness pallor abdominal distension enlarged uterus tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg) shock or collapse orthostatic hypotension.

8. Types of ectopic pregnancy Tubal pregnancy Interstitial pregnancy Cervical pregnancy Caesarean scar pregnancy Cornual pregnancy Ovarian pregnancy Abdominal pregnancy Heterotropic pregnancy

9. DIAGNOSIS OF ECTOPIC PREGNANCY History collection Physical examination: pelvic exam to check for pain, tenderness or a mass . Urine pregnancy test

10. Ultrasound Transvaginal ultrasound is the diagnostic tool of choice for tubal ectopic pregnancy. an adnexal mass, moving separate to the ovary (sometimes called the 'sliding sign'), comprising a gestational sac containing a yolk sac . or • an adnexal mass, moving separately to the ovary, comprising a gestational sac and fetal pole (with or without fetal heartbeat).

11. When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating a possible ectopic pregnancy: an empty uterus .or a collection of fluid within the uterine cavity (sometimes described as a pseudo-sac; this collection of fluid must be differentiated from an early intrauterine sac, which is identified by the presence of an eccentrically located hypoechoic structure with a double decidual sign [gestational sac surrounded by 2 concentric echogenic rings] in the endometrium).

12. Serum beta HCG Use serum hCG measurements only for assessing trophoblastic proliferation to help to determine subsequent management. Take 2 serum hCG measurements as near as possible to 48 hours apart (but no earlier) to determine subsequent management

13. DIAGNOSIS OF CERVICAL PREGNANCY The following ultrasound criteria have been described in the diagnosis of cervical ectopic pregnancy: 1. Empty uterine cavity. 2. A barrel-shaped cervix. 3. A gestational sac present below the level of the internal cervical os . 4. The absence of the ‘sliding sign’. 5. Blood flow around the gestational sac using colour Doppler.

14. The ‘sliding sign’ enables cervical ectopic pregnancies to be distinguished from miscarriages that are within the cervical canal. When pressure is applied to the cervix using the probe, in a miscarriage, the gestational sac slides against the endocervical canal, but it does not in an implanted cervical pregnancy

15. DIAGNOSIS OF CAESAREAN SCAR PREGNANCY The diagnostic criteria described for diagnosing caesarean scar implantation on transvaginal ultrasound include: 1. Empty uterine cavity. 2. Gestational sac or solid mass of trophoblast located anteriorly at the level of the internal os embedded at the site of the previous lower uterine segment caesarean section scar. 3 . Thin or absent layer of myometrium between the gestational sac and the bladder. 4. Evidence of prominent trophoblastic/placental circulation on Doppler examination. 5. Empty endocervical canal

16. Diagnosis of cornual pregnancy The following ultrasound scan criteria can be used for the diagnosis of cornual pregnancy Visualisation of a single interstitial portion of fallopian tube in the main uterine body. Gestational sac/products of conception seen mobile and separate from the uterus and completely surrounded by myometrium. A vascular pedicle adjoining the gestational sac to the unicornuate uterus

17. DIAGNOSIS OF INTERSTITIAL PREGNANCY Interstitial pregnancy occurs when the ectopic pregnancy implants in the interstitial part of the fallopian tube.

18. Ultrasound criteria have been described for the diagnosis of interstitial pregnancy. These include: 1. Empty uterine cavity. 2. Products of conception/gestational sac located laterally in the interstitial (intramural) part of the tube and surrounded by less than 5 mm of myometrium in all imaging planes

19. On MRI examination, a gestational sac-like structure is seen lateral to the cornua surrounded by the myometrium. The presence of the intact junctional zone ( endomyometrial junction) between the uterine cavity and the gestational sac-like structure also supports the diagnosis

20. DIAGNOSIS OF OVARIAN PREGNANCY There are no specific agreed criteria for the ultrasound diagnosis of ovarian ectopic pregnancy It can be difficult to distinguish ovarian ectopic pregnancies from corpus luteal cysts, tubal ectopic pregnancy stuck to the ovary, a second corpus luteum , ovarian germ cell tumours and other ovarian pathologies, diagnosis is usually confirmed surgically and histologically

21. DIAGNOSIS OF ABDOMINAL PREGNANCY T he following ultrasound criteria is diagnostic of an early abdominal pregnancy: 1. Absence of an intrauterine gestational sac. 2. Absence of both an evident dilated tube and a complex adnexal mass. 3. A gestational cavity surrounded by loops of bowel and separated from them by peritoneum

22. MRI can be a useful diagnostic adjunct in advanced abdominal pregnancy and can help to plan the surgical approach

23. HETEROTROPIC PREGNANCY A heterotopic pregnancy is diagnosed when the ultrasound findings demonstrate an intrauterine pregnancy and a coexisting ectopic pregnancy Heterotopic pregnancy should be considered in all women presenting after assisted reproductive technologies, in women with an intrauterine pregnancy complaining of persistent pelvic pain and in those women with a persistently raised b- hCG level following miscarriage or termination of pregnancy

24. MANAGEMENT OF ECTOPIC PREGNANCY EXPECTANT MANAGEMENT Offer expectant management as an option to women who: • are clinically stable and pain free • have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on trans vaginal ultrasound scan • have serum hCG levels of 1,000 IU/L or less • are able to return for follow-up

25. For women with a tubal ectopic pregnancy being managed expectantly, repeat hCG levels on days 2, 4 and 7 after the original test and: • if hCG levels drop by 15% or more from the previous value on days 2, 4 and 7, then repeat weekly until a negative result (less than 20 IU/L) is obtained or • if hCG levels do not fall by 15%, stay the same or rise from the previous value, review the woman's clinical condition and decide further management.

26. MEDICAL MANAGEMENT Methotrexate at a dose of 50 mg/m2 has been widely used It is a type of medicine that interferes with DNA synthesis and stop cells from dividing and multiplying

27. A good candidate for methotrexate has the following characteristics: haemodynamic stability low serum b- hCG , ideally less than 1500 iu /l but can be up to 5000 iu /l no fetal cardiac activity seen on ultrasound scan certainty that there is no intrauterine pregnancy willingness to attend for follow-up no known sensitivity to methotrexate.

28. NICE recommends that methotrexate should be the first-line management for women who are able to return for follow-up and who have: no significant pain an unruptured ectopic pregnancy with a mass smaller than 35 mm with no visible heartbeat a serum b- hCG between 1500 and 5000 iu /l no intrauterine pregnancy (as confirmed on ultrasound scan

29. For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman's condition for further treatment

30. SIDE EFFECTS OF METHOTREXATE Bone marrow supression Pulmonary fibrosis Non specific pneumonitis Liver cirrhosis Renal failure Gastric ulceration Flatulence Bloating Stomatitis Mild elevation in liver enzymes

31. Contraindications to methotrexate Hemodynamic instability presence of intrauterine pregnancy Breast feeding If unable to comply with followup Known sensitivity to methotrexate Chronic liver disease Immunodeficiency Peptic ulcer disease Pre existing blood dyscrasia

32. Surgical management Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following: an ectopic pregnancy and significant pain an ectopic pregnancy with an adnexal mass of 35 mm or larger an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan an ectopic pregnancy and a serum hCG level of 5,000 IU/litre or more.

33. Laparoscopy: When surgical treatment is indicated for women with an ectopic pregnancy, it should be performed laparoscopically whenever possible, taking into account the condition of the woman and the complexity of the surgical procedure.

34. SALPINGECTOMY AND SALPINGOTOMY Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility. Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage. Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy.

35. For women who have had a salpingotomy , take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained. Advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive.

36. Complications The most common complication is rupture with internal bleeding which may lead to hypovolemic shock or even death. Emergency laparotomy is needed in case of rupture. Other complications may include recurrence, infertility, chronic ectopic pregnany leading to formation of pelvic mass.

37. ANTI D IMMUNOGLOBULINS PROPHYLAXIS Offer anti-D immunoglobulin prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy