Management of ectopic pregnancy

a review project

1. prepared byprepared by
M.Sadhana Reddy M.Sadhana Reddy

2. Definition:Definition:

An ectopic pregnancy, or eccysis, is a complication of An ectopic pregnancy, or eccysis, is a complication of
pregnancy in which the embryo implants outside pregnancy in which the embryo implants outside
the uterine cavity. With rare exceptions, ectopic the uterine cavity. With rare exceptions, ectopic
pregnancies are not viable. Furthermore, they are pregnancies are not viable. Furthermore, they are
dangerous for the mother, since internal haemorrhage dangerous for the mother, since internal haemorrhage
is a life-threatening complicatiois a life-threatening complication. n.

6. Classification:Classification:

Tubal pregnancyTubal pregnancy

Nontubal ectopic pregnancyNontubal ectopic pregnancy

Heterotopic pregnancyHeterotopic pregnancy

Persistent ectopic pregnancyPersistent ectopic pregnancy

Pregnancy of unknown locationPregnancy of unknown location

7. The vast majority of ectopic pregnancies implant in The vast majority of ectopic pregnancies implant in
the Fallopian tubethe Fallopian tube. .

8. Nontubal ectopic pregnancyNontubal ectopic pregnancy

Two percent of ectopic pregnancies occur in Two percent of ectopic pregnancies occur in
the ovary, cervix, or are intraabdominal. the ovary, cervix, or are intraabdominal.

9. Heterotopic pregnancyHeterotopic pregnancy

In rare cases of ectopic pregnancy, there may In rare cases of ectopic pregnancy, there may
be two fertilized eggs, one outside the uterus be two fertilized eggs, one outside the uterus
and the other inside. This is called a and the other inside. This is called a
heterotopic pregnancy. heterotopic pregnancy.

10. Persistent ectopic pregnancyPersistent ectopic pregnancy

A persistent ectopic pregnancy refers to the A persistent ectopic pregnancy refers to the
continuation of trophoplastic growth after a continuation of trophoplastic growth after a
surgical intervention to remove an ectopic surgical intervention to remove an ectopic
pregnancy. pregnancy.

For this reason hCG levels may have to be For this reason hCG levels may have to be
monitored after removal of an ectopic monitored after removal of an ectopic
pregnancy to assure their decline, pregnancy to assure their decline,
also methotrexate can be given at the time of also methotrexate can be given at the time of
surgery prophylactically.surgery prophylactically.

11. Pregnancy of unknown locationPregnancy of unknown location

Pregnancy of unknown location (PUL) is the Pregnancy of unknown location (PUL) is the
term used for a pregnancy where there is a term used for a pregnancy where there is a
positive pregnancy test but no pregnancy has positive pregnancy test but no pregnancy has
been visualized using transvaginal been visualized using transvaginal
ultrasonographyultrasonography

Between 30 and 47% of women with Between 30 and 47% of women with
pregnancy of unknown location are ultimately pregnancy of unknown location are ultimately
diagnosed with an ongoing intrauterine diagnosed with an ongoing intrauterine
pregnancypregnancy

12. Signs and symptoms:Signs and symptoms:

Early signs includeEarly signs include
1.Vaginal bleeding1.Vaginal bleeding
2. Abdominal pain2. Abdominal pain
3. Less common features of ectopic 3. Less common features of ectopic
pregnancy nausea, vomiting and diarrhoea.pregnancy nausea, vomiting and diarrhoea.
4. Heavy bleeding4. Heavy bleeding

13. Risk Factor for Ectopic PregnancyRisk Factor for Ectopic Pregnancy

Previous PID – chalamydia infectionPrevious PID – chalamydia infection

Previous ectopic pregnancyPrevious ectopic pregnancy

Tubal ligationTubal ligation

Previous tubal surgeryPrevious tubal surgery

Intrauterine device (IUD)Intrauterine device (IUD)

Prolonged infertilityProlonged infertility

Diethylstilbestrol (DES) exposure Diethylstilbestrol (DES) exposure

Multiple sexual partnersMultiple sexual partners

smoking smoking

14. Clinical Finding:

Variable - Early diagnosisVariable - Early diagnosis
- location of the implantation- location of the implantation
- Whether rupture has occurred- Whether rupture has occurred
 Classic symptom trait with unruptured ectopic Classic symptom trait with unruptured ectopic
pregnancy:pregnancy:
 Amenorrhoea, abdominal pain, abnromal Amenorrhoea, abdominal pain, abnromal
vagina bleedingvagina bleeding
 Classic signs – adnexal or cervical motion Classic signs – adnexal or cervical motion
tenderness.tenderness.
 With ruptured ectopic pregnancy, finding parallel With ruptured ectopic pregnancy, finding parallel
with the degree of internal bleeding and with the degree of internal bleeding and
hypovolemia – abdominal guarding and rigidity, hypovolemia – abdominal guarding and rigidity,
shoulder pain and fainting attacks and shock.shoulder pain and fainting attacks and shock.

15. DiagnosisDiagnosis

Transvaginal ultrasonographyTransvaginal ultrasonography: it has : it has
a sensitivity of at least 90% for ectopic a sensitivity of at least 90% for ectopic
pregnancy. The diagnostic ultrasonographic pregnancy. The diagnostic ultrasonographic
finding in ectopic pregnancy is an adnexal finding in ectopic pregnancy is an adnexal
mass that moves separately from the ovary.mass that moves separately from the ovary.

16. Ultrasonography and β-hCGUltrasonography and β-hCG

Where no intrauterine pregnancy is seen on Where no intrauterine pregnancy is seen on
ultrasound, measuring β-human chorionic ultrasound, measuring β-human chorionic
gonadotropin (β-hCG) levels may aid in the gonadotropin (β-hCG) levels may aid in the
diagnosis. The ration is that a low β-hCG level diagnosis. The ration is that a low β-hCG level
may indicate that the pregnancy is intrauterine may indicate that the pregnancy is intrauterine
but yet too small to be visible on but yet too small to be visible on
ultrasonography. ultrasonography.

The fall in serum hCG over 48 hours may be The fall in serum hCG over 48 hours may be
measured as the hCG ratio, which is calculated measured as the hCG ratio, which is calculated
as: as: hCGratio= hCGat 48h/ hCGat 0h hCGratio= hCGat 48h/ hCGat 0h

17. 
Laparoscopy: for identifying an unruptured Laparoscopy: for identifying an unruptured
tubal pregnancy which is producing tubal pregnancy which is producing
equivocal symptoms and for exclude equivocal symptoms and for exclude
salpingitis and bleeding from small ovarian salpingitis and bleeding from small ovarian
cyst.cyst.
--For operative treatment using minimally For operative treatment using minimally
invasive methods.invasive methods.

18. 
Treatment:Treatment:

If haemorrhage and shock presentIf haemorrhage and shock present

Restore blood volume by the transfusion of red cells Restore blood volume by the transfusion of red cells
or volume expanderor volume expander

Proceed with LaparotomyProceed with Laparotomy

The earlier diagnosis of tubal pregnancy has The earlier diagnosis of tubal pregnancy has
allowed a more conservative approach to allowed a more conservative approach to
management where the tube is less damage.management where the tube is less damage.

Pregnancy removed from the tube by laparoscopy Pregnancy removed from the tube by laparoscopy
(salpingostomy) hopefully retaining tubal function.(salpingostomy) hopefully retaining tubal function.

Trophoblast destroyed by chemotherapeutic agent Trophoblast destroyed by chemotherapeutic agent
such as methotrexatesuch as methotrexate

19. 
Medical ManagmentMedical Managment

Methotrexate 1 mg/kg body weightMethotrexate 1 mg/kg body weight

Indications:Indications:

Haemodynamically stable, no active bleeding Haemodynamically stable, no active bleeding
minimal bleeding and no painminimal bleeding and no pain

No contra indication to methotrexateNo contra indication to methotrexate

Able to return for follow up for several weeksAble to return for follow up for several weeks

Non laparoscopic diagnosis of ectopic pregnancyNon laparoscopic diagnosis of ectopic pregnancy

General anaesthesia poses a significant riskGeneral anaesthesia poses a significant risk

Unruptured adenexal mass < 4cm in size by scanUnruptured adenexal mass < 4cm in size by scan

20. 
HCG does not exceed 5000 IU/LHCG does not exceed 5000 IU/L

Contraindications:Contraindications:

BreastfeedingBreastfeeding

Immunodeficiency / active infectionImmunodeficiency / active infection

Chronic liver diseaseChronic liver disease

Active pulmonary diseaseActive pulmonary disease

Active peptic ulcer or colitisActive peptic ulcer or colitis

Blood disorderBlood disorder

Hepatic, Renal or Haematological Hepatic, Renal or Haematological
dysfunctiondysfunction

21. 
Side Effects:Side Effects:

Nausea & VomitingNausea & Vomiting

Diarrhorea, abdominal painDiarrhorea, abdominal pain

Photosensitivity skin reactionPhotosensitivity skin reaction

Impaired liver function, Impaired liver function,

PneumoniaPneumonia

Severe neutropeniaSevere neutropenia

Reversible alopeciaReversible alopecia

22. 
Treatment EffectsTreatment Effects::

 Abdominal pain (2/3 of patient)Abdominal pain (2/3 of patient)

 HCG during first 3 days of treatmentHCG during first 3 days of treatment

Vaginal bleedingVaginal bleeding

Signs and Treatment failureSigns and Treatment failure

Significantly worsening abdominal pain, regardless Significantly worsening abdominal pain, regardless
of change in serum HCG of change in serum HCG

Level of HCG do not decline by at least 15% Level of HCG do not decline by at least 15%
between Day 4 & 7 post treatmentbetween Day 4 & 7 post treatment

 or plateauing HCG level after first week of or plateauing HCG level after first week of
treatmenttreatment

23. SURGICAL MANAGEMENT:SURGICAL MANAGEMENT:

Laparoscopy approach – Laparoscopy approach – incise the affected incise the affected
Fallopian and remove only the pregnancy Fallopian and remove only the pregnancy
(salpingostomy) (salpingostomy)
remove the affected tube with the pregnancy remove the affected tube with the pregnancy
(salpingectomy).(salpingectomy).

25. 1. Positive pregnancy test
Lower abdominal pain +
Minimal Vaginal bleeding
Asymptomatic with factors
for ectopic pregnancy
Risk factors
Previous ectopic pregnancy
Previous PID
Tubal surgery
Tubal pathology (PID, endometriosis
Infertility, ovarian stimulation
Sterilization failure
Previous abdominal surgery
DES exposure in utero
Multiple sexual partners
2. History + clinical examination
MANAGEMENT OF ECTOPIC PREGNANCY

26. Regular cycle, i.e.
>6 wks. gestation,
Arrange TV ultrasound
irregular cycle,
Measure serum hCG
If hCG <100
(?early Intrauterine/
? Ectopic pregnancy
If Hcg >1000, susept
Ectopic pregnancy
3. Empty uterus + serum hCG > 1000
Meet criteria for
Methorexate treatment
Does not meet criteria
for methotrexate treatment
Use methotrexate
protocol
Laproscopic /salpingotomy/
Salpingectomy ?Proceed to
laparotomy OR Laparotomy if
haemodynamically unstable