Ectopic Pregnancy4

8/17/2019 Ectopic Pregnancy4

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Benha University Hospital, Egypt

Aboubakr Elnashar



Definition

Implantation of the fertilized ovum outside the normaluterine cavity.

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IncidenceIncreased dramatically in the past few decades

1970: 4.5/1,000 pregnancies1992: 19.7/ 1,000 pregnancies

From 1947 to1967: only 8.5% of EPs were

diagnosed before rupture (Breen, 1970)

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Risk factors(Meta- analyses: Ankum et al 1996; Mol et al 1997& Skjeldestad 1998)

Risk Factor Relative Risk (Fold)

1-Tubal surgery 21.0

2-Tubal Sterilization 9.3

3-Previous Ectopic 8.0

4-Previous Salpingitis 6.0

5-DES Exposure 5.0

6-Contraceptive 4.5

7-Assisted reproduction 4.0

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Ectopic pregnancy/1000 Woman-

Years (Sivin &Steren,1994)

All U.S. women 1.50

Noncontraceptive users 3.00

Copper T-380 IUD 0.20

Progesterone IUD 6.80

Levonorgestrel IUD 0.20

Norplant 0.28

So Tcu-380A and the Levonorgestrel IUD are acceptable choices

for women with previous ectopic pregnancies. Aboubakr Elnashar



ART

increase the incidence of tubal &

heterotopic pregnancy.

Heterotypic pregnancy:

was 1/ 30,000

now 1/7000.

After superovulation or ART: 1/ 100-

900 (Savare et al ,1993)

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Clinical presentationSymptoms

Abdominal pain 95%

Amenorrhoea 80%

Vaginal bleeding 70% Pregnancy sympt 20%

Dizziness or syncope 50%

Gastrointestinal sym 80%

The most important sign isabdominal pain

Signs

Adnexal tender 80%

Abd. tender 90% Adnexal mass 50%

Uterine enlarg 25%

Fever 5%

The most important sign isadnexal tenderness that isaggravated by moving thecervix sideways (cervical

excitation).

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2. Subacute cases:

Frequently give rise todiagnostic confusion

3. Asymptomatic cases:

suspected early in high-risk

women.

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Uncommon Sites of Ectopic

Pregnancy

(I) Cornual angular pregnancy:

Implantation in the interstitial portion

of the tube.

Uncommon but dangerous {when

rupture occurs bleeding is severeand disruption is extensive that it

needs hysterectomy}.

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(IV) Ovarian pregnancy:

Etiology:

1. Pelvic adhesions.

2. O varian endometriosis.

Pathogenesis:

Fertilization of the ovum inside the ovary or ,

Implantation of the fertilized ovum in the ovary.

Spiegelberg criteria:

1. Gestational sac

located in the region of the ovary,attached to the uterus by the ovarian ligament,

Its wall contain ovarian tissue

2. The tube on the involved side is intact. Aboubakr Elnashar

V) Abd i l



V) Abdominal pregnancy:

1. Primary :

in the peritoneal cavity from the start. 2. Secondary :

after tubal rupture or abortion.

3. Intraligamentous pregnancy:abdominal but extraperitoneal, betweenthe anterior and posterior leaves of the

broad ligament after rupture of tubalpregnancy in the mesosalpingeal border.

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Heterotopic ectopic pregnancy:

Incidence:

Increased with fertility treatments reaching 1/100 Diagnosis:

extremely difficult

50% identified after tubal rupture.

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Sh ld b id d



Should be considered:

1. After ART

2. Persistent or rising HCG levels after D & C for

spontaneous or induced abortion

3.uterine fundus > menstrual date

4. more than one corpus luteum

5. Absence of vaginal bleeding in presence of S& S ofectopic pregnancy

6. Ultrasound evidence of uterine & extrauterine

pregnancy

Treatment:

If retention of the intrauterine gestation is desired, the

ectopic pregnancy must be treated surgically.

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Multifetal tubal pregnancy

Twin tubal pregnancy has been reported with

both embryos in same tube as well as one

in each tube

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(1) S ß hCG



(1) Serum ß hCG:

Urine pregnancy tests are positive in only 50-60% of

ectopic.

Serum ß hCG:

more sensitive

can detect very early pregnancy about 10 days after

fertilization i.e. before the missed period. Detection level: 25 mu/Ml

Negative test: exclude EP in > 98% of cases.

Useful in:-

1. Acute cases

2. Sub acute (D.D. of extra-uterine causes)

(Barnes etal, 1985; Cartwrighte et al, 1986; Kim and Fox; 1999) Aboubakr Elnashar



Quantitative ß sub HCG

Detection Level= 5 mIU/mL

•Discriminatory zone:

TVS: 1500-2000 mIU/mL

TAS: 6000 mIU/mL

•Empty uterus + HCG >1500mu/mL= 100% ectopic

(Barnhart et al,1994)

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2 Ult h



2. Ultrasonography

A.Uterine

1. No IU gestational sac2. Pseudogestational sac (a fluid collection or debris in

the cavity)

10-20% of Ectopic P.

No double decidual sac sign

No yolk sac or embryo

Not eccentric (within the cavity)

3. No yolk sac in a G. sac > 20 mm

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B Ad l



B. Adnexal

1. Non cystic mass: (Blob sign)

inhomogeneous small mass

next to the ovary with no sac or embryo.

By pressing the vaginal probe gently against the ectopic

it moves separately to the ovary.

The most appropriate sign.

Sensitivity 84% & specificity 99%

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2 C stic mass



2. Cystic mass:

3. Ring: (Bagel sign)

hyperechoic ring around the gestational sac4.Sac & embryo.

Ipsilateral side: Corpus luteum: 85% of cases

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C D h



C. D. pouch:

Fluid with or without blood clots

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Discriminatory zones:



Discriminatory zones:

Diagnosis of ectopic pregnancy is made if there is:

1. An empty uterine cavity by TAS with ß hCG > 6000

mIU/ml.

2. An empty uterine cavity by TVS with ß hCG >1500-

2000 mIU/ml.

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TVS Versus TAS



TVS Versus TAS

1-IUG sac can be excluded 1-2 w earlier than TAS.

2. Discrimination Zone is (1500 Vs 6000 mu/ml)

3-More ability to detect the adnexal mass

4- Early detection of cardiac activity .

5- More ability to dd true from pseudo-sac

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Uterine:



True sac

False sac

Uterine:

Double Decidual Sac Sign: Twoconcentric reflective rings

The outer is the reflective ring ofdecidua vera

The inner is the reflective ring of

combination of chorion & decidua

capsularis

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Non cystic mass

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ov

Cystic mass

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Ring

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U

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Abdominal



Cervical pregnancy

Abdominal

pregnancy

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(3) Serum Progesterone:



(3) Serum Progesterone:

lower in ectopic than normal pregnancy

usually <15ng/ml.

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(4) Culdocentesis:



(4) Culdocentesis:

Non-clotting blood: intraperitoneal hge.

if not: ectopic pregnancy cannot beexcluded.

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(5) Curettage:



(5) Curettage: Helpful when:

HCG < 2000 mU/mL & non-rising(Stovell et al ,1992)

1. IU abortion:decidua & chorionic villi.

2. Ectopic:

Decidua only or

Arias Stella reaction in the endometrium as well cellularatypism, mitotic activity and glandular proliferation

3. IU complete abortion:

Decidua only

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6. Laparoscopy



6. Laparoscopy

The need decreased after the use of B-HCG &

TVS (Speroff et al, 1999)

Indications:

1-Definite diagnosis if there is doubt

2-Concurrent operative Laparoscopy

3-Local injection of chemotherapeutics

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(7) CBC:



( )

Hgb & hct:

assess anemia.

Leucocytic count:

exclude infections as appendicitis & salpingitis.

(8) Special investigation: (abdominal pregnancy)

MRI:

preoperative detection of placental anatomic

relationships

Plain X-ray:shows abnormal lie.

In lateral view the fetus overshadows the maternal

spines Aboubakr Elnashar



B. Intrauterine Pregnancy



g y

Exclude by:

1-Clinical Characteristics.2- Quantitative B sub unit HCG.

3- TVS .

4-Laparoscopy.

5-Curettage

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Suspected Ectopic Pregnancy



S. B HCG levcl Mu/mL

<2000 >2000

Ectopic PRepeat in 2-3 D

Abnormal rise Normal rise IUP

Activemanagement

p p g yPositive B Qualitative B-HCG 25mu/Ml

No Sac

TVS

IUPExtr UP

Activemanageme

nt

B HCG level mu/ml

Aboubakr Elnashar

Suspected Ectopic Pregnancy Cont



Failed IUP

Decreasing

Villi identified No Villi

Rising or

plateauing

Follow HCG until negative

Repeat HCG in 2-3 D

Expectant

Active

management

Suspected Ectopic Pregnancy Cont.

Uterine Curettage

Abnormal S. B HCG rise

Laparoscopy

>2000 Mu/mL <2000 Mu/mL

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A. Active B. Expectant

I. Surgical T. II. Medical T.

1. Laparoscopy 2.Laparotomy

Salpingectomy Salpingotomy

Systemic Local

Kim and Fox, 1999 Aboubakr Elnashar



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1. Laparoscopy

Indication:Haemodynamically stable patient

(RCOG Recommendations, Grade A)

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laparoscopic surgery appears to be the tt of



laparoscopic surgery appears to be the tt of

choice (Cochrane library,2002).

• Compared to open surgery, laparoscopicconservative surgery was:

*less successful in the elimination of tubal

pregnancy {higher persistence of trophoblast}

*Safe

*comparable intrauterine pregnancy

*less costly

*lower repeat ectopic pregnancy rate. Aboubakr Elnashar

A Salpingectomy:



A. Salpingectomy:

Indications :

1. Childbearing completed.

2. Second ectopic pregnancy in the same tube.

3. Uncontrolled bleeding.

4. Severely damaged tube (Kim and Fox,1999)

. In the presence of a healthy contralateral tube thereis no clear evidence that salpingotomy should beused in preference to salpingectomy(RCOG Recommendations May 2004 “Grade B”)

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Indications



(RCOG Recommendations,2004 Grade B)

Contralateral tubal disease and desire for

future fertility.

Women must be made aware of the risk of

a further ectopic pregnancy.

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B. Salpingotomy N t f bl



Not preferable:

*IU pregnancy rates were similar (salpingotomy 60% vs

54%)

*1. Trend toward lower repeat ectopic pregnancy rates

(salpingeotomy 18% vs 8%).

2. Trend towards higher rates of persistent trophoblast

(RCOG May 2004, Evidence level IIa)

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Operative Complications: Bleeding from FallopianTube



Tube

Occurs during:

salpingotomy or

extraction of ectopic pregnancy. Prevention:

Careful manipulations.

Injection of petrissin in the mesosalpinx.

Treatment:

Grasping the bleeding point for 5 m with raising of thetube to kink blood flow

Bipolar coagulation or endocoagulation of bleeding point

Laparoscopic salpingectomy.

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2 Laparotomy



Indications ( Kim and Fox, 1999)

* Hemodynamical unstability.

* Laparoscopic contraindication: obesity or

severe adhesions

* Surgeon is not trained in laparoscopic

surgery

* Necessary laparoscopic equipment is not

available

2. Laparotomy

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Persistent Trophoblast



Incidence (Graczykowski and Mishell 1997):

5% after laparotomy

10% after laparoscopy

15% after Salpingostomy

Factors that increasing the risk:

1. Higher preoperative serum hCG levels (>3000 iu/l2. Rapid preoperative rise in serum hCG

3. The presence of active tubal bleeding(RCOG May 2004 Evidence level IV)

Prophylaxis:

Single dose Methot 1mg/kg

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Prophylactic Methotrexate:



(Gracia et al,2002)

single dose 1 mg/kg after laparoscopic

salpingostomy: Reduce

risk of tubal rupture by 90%,

need for additional surgery by 60%,costs by 46%.

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1.Systemic2. Local

Methotrexate is the drug of choice(Cochrane library,2002).

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Indications of medical treatment:(Stovall et al 1991,, Gross et al 1995& Alito et al 1999)



(Stovall et al 1991,, Gross et al 1995& Alito et al 1999)

1. The Patient:

hemodynamically stable.

Healthy

(SGOPT<50U, creatinine <1.3 mg/ml& WBC >3000mm3)

2. U/S:

Gestational sac <4 cm

No intrauterine pregnancy.

No evidence of rupture (haemoperitoneum)

No fetal cardiac activity

3. HCG:

< 10,000 IU/mL.

Best results when <3,000 (RCOG,2004) Aboubakr Elnashar

Women should be given clear information



Women should be given clear information

(preferably written) about the possible need for

further treatment & adverse effects following

treatment.

Women should be able to return easily for

assessment at any time during follow-up(RCOG, Grade B)

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1 Systemic:



1. Systemic: A. Single-dose

(50 mg/m2) I.M.

In UK• The most widely used medical tt

• Serum hCG: checked on days 4 & 7

• Further dose: if hCG failed to fall by > 15%

• Surface area: 4wt+7/wt+90 or from table

• Results:

Success rate: 80-90% (Lipscomb et al, 1998; Morlock, 2000).

15%: require more than one dose .10%: require surgical intervention.

• cost-effective (Lecuru et al, 2000; Morlock, 2000)

• Side effect: <1 % (Speroff, 1999)

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B. Multi-doseP t l



Protocol:

In USA

1 mg/kg

on days 1,3,& 5 with

folonic acid rescue

on days 2,4 & 6

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Methotrexate in a single dose IM is not effective

enough to advocate its routine use

(Cochrane library,2002).

• Additional injections for inadequately declining serum

hCG concentrations are frequently necessary.

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Document tubal gestation as defined by BhCG &T.V.S.

I. Ensure the following criteria are met:



BhCG <10,000 mIu/ml

Tubal diameter <3.5 cm

Absence of fetal heart

II. Inform the patient about:

Alternative therapeutic optionsPossible side effect

Risk of treatment failure

Prospect of future fertility

III. If medical treatment is chosen:

Day 1: FBC, LFT, KFT, If Rh – Ve, Anti D

Do not start medical treatment if unsatisfactory

If BhCG <5,000 mIu/ml

Single dose methotrexate regimen

If BhCG >5,000 mIu/Ml

Two doses methotrexate regimen

IV. On discharge: Inform patient:

If abd pain {as the pregnancy resolves}: simple analgesia

Avoid intercourse until follow is complete

Contraception for 3 ms.

Avoid herbal remedies &vit preparation containing folate.

Contact ER if concerns regarding pain or bleeding.

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Single dose methotrexate regimen:



Day 1: Methotrexate 50 mg/m2 I.M.

Day 4: BhCG

Day 7: FBC, BhCG, LFT, KFTD14: FBC, BhCG

Weekly BhCG unitl BhCG <25 mIu/ml

If BhCG doesn’t fall by more than 15% between D4 –

D7 administer 2nd doseIf 2nd dose is administered:

Day 7: have NL LFT, injection should be given in

opposite gluteal.

Day 11: BhCG

Day 14: FBC, BhCG, LFT, KFT

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2. Local:



A. Laparoscopic

B. Transvaginal

There is no place for local methotrexate under

laparoscopic guidance (Cochrane library,2002):

1.less effective than laparoscopic salpingostomy in

the elimination of tubal pregnancy.

2. The risks of anesthesia and trocar insertion

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• Compared to laparoscopic adminstration ofmethotrexate transvaginal administration of



methotrexate, transvaginal administration of

methotrexate under sonographic guidance is:

1- less invasive and

2- More effective

3- Requires visualization of an ectopic gestational

sac and specific skills and expertise of the clinician.

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Indications ( RCOG, 2004 Grade C)



1. Patient:

Clinically stable or asymptomatic

2. US:

Unruptured mass <4 cm

3. HCG:

Initially < 1000 iu/l

Decreasing level

Clear information (preferably written) about the

importance of compliance with follow-up

Should be within easy access to the hospital

treating them.

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Follow up:



p

1. HCG:

Twice weekly (< 50% of its initial level within 7d)Then weekly until < 20 iu/l

2. TVS: weekly (reduction in the size) .

Indication of active intervention(RCOG 2004)

If symptoms of ectopic pregnancy occur

Serum hCG levels rise above 1000 iu/l

Levels start to plateau.

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The 18- month cumulative rate



of IU Pregnancy (Bouyer et al 2000)

Salpingectomy * 57

Salpingostomy

Salpingotomy

Methotrexate (systemic)

% of IUP

}* 73

80

P < 0.01

* Pregnancy was very similar if there is no fertility factor

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Pregnancy of unknown location

PUL

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Progesterone



nmol/L

>60

Viable IUP

<20

Probablefailing PUL

Repeat HCGin 1W

Ng/ml=3.18 nmol/L

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Ectopic Pregnancy4