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    4 5863767301307762593

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    ECTOPIC PREGNANCY

    Objectives
     By the end of this lecture the students should be able :-
    1. Define ectopic pregnancy.
    2. list sites where ectopic pregnancies may implant.
    3. Specify predisposing/etiologic factors.
    4. Describe clinical features .
    5. To review different strategies for management.

    24/02/2020
    Ectopic Pregnancy 2
    16:41
    ECTOPIC PREGNANCY

    DEFINITION

    The implantation of a pregnancy


    outside the normal uterine cavity

    24/02/2020
    Ectopic Pregnancy 3
    16:41
    INCIDENCE
    One in 80 pregnancies

     incidence of ectopic pregnancy has been rising in


    many countries.???
     The incidence of a heterotopic pregnancy in the
    general population is low (1:25,000–30,000), but
    significantly higher IVF treatment (1%).
     The recurrence rate is 15% after the first ectopic
    pregnancy, and 30% after the second

    Ectopic Pregnancy 4 24/02/2020 16:41


    Sites:
     Most common site is the fallopian tube(95%)
     74 % in the ampulla,
     12 %in the fimbria
     12 %in the isthmus
     2% in the interstitial portion.
     Less commonly.
     Ovaries (3 per cent)
     Peritoneal cavity (1 per cent).
     Cervix-0.2%
    Ectopic Pregnancy 5 24/02/2020
    16:41
    SITES OF ECTOPIC PREGNANCY

    Ampulla (>95%) Peritoneal cavity (1%)


    Isthmus (12%)

    Cornual (< 2%)


    Ovary (3%)
    Cervix (< 2%)

    1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian


    6)Cervical 7)Cornual-Rudimentary horn 8)Secondary
    abdominal 9)Broad ligament 10)Primary abdominal
    Ectopic Pregnancy 6
    24/02/2020
    16:41
    AETIOLOGY
     Any factor that causes delayed transport of the
    fertilised ovum through the fallopian tube favours
    implantation in the tubal mucosa itself thus giving
    rise to a tubal ectopic pregnancy.
     These factors may be Congenital or Acquired.
     Risk factors:
     Previous Tubal surgery
     H/o pelvic inflammatory disease(40%).
     Previous ectopic pregnancy
     Contraception-IUD use, Progestine-only pile
    7 24/02/2020
    Ectopic Pregnancy 16:41
    CLINICAL PRESENTATION
     Symptoms f pregnancy
     The majority of patients with an EP present with a
    subacute clinical picture of abdominal/pelvic pain
    and/or vaginal bleeding in early pregnancy
     Rarely, patients present very acutely with rupture of
    the EP and massive intraperitoneal bleeding.
     Shoulder tip pain
     Syncope
     Amenorrhea of short period
    24/02/
    Ectopic Pregnancy 8 2020
    16:41
    Examination
     Signs of anemia.
     Signs of hypovolaemic shock(rupture EP)
     Bimanual examination:
     Tenderness in the fornices
     Cervical excitation,
     A palpable Pelvic Mass
     Uterine size is normal in size ( 70%)

    24/02/
    Ectopic Pregnancy 2020 9
    16:41
    Diagnosis

     History and Physical Exam


     Serial Quantitative β-hCG
     Ultrasound
     Culdocentesis
     Laparoscopy( this can be used to diagnose
    and treat ectopic pregnancy

    24/02/
    Ectopic Pregnancy 10 2020
    16:41
    Serial Human chorionic
    gonadotrophin (B-hCG)
     A β-HCG level of:-
    < 5 mIU/mL = negative
    > 25 mIU/mL is = positive.
     In normal pregnancy, HCG Values
    doubles every 48 hour.
     In normal pregnancy values, serum
    B.HCG > 1500 mIU/mL, Must see
    gestational sac intra uterine by TVSS

    24/02/
    Ectopic Pregnancy 11 2020
    16:41
    Human chorionic gonadotrophin and transvaginal
    ultrasound

    TVS can visualise a gestational sac as early as 4-5


    weeks from LMP.
    During this time the lowest serum β-HCG 1500 mIU/ml
    When β-HCG level is greater than this and there is an
    empty uterine cavity on TVS, ectopic pregnancy can be
    suspected.
     when the value of β-HCG does not double in 48 hours
    ectopic pregnancy will be confirmed.

    24/02/
    Ectopic Pregnancy 12 2020
    16:41
    MANAGEMENT
     Depends on presentation and the condition of the
    patient at diagnosis.
     Options-
     Surgery – Laparoscopy / Laparotomy
     Medical –
     Expectant – Observation

    24/02/
    Ectopic Pregnancy 13 2020
    16:41
    MANAGEMENT OF ACUTE
    ECTOPIC PREGNANCY

     Hospitalisation
     Resuscitation -then------
    laparatomy
     Salpingectomy is the
    definitive treatment.
    24/02/
    2020
    16:41
    Ectopic Pregnancy 14
    MANAGEMENT OF UNRUPTURED
    ECTOPIC PREGNANCY
     SURGERY:
    -Carried out either by Laparoscopy OR Laparotomy.
     The procedures are: -
     Salpingectomy

     Conservative surgery (in cases of Infertility & desire for


    pregnancy)
     Linear salpingostomy.
     Segmental resection and anastomosis.
     Milking of the tube.
    24/02/
    2020
    Ectopic Pregnancy 15 16:41
    Medical management

     Intramuscular methotrexate is a treatment


    option for patients with:
     Minimal symptoms,
     An adnexal mass <40 mm in diameter
     A current serum hCG concentration under
    3,000 IU/l.
     Cornual pregnancy.

    24/02/202
    Ectopic Pregnancy 16
    0 16:41
    Medical management
     Patient with one Fallopian tube and fertility desired
     Patient who refuses surgery or in whom risks of surgery is
    too high.
     Treatment of ectopic pregnancy where trophoblast is
    adherent to bowel or blood vessel.
    NOTE:
    Medical treatment should be offered only if facilities for
    regular follow up visits are present

    24/02/
    2020
    Ectopic Pregnancy 17 16:41
    EXPECTANT TREATMENT
     Based on that a significant proportion of EPs will
    resolve without any treatment.
     This option is suitable for patients who are
    haemodynamically stable and asymptomatic .
     The patient requires serial hCG measurements until
    levels are undetectable.

    24/02/
    2020
    Ectopic Pregnancy 18
    16:41
    SUMMARY - KEY POINTS
     Incidence of ectopic pregnancy is rising while
    maternal mortality from it is falling.
     Early diagnosis is the key to less invasive treatment.
     Management of an ectopic pregnancy should be based
    on the clinical presentation, bHCG and ultrasound
    findings.
     An intrauterine gestational sac should be visualized at
    about 4-5 weeks of gestation via TVS, with the
    corresponding bHCG at that gestation being around
    1500 mIU/mL.
    24/02/
    19 2020
    16:41
    Key Points
     Identifiation of an intrauterine pregnancy on TVS
    effectively excludes the possibility of an ectopic
    pregnancy in most patients, except in those with rare
    heterotopic pregnancy.
     Methotrexate is an option for a selected group of
    patients who are haemodynamically stable.
     The choice today is Laparoscopic treatment of
    unruptured ectopic pregnancy.
     The trend is towards conservative treatment
     Surgical treatment will remain the mainstay treatment
    modality for ectopic pregnancy in most units.

    24/02/202
    Ectopic Pregnancy 20
    0 16:41
    What are the
    differential
    diagnosis‫؟‬

    24/02/
    Ectopic Pregnancy 21 2020
    16:41

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