Ectopic pregnancy
Dr.F Mostajeran MD
 Ectopic pregnancy remains
 Leading cause life/hreatening F- Trimester (morbidity)
 Medical therapy method terexate as standard first line
therop.
Surgery
 Hemorrhage?
 Medical failures
 Neglected cases
 Medical contraindicated
Incidence E.P
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Unprecedented sexual liberties.
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↑Ascertainment E.P
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↑ART
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Leading cause maternal death U.S 5-6% all
M. death
Pathogenesis
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Ability tube transport gametes embryos
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Clinical picture
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Most common site Tub 98-3%
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Ampoule – isthmus – fimbrial cornual.
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Rarely abdominal – ovarian – cervical.
site E.P
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Proliferating trophoblast
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Tubale wall
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Growth may extend luminal mucosa.
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Muscularis- serosa full thickness blood vessels
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Distorts tube stretches serosa → pain bleeding
takes phase.
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80% embryo degenerates.
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50% often clinically silent.
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Tubal abortion self limited.
Risk factors
 Needs aggressive monitoring pregnancy
immediately after first missed menses
 High risk
• Tubal surgery (21)
• Risk factors
• Tubal ligation
• Tubal Epithelial damage.
• Previous E.P (6-8)
• I U D , Morning after pill
• ART
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Moderate risk
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Infertility
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PID
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Multiple sexual partners
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Salpingitis
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Low risk
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Cigarette
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Vaginal douching
first intercourse <18
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Signs and symptoms
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Many E.P never produce symptoms rather
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Timely diagnosed and treated (H.R)
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If diagnosis → delayed → classic triad.
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Amenorrhea , irregular V.B , lower ab- pain.
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Sudden sever ab pain 90-100% symptomatic patient.
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Pain radiating shoulder.
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Syncope shock → hemoperitaneum.( up to 20%)
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Most common signs ab EX
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90% tenderness ,rebound tenderness in 70%.
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P.EX nonspecific.
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2⁄3 C-motion tenderness .
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Adnexal mass 50%.
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Diagnosis
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Diag as early as 4.5 WK.
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Visualization is frequently not possible.
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Traditional laparoscopic visualization rarely necessary.
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Routine diagnostic Tests.
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Serial 3HCG.
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U.S
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Progesterone levels.
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U - curettage.
Treatment for E.P
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Medical management .
Methotrexate therapy.
Folic acid antagonist
DNA synthesis and cell multiplication.
Single dose 50 mg/m2
Blunts HCG increment (7)
Drop progesterone, 17 × hydroxy progesterone prior to
abortion
Hemodiamically stable.
E.P unruptured less 4cm
Eligible for methatrexate therapy.
Multiple-dose: tailored weight-E.P responsiveness.
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Comparing multiple-dose-laparoscopic salpingostomy.
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Patent fallopian tubes.
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Subsequent IU pregnancy.
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Repeat E.P comparable .
Single dose:
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Resent metaanalysis 26 studies.
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Based on clinical evidence presently available.
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Routine use methotrexate single dose IM not as
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Effective as multiple dose (tubal rupture↑)
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Indication for systemic M-dose methotrexate
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No rupture
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Tubal size ≤4cm
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HCG ≤ 10,000
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Positive F.H heartbeat proceed with caution.
Methotrexate by direct injection
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Methotrexate E. gestational sac TVS.
Resolution within 2 weeks
Higher concentrations site of implantation.
Less systemic distribution drug
75.1% successfully treated
Subsequent p–tubal patency (laparoscopicsystemic Mehta)
Subsequent – P, recurrent E.P
Methotrexate failure
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Pain is sever and persistent (>12h 4-12
3-7 after start therapy)
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Falling HCT
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Orthostatic hypotension.
Side effects
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High dose
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Bone marrow supp
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Hepatotoxicity
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Stomatitis
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Pulmonary fibrosis
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Alopecia
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Photosensitivity
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Infrequent in E.P therapy
Surgical Treatment
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1884 E.P laparotomy salpingectom.
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1953 salpingostomy
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Manual fimbrial expression
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Segmental resection.
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Ruptured E.P
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Laparoscopy – laparotomy – salpingectomy.
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Inpatients hypovolemic shock.
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Surgery is choice.
Stable E.P
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If methotrexate contraindicated.
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Laparoscopic salpigostomy first surgical choice.
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Salpingectomy
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Laparoscopy
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Laparotomy
Expectant management
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E.P may resolve spontaneously
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67.2% E.P resolved without surgery (over treats)
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Falling 3HCC under 1000 fallowed with
conservative expectant management
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With low initial and falling HCG
Rare types of E.P
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Abdominal pregnancy
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1⁄8000 birth
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M.M 5.1⁄1000 7.7 higher than other E.P
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(Higher due to delay in diagnosis)
prognosis poor
Primary - Secondary
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Symptoms → normal for pregnancy to sever if time
permits
Abdominal pain intra abdominal hemorrhage shock
Primary rare usually abort
Secondary (reimplantation → abortion ,rupture)
U.S choice empty uterus
If fetus near viability → hospitalization
Adequate blood, bowel preparation
Placenta removed unless major vessels, vital organ
methotrexate
Ovarian pregnancy
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Most common form abdominal pregnancy
less than 3% of E.P
Clinical finding similar tubal E.P
ab-pain ,V.B Amenorrhea
30% hemodynamic instability → rupture
Usually young multiparous cause
Treatment → systectomy, wedge resection
or oophorectomy
Cornual pregnancy
or interstitial pregnancy
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4.7% E.P 2.2% M. mortality
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Most frequent symptom menstrual aberration
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Abdominal pain V.B, shock → rapture uterine(9-12nk)
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Risk factor previous salpingectomy
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Repeat U.S with Doppler flow studies → early diagnosis
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Cornual resection lapa - resection systemic methatraxate
local
Cervical pregnancy
1⁄12000
Most common risk factor
 D.C
 Previous CS
 IVF
• Symptom most common V.B painless
• C.EP usually diagnosis incidentally during routine U.S
or at time surgery for abortion
• Cervix enlarged- globular, distended it appears
cyanotic hyperemic soft
• Diagnosis – US, MRI , GSOC below C.OS,
• Metha, U. Artery embolization, hysterectomy
Heterotopic pregnancy
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E.P + intrauterine pregnancy 1⁄6778
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Most causes diagnosed after sign symptoms
develop admitted for emergency surgery
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Lower abdominal pain serial 3HCG not helpful