Ectopic pregnancy By Dr Samera Al Basri 1142020

Ectopic pregnancy By Dr Samera Al. Basri 11/4/2020 1

INTRODUCTION Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity. The most common extra-uterine location is the fallopian tube, which accounts for 98% of all Ectopic gestations 11/4/2020 2

Ectopic pregnancy hemorrhage from Ectopic pregnancy is still the leading cause of pregnancy related maternal death in the first trimester and accounts for 4 to 10 % of all pregnancy related deaths, despite improved diagnostic methods leading to earlier detection and treatment 11/4/2020 3

The prevalence of Ectopic pregnancy among women who go to an emergency department with first trimester bleeding, pain, or both ranges from 6 - 16 % With almost 20 per 1000 pregnancies 11/4/2020 4

RISK FACTORS Previous ectopic pregnancy -conservative treatment for ectopic pregnancy are at high risk 15 % -after single dose MTX, salpingectomy, and linear salpingostomy were 8, 9. 8, and 15. 4 %, respectively 11/4/2020 5

RISK FACTORS Tubal pathology and surgery Reconstructive surgery Sterilization 0. 1 -0. 8% In-utero DES exposure Intrauterine contraception 11/4/2020 6

RISK FACTORS Pelvic Previous genital infections Multiple sexual partners Smoking 11/4/2020 7

RISK FACTORS In vitro fertilization/ART over all 2. 1% 11/4/2020 8

RISK FACTORS others : Age Vaginal douching 11/4/2020 9

RISK FACTORS Infertility 11/4/2020 10

Protective factors Women using hormonal contraception or an IUD are at very low risk of conceiving either an intrauterine or Ectopic pregnancy. However, if they conceive, the probability of an Ectopic pregnancy is generally higher than in women not using contraception 11/4/2020 11

Ectopic pregnancy Tubal 11/4/2020 12

Pathology Almost all Ectopic pregnancies occur in the fallopian tube (over 95 %). the distribution of sites was ampullary (70 %), isthmic (12 %), fimbrial (11. 1 %), ovarian (3. 2 %), interstitial (2. 4 %), and abdominal (1. 3 %). Several factors may be involved in the pathogenesis of Tubal pregnancies, but they are generally believed to be the result of (1) conditions that delay or prevent passage of the fertilized oocyte into the uterine cavity or (2) factors inherent in the embryo that result in premature implantation. The endometrium often responds to ovarian and placental production of pregnancy related hormones. The most common types of endometrium associated with Ectopic pregnancy are decidual reaction (42 %), secretory endometrium (22 %), and proliferative endometrium (12 %) 11/4/2020 13

— Heterotopic pregnancy refers to the combination of an intrauterine pregnancy and a concurrent pregnancy at an ectopic location 11/4/2020 14

— Abdominal pregnancy An abdominal pregnancy may be primary, from direct implantation of the blastocyst on the peritoneal surface or abdominal viscera, or secondary, resulting from extrusion of an embryo from the tube 11/4/2020 15

History Abdominal pain Amenorrhea Vaginal bleeding 11/4/2020 16

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expectant management We employ in limited clinical situations: when we suspect Ectopic pregnancy, but TVUS fails to reveal suggestive extrauterine findings and the beta-human chorionic gonadotropin (h. CG) concentration is low (<200 m. IU/m. L) and declining 11/4/2020 18

Salpingectomy 11/4/2020 19

Salpingestomy 11/4/2020 20

Contraindications of MTX Hemodynamically unstable Signs of impending or ongoing Ectopic mass rupture (ie, severe or persistent abdominal pain or >300 m. L of free peritoneal fluid (outside the pelvic cavity Clinically important abnormalities in baseline hematological, renal or hepatic laboratory values Immunodeficiency, active pulmonary disease, peptic ulcer disease Hypersensitivity to MTX Coexistent viable intrauterine pregnancy Breastfeeding Unwilling or unable to be compliant with post-therapeutic monitoring Do not have timely access to a medical institution 11/4/2020 21

— DRUG ADMINISTRATION MTX can be given systemically (intravenously, intramuscularly, or orally) or by direct local injection into the Ectopic pregnancy sac transvaginally or laparoscopically. Intramuscular (IM) administration is most common Intramuscular MTX administration is the predominant route for treatment of Tubal pregnancy 11/4/2020 22

MTX dose single IM dose of MTX (50 mg per square meter of body surface area) BSA = square root ((cm X kg)/3600) or by a BSA calculator 11/4/2020 23

MTX success The overall rate of resolution of Ectopic pregnancy reported in the literature is about 90 percent for both single and multiple dose protocols 11/4/2020 24

Thanks 11/4/2020 25