Ectopic pregnancy Dr F Mostajeran MD Ectopic pregnancy

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 o Unprecedented sexual liberties. o ↑Ascertainment E. P o ↑ART o Leading cause maternal death U. S 5 -6% all M. death

Pathogenesis • Ability tube transport gametes embryos • Clinical picture • Most common site Tub 98 -3% • Ampoule – isthmus – fimbrial cornual. • Rarely abdominal – ovarian – cervical. site E. P

• Proliferating trophoblast • Tubale wall • Growth may extend luminal mucosa. • Muscularis- serosa full thickness blood vessels • Distorts tube stretches serosa → pain bleeding takes phase. • 80% embryo degenerates. • 50% often clinically silent. • Tubal abortion self limited.

Risk factors o Needs aggressive monitoring pregnancy immediately after first missed menses Ø High risk • Tubal surgery (21) • Risk factors • Tubal ligation • Tubal Epithelial damage. • Previous E. P (6 -8) • I U D , Morning after pill • ART

• Moderate risk • Infertility • PID • Multiple sexual partners • Salpingitis ü Low risk • Cigarette • Vaginal douching first intercourse <18

• Signs and symptoms • Many E. P never produce symptoms rather • Timely diagnosed and treated (H. R) • If diagnosis → delayed → classic triad. • Amenorrhea , irregular V. B , lower ab- pain. • Sudden sever ab pain 90 -100% symptomatic patient. • Pain radiating shoulder. • Syncope shock → hemoperitaneum. ( up to 20%)

• Most common signs ab EX • 90% tenderness , rebound tenderness in 70%. • P. EX nonspecific. • 2⁄3 C-motion tenderness. • Adnexal mass 50%.

• Diagnosis • Diag as early as 4. 5 WK. • Visualization is frequently not possible. • Traditional laparoscopic visualization rarely necessary. • Routine diagnostic Tests. • Serial 3 HCG. • U. S • Progesterone levels. • U - curettage.

Treatment for E. P • • • Medical management. Methotrexate therapy. Folic acid antagonist DNA synthesis and cell multiplication. Single dose 50 mg/m 2 Blunts HCG increment (7) Drop progesterone, 17 × hydroxy progesterone prior to abortion Hemodiamically stable. E. P unruptured less 4 cm Eligible for methatrexate therapy.

Multiple-dose: tailored weight-E. P responsiveness. • Comparing multiple-dose-laparoscopic salpingostomy. • Patent fallopian tubes. • Subsequent IU pregnancy. • Repeat E. P comparable. Single dose: • Resent metaanalysis 26 studies. • Based on clinical evidence presently available. • Routine use methotrexate single dose IM not as • Effective as multiple dose (tubal rupture↑)

• Indication for systemic M-dose methotrexate • No rupture • Tubal size ≤ 4 cm • HCG ≤ 10, 000 • Positive F. H heartbeat proceed with caution.

Methotrexate by direct injection • • 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 o Pain is sever and persistent (>12 h 4 -12 3 -7 after start therapy) o Falling HCT o Orthostatic hypotension.

Side effects • High dose • Bone marrow supp • Hepatotoxicity • Stomatitis • Pulmonary fibrosis • Alopecia • Photosensitivity • Infrequent in E. P therapy

Surgical Treatment • 1884 E. P laparotomy salpingectom. • 1953 salpingostomy • Manual fimbrial expression • Segmental resection.

• Ruptured E. P • Laparoscopy – laparotomy – salpingectomy. • Inpatients hypovolemic shock. • Surgery is choice.

Stable E. P • If methotrexate contraindicated. • Laparoscopic salpigostomy first surgical choice. • Salpingectomy v Laparoscopy v Laparotomy

Expectant management • E. P may resolve spontaneously • 67. 2% E. P resolved without surgery (over treats) • Falling 3 HCC under 1000 fallowed with conservative expectant management • With low initial and falling HCG

Rare types of E. P • Abdominal pregnancy • 1⁄8000 birth • M. M 5. 1⁄1000 7. 7 higher than other E. P • (Higher due to delay in diagnosis) prognosis poor

Primary - Secondary • • 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 • • 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 • 4. 7% E. P 2. 2% M. mortality • Most frequent symptom menstrual aberration • Abdominal pain V. B, shock → rapture uterine(9 -12 nk) • Risk factor previous salpingectomy • Repeat U. S with Doppler flow studies → early diagnosis • Cornual resection lapa - resection systemic methatraxate local

Cervical pregnancy 1⁄12000 Most common risk factor o D. C o Previous CS o 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 • E. P + intrauterine pregnancy 1⁄6778 • Most causes diagnosed after sign symptoms develop admitted for emergency surgery • Lower abdominal pain serial 3 HCG not helpful