ectopic pregnancy4
TRANSCRIPT
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 1/94
Benha University Hospital, Egypt
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 2/94
Definition
Implantation of the fertilized ovum outside the normaluterine cavity.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 3/94
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)
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 4/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 5/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 6/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 7/94
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
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 8/94
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
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 9/94
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)
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 10/94
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).
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 11/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 12/94
2. Subacute cases:
Frequently give rise todiagnostic confusion
3. Asymptomatic cases:
suspected early in high-risk
women.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 13/94
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}.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 14/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 15/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 16/94
(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
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 17/94
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.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 18/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 19/94
Heterotopic ectopic pregnancy:
Incidence:
Increased with fertility treatments reaching 1/100 Diagnosis:
extremely difficult
50% identified after tubal rupture.
Aboubakr Elnashar
Sh ld b id d
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 20/94
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.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 21/94
Multifetal tubal pregnancy
Twin tubal pregnancy has been reported with
both embryos in same tube as well as one
in each tube
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 22/94
Aboubakr Elnashar
(1) S ß hCG
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 23/94
(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
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 24/94
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)
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 25/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 26/94
Aboubakr Elnashar
2 Ult h
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 27/94
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
Aboubakr Elnashar
B Ad l
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 28/94
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%
Aboubakr Elnashar
2 C stic mass
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 29/94
2. Cystic mass:
3. Ring: (Bagel sign)
hyperechoic ring around the gestational sac4.Sac & embryo.
Ipsilateral side: Corpus luteum: 85% of cases
Aboubakr Elnashar
C D h
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 30/94
C. D. pouch:
Fluid with or without blood clots
Aboubakr Elnashar
Discriminatory zones:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 31/94
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.
Aboubakr Elnashar
TVS Versus TAS
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 32/94
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
Aboubakr Elnashar
Uterine:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 33/94
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
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 34/94
Non cystic mass
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 35/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 36/94
ov
Cystic mass
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 37/94
Ring
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 38/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 39/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 40/94
U
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 41/94
Aboubakr Elnashar
Abdominal
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 42/94
Cervical pregnancy
Abdominal
pregnancy
Aboubakr Elnashar
(3) Serum Progesterone:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 43/94
(3) Serum Progesterone:
lower in ectopic than normal pregnancy
usually <15ng/ml.
Aboubakr Elnashar
(4) Culdocentesis:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 44/94
(4) Culdocentesis:
Non-clotting blood: intraperitoneal hge.
if not: ectopic pregnancy cannot beexcluded.
Aboubakr Elnashar
(5) Curettage:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 45/94
(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
Aboubakr Elnashar
6. Laparoscopy
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 46/94
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
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 47/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 48/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 49/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 50/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 51/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 52/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 53/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 54/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 55/94
Aboubakr Elnashar
(7) CBC:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 56/94
( )
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
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 57/94
B. Intrauterine Pregnancy
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 58/94
g y
Exclude by:
1-Clinical Characteristics.2- Quantitative B sub unit HCG.
3- TVS .
4-Laparoscopy.
5-Curettage
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 59/94
Aboubakr Elnashar
Suspected Ectopic Pregnancy
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 60/94
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
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 61/94
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
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 62/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 63/94
A. Active B. Expectant
I. Surgical T. II. Medical T.
1. Laparoscopy 2.Laparotomy
Salpingectomy Salpingotomy
Systemic Local
Kim and Fox, 1999 Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 64/94
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 65/94
1. Laparoscopy
Indication:Haemodynamically stable patient
(RCOG Recommendations, Grade A)
Aboubakr Elnashar
laparoscopic surgery appears to be the tt of
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 66/94
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:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 67/94
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”)
Aboubakr Elnashar
Indications
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 68/94
(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.
Aboubakr Elnashar
B. Salpingotomy N t f bl
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 69/94
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)
Aboubakr Elnashar
Operative Complications: Bleeding from FallopianTube
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 70/94
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.
Aboubakr Elnashar
2 Laparotomy
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 71/94
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
Aboubakr Elnashar
Persistent Trophoblast
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 72/94
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
Aboubakr Elnashar
Prophylactic Methotrexate:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 73/94
(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%.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 74/94
1.Systemic2. Local
Methotrexate is the drug of choice(Cochrane library,2002).
Aboubakr Elnashar
Indications of medical treatment:(Stovall et al 1991,, Gross et al 1995& Alito et al 1999)
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 75/94
(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
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 76/94
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)
Aboubakr Elnashar
1 Systemic:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 77/94
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)
Aboubakr Elnashar
B. Multi-doseP t l
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 78/94
Protocol:
In USA
1 mg/kg
on days 1,3,& 5 with
folonic acid rescue
on days 2,4 & 6
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 79/94
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.
Aboubakr Elnashar
Document tubal gestation as defined by BhCG &T.V.S.
I. Ensure the following criteria are met:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 80/94
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.
Aboubakr Elnashar
Single dose methotrexate regimen:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 81/94
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
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 82/94
2. Local:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 83/94
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
Aboubakr Elnashar
• Compared to laparoscopic adminstration ofmethotrexate transvaginal administration of
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 84/94
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.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 85/94
Aboubakr Elnashar
Indications ( RCOG, 2004 Grade C)
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 86/94
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.
Aboubakr Elnashar
Follow up:
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 87/94
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.
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 88/94
The 18- month cumulative rate
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 89/94
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
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 90/94
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 91/94
Pregnancy of unknown location
PUL
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 92/94
Progesterone
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 93/94
nmol/L
>60
Viable IUP
<20
Probablefailing PUL
Repeat HCGin 1W
Ng/ml=3.18 nmol/L
Aboubakr Elnashar
8/17/2019 Ectopic Pregnancy4
http://slidepdf.com/reader/full/ectopic-pregnancy4 94/94