Ectopic Pregnancy: Causes, Risks, and Management

 
 
 
Ectopic pregnancy
 
Dr.Inaam Faisal
 
Introduction:
 
The blastocyst normally implants in the endometrial lining of
the uterine cavity. Implantation anywhere else is considered
an ectopic pregnancy. It is derived from the Greek ektopos—
out of place .
I
n
c
i
d
e
n
c
e
:
-
According to the American College of Obstetricians and
Gynecologists (2008), 2 % of all first-trimester pregnancies in
the United States are ectopic, and these account for 6 % of all
pregnancy-related deaths.
undefined
 
Incidence
 
and
 
aetiology
One
 
in
 
80
 
pregnancies
 
are
 
ectopic.
 
They
account
 
for
 
9–13%
 
of
 
maternal
 
deaths
 
 in the
 
Western
 
world
 
and 10–30%
 
in
 
low
 
resource
countries.
The
 
incidence
 
of
 
a
 
heterotopic
 
pregnancy (one
pregnancy is intrauterine & other is extrauterine )
 
in
 
the general
 
population
 
is low
 
(1:25,000–30,000),
 
but significantly
 
higher
 
after
 
in-vitro
 
fertilization
 
(IVF) treatment
 
(1%)
 
due
 
to
 
the transfer
 
of
 
two blastocysts.
 
C
l
a
s
s
i
f
i
c
a
t
i
o
n
 
Nearly 95 % of ectopic pregnancies are implanted
in the various segments of the fallopian tubes .Of
these, most are ampullary implantations. The
remaining 5 % implant in the ovary, peritoneal
cavity, or within the cervix.
 
T
u
b
a
l
 
P
r
e
g
n
a
n
c
y
 
The fertilized ovum may lodge in any portion of the
oviduct, giving rise to ampullary, isthmic, and
interstitial tubal pregnancies). In rare instances, the
fertilized ovum may implant in the fimbriated
extremity. The ampulla is the most frequent site,
followed by the isthmus. Interstitial pregnancy
accounts for only 
About 2%
.From these primary
types, secondary forms of tubo-abdominal, tubo-
ovarian, and pregnancies occasionally develop
.
 
 
 
 
 
 
 
 
R
i
s
k
 
F
a
c
t
o
r
s
 
1-previous ectopic pregnancy                                                                      3-13%
2-Tubal corrective surgery                                                                                4%
3-Tubal sterilization                                                                                           9%
4-Intrauterine device                                                                                      1-4%
5-Documented tubal pathology                                                               3.8–21%
6-Infertility                                                                                                  2.5–3%
7-Assisted reproductive technolog y                                                            2–8%
8-Previous genital infection                                                                         2–4 %
  Chlamydia                                                                                                    2%
  Salpingitis                                                                                          1.5–6.2%
 
9-Smoking                                                  1.7–4%
 
10-Multiple sexual partners                      1.6–3.5%
 
11-Prior cesarean delivery                         1–2.1%
 
12-
Maternal age (peak 25 to 34 years).
 
Recurrence rate is about 10-15%
 
 
 
 
Pathophysiology:
In theory, any mechanical or functional factors that prevent
or interfere with the passage of the fertilized egg to the uterine
cavity may be etiological factor for an ectopic pregnancy. In
general the main cause is a low grade infection- chronic PID.
In an ectopic pregnancy, the uterine endometrium usually
responds to the hormonal changes of pregnancy & undergoes
focal decidual
 
Natural history of untreated tubal pregnancy:
The most common outcomes of established tubal
pregnancies include the following:
1.
Tubal rupture.
2.
Pregnancy resorption.
3.
Tubal abortion into the peritoneal cavity.
 
Clinical presentation:
a.
Acute presentation (tubal rupture):
1.
Acute abdominal pain referred to the shoulder tip.
2.
Cardiovascular collapse.
3.
Normal temperature.
4.
Uterus slightly enlarged & there is a tender mass to
one side.
5.
Positive cervical excitation
.
 
b. Subacute presentation:
Give rise to diagnostic confusion.
1.
Abdominal pain which can be localized to one iliac
fossa.
2.
Delayed menstruation.
3.
Episodes of vaginal bleeding.
4.
There may be referred pain to shoulder.
5.
Abdominal & pelvic examination reveal sign of
peritoneal irritation less marked than in an acute
situation.
 
c. Asymptomatic (silent presentation
).
:
discovered during assessment of early pregnancy or while investigating for
other complain
 
Diagnosis:
Symptoms of ectopic pregnancy tend to have a poor
positive predictive value to help discriminate between
intra & extra uterine pregnancy. They may present as
acute/ subacute or silent presentation.
 
Signs: often have no specific signs:
1.
Rapid heart rate, low BP may be noticed.
2.
peritonism (due to intra abdominal blood if ruptured).
3.
Gynecological examination:
      speculum or bimanual examination must be
performed in an environment where facilities for
resuscitation are available because may provoke tubal
rupture.
 
 
uterus usually normal size.
 cervical excitation & tenderness occasionally.
 adnexial tenderness.
 adnexial mass.
 
Investigation:
I.
Ultrasound: 
transvaginal U/S : gestational sac of an intra uterine
pregnancy should be detectable when serum B-hCG level exceeds
1000IU/L.
The presence or absence of an intra uterine gestational sac is the
principle point of distinction between intra uterine and tubal
pregnancy.
Morphology of ectopic pregnancy can be classified by U/S into 5
categories:
1.
Gestational sac with a live embryo.
2.
Sac with an embryo but no heart rate.
3.
Sac containing yolk sac.
4.
Empty gestational sac.
5.
Solid tubal swelling
 
The presence of fluid in the pouch of Douglas is a non
specific sign of ectopic pregnancy. In 10 to 20% of ectopic
pregnancy a pseudo gestational sac is seen as a small,
central located endometrial fluid collection surrounded
by a single echogenic rim of endometrial tissue
undergoing decidual reaction.
 
II. Biochemical measurements:
1.
Serum hCG:
Healthy normally developing pregnancies generally can
be detected by a normal rate of increase of maternal
serum B-hCG levels.
 
Normal pregnancies show doubling of hCG levels every
48 hours in the first few weeks of pregnancy & sub
optimal rise is suspicious of an ectopic pregnancy i.e. a
prolonged hCG doubling time is an indicator of an
abnormal pregnancy.
 
2. Serum progesterone:
Serum progesterone levels will respond quickly to any
decrease in hCG production.
Serum progsterone <20 nmol/L reflects fast decreasing
hCG levels and can be used to diagnose spontaneous
resolving pregnancies.
Progesterone level >60 nmol/L indicate normal increase
in hCG level but those between 20 & 60 nmol/L are
strongly associated with abnormal pregnancy
 
Culdocentesis
This simple technique was used commonly in the past to identify
hemoperitoneum. The cervix is pulled toward the symphysis with a
tenaculum, and a long 16- or 18-gauge needle is inserted through
the posterior vaginal fornix into the cul-de-sac. If present, fluid
can be aspirated, however, failure to do so is interpreted only as
unsatisfactory entry into the cul-de-sac and does not exclude an
ectopic pregnancy, either ruptured or unruptured. Fluid
containing fragments of old clots, or bloody fluid that does not
clot, is compatible with the diagnosis of hemoperitoneum resulting
from an ectopic pregnancy. If the blood subsequently clots, it may
have been obtained from an adjacent blood vessel rather than from
a bleeding ectopic pregnancy
 
Multimodality Diagnosis:
 
Ectopic pregnancies are identified with the combined use of clinical
findings along with serum analyte testing and transvaginal
sonography. A number of algorithms have been proposed, but most
include five key components:
 
1.
Transvaginal sonography
2.
Serum
 
hCG level
 
both the initial level and the pattern of
subsequent rise or decline
3.
Serum progesterone level
4.
Uterine curettage
5.
Laparoscopy and occasionally, laparotomy.
 
 
Management
In many cases, early diagnosis allows definitive surgical or medical
management of unruptured ectopic pregnancy—sometimes even
before the onset of symptoms. In either case, treatment before
rupture is associated with less morbidity and mortality and a better
prognosis for fertility. 
D-negative women with an ectopic
pregnancy who are not sensitized to D-antigen should be given
anti-D immunoglobulin
Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic
pregnancy unless the woman is hemodynamically unstable.
 
undefined
 
The
 
standard
 
surgical
 
  treatment
 
approach
 
is
laparoscopy.
 
Laparotomy
 
is
 
reserved for severely
compromised
 
patients
 
or
 
where
 
there
 
are
 
no endoscopic
facilities.
 
The
 
operation
 
of
 
choice
 
is removal of the
Fallopian
 
tube
 
and
 
the
 
EP
 
within
 
(salpingectomy),
or
 
in
 
some
 
cases
 
a
 
small
 
opening
 
can
 
be
made
 
over
 
the
 
site
 
of
 
the
 
EP
 
and
 
the EP
extracted
 
via
 
this
 
opening
 
 ( salpingostomy). Salpingostomy
is recommended
 
only
 
if
 
the
 
contralateral
 
tube
 
is
absent
 
or
 
visibly
 
damaged,
 
and
 
it
 
is associated
with
 
a higher
 
rate
 
of
 
subsequent
 
EP.
 
Pregnancy rates
subsequently
 
remain
 
high
 
if
 
the
 
contralateral
 
tube is
normal because
 
the
 
oocyte
 
can
 
be
 
picked
 
up
 
by the
ipsilateral
 
or
 
contralateral
 
tube.
 
Tubal surgery 
is considered 
conservative
 when there is tubal
salvage. Examples include salpingostomy, salpingotomy, and
fimbrial expression of the ectopic pregnancy.
Radical surgery 
is defined by salpingectomy. Conservative surgery
may increase the rate of subsequent uterine pregnancy but is
associated with higher rates of persistently functioning
trophoblast .
Salpingostomy
This procedure is used to remove a small pregnancy that is usually
less than 2 cm in length and located in the distal third of the
fallopian tube .A 10- to 15-mm linear incision is made with
unipolar needle cautery on the antimesenteric border over the
pregnancy. The products usually will extrude from the incision
and can be carefully removed or flushed out using high-pressure
irrigation that more thoroughly removes the trophoblastic tissue
 
.
Small bleeding sites are controlled with needlepoint
electrocoagulation or laser, and the incision is left unsutured to
heal by secondary intention
,it is used if other tube is not healhty or
absent
 
Salpingotomy
Seldom performed today, salpingotomy is essentially the same
procedure as salpingostomy except that the incision is closed with
delayed-absorbable suture.
Salpingectomy
Tubal resection may be used for both ruptured and unruptured
ectopic pregnancies. When removing the oviduct, it is advisable to
excise a wedge of the outer third (or less) of the interstitial portion
of the tube. This so-called cornual resection is done in an effort to
minimize the rare recurrence of pregnancy in the tubal stump.
Even with cornual resection, however, a subsequent interstitial
pregnancy is not always prevented
undefined
 
Medical
 
management Intramuscular
methotrexate
 
is
 
a
 
treatment
option
 
for
 
patients
 
with
 
minimal
symptoms,
 
an
 
adnexal
 
mass <40
mm
 
in
 
diameter
 
and
 
a
 
current
serum
 
hCG
 
concentration
 
under
3,000
 
IU/l.
 
 
 
Methotrexate
 
is
 
a
 
folic
 
acid antagonist
 
that
inhibits
 
deoxyribonucleic
 
acid
 
(DNA)
 
synthesis,
particularly
 
affecting
 
trophoblastic
 
cells. The
 
dose
of
 
methotrexate
 
is
 
calculated
 
based
 
on
 
the
patient’s
 
body
 
surface
 
area
 
and
 
is
 
50
mg/m2.
 
After methotrexate
 
treatment
 
serum
 
hCG
is
 
usually
 
routinely
 
measured
 
on
 
days
4,
 
7
 
and
 
11,
 
then
 
weekly thereafter
 
until
undetectable
 
(levels
 
need
 
to
 
fall
 
by
 
15%
between
 
day
 
4
 
and
 
7,
 
and
 
continue to
fall
 
with treatment).
 
Medical
 
treatment should
therefore
 
only
 
be
 
offered
 
if
 
facilities are
present
 
for
 
regular
 
follow up
 
visits.
undefined
 
The
 
few
 
contraindications
 
to
 
medical
 
treatment
 
include:
(1)
 chronic
 
liver,
 
renal
 
or  haematological
 
 disorder;
(2)
 active infection;
(3)
 immunodeficiency;
 
and
(4)
 breastfeeding.
(5)
 Fetal cardiac activity. this is a relative contraindication to
medical therapy
undefined
 
There
 
are also known side-effects
 
such as stomatitis,
conjunctivitis,  gastrointestinal
 
upset
 
and photosensitive
skin reaction,
 
and
 
about two-thirds
 
of
 
patients will
suffer
 
from
 
non-specific abdominal pain.
 
It
 
is
important
 
to  advise
 
women
 
to
 
avoid sexual
intercourse
 
during
 
treatment
 
and
 
to
 
avoid
conceiving for 3 months
 
after methotrexate
 
 treatment
because
 
of
 
the
 
risk
 
of teratogenicity.
 
It is
also
 
important
 
to
 
advise
 
them to
 
avoid
alcohol
 
and
 
prolonged
 
exposure
 
to sunlight
during treatment.
 
Patient Selection
The best candidate for medical therapy is the woman who is
asymptomatic, motivated, and compliant. With medical therapy,
some classical predictors of success include:
1.
Initial serum  hCG level.
2.
Ectopic pregnancy  size .. A 93% success rate with single dose
methottexate when the ectopic mass was  < 3.5 cm ,
 
E
x
p
e
c
t
a
n
t
 
M
a
n
a
g
e
m
e
n
t
In select cases, it is reasonable to observe very early tubal pregnancies 
.
Expectant
 
management
 
is
 
based
 
on
 
the assumption
that
 
a
 
significant
 
proportion
 
of
 
all
 
Eps will
resolve without
 
any
 
treatment.
 
E
xpectant management 
is
 indicated
women with these criteria:
1.
Tubal ectopic pregnancies only
2.
Decreasing serial  hCG levels
3.
Diameter of the ectopic mass not 
<or=3.5
  cm
4.
No evidence of intra-abdominal bleeding or rupture by transvaginal
sonography.
 
So,.
 
This
 
option
 
is
 
suitable
 
for
 
patients
 
 who
 
are
haemodynamically
 
stable
 
and asymptomatic
 
(and
 
remain
so).
 
The
 
patient
 
requires
 
serial
 
hCG
 
measurements
 
until
levels
 
are undetectable.
With expectant management, subsequent rates of tubal patency and
intrauterine pregnancy are comparable with surgery and medical
management 
.
 
 
 
 
 
 
Increasing Ectopic Pregnancy Rates
 
A number of reasons at least partially explain the increased rate of
ectopic pregnancies in the United States and many European
countries. Some of these include:
1-Increasing prevalence of sexually transmitted infections,
especially those caused by Chlamydia trachomatis
2-Identification through earlier diagnosis of some ectopic
pregnancies otherwise destined to resorb spontaneously
3-Popularity of contraception that predisposes pregnancy failures
to be ectopic
4-Tubal sterilization techniques that with contraceptive failure
increase the likelihood of ectopic pregnancy
5-Assisted reproductive technology
6-Tubal surgery, including salpingotomy for tubal pregnancy and
tuboplasty for infertility
 
Differential diagnosis of ectopic pregnancy:
Gynecologic problems:
Threatened or incomplete abortion.
Ruptured corpus luteum cyst.
Acute PID.
Adnexal torsion.
Degenerating leiomyoma (especially in
pregnancy).
 
Non- gynecologic problems:
Acute appendicitis.
Pyelonephritis.
Pancreatitis.
undefined
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Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, most commonly in the fallopian tubes. This abnormal implantation can lead to serious complications, including maternal mortality. Risk factors include previous ectopic pregnancy, tubal surgery, and maternal age. Recognizing the signs and managing ectopic pregnancies promptly is crucial for a positive outcome.


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  1. Dr.Inaam Faisal

  2. Introduction: The blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation anywhere else is considered an ectopic pregnancy. It is derived from the Greek ektopos out of place . Incidence:- According to the American College of Obstetricians and Gynecologists (2008), 2 % of all first-trimester pregnancies in the United States are ectopic, and these account for 6 % of all pregnancy-related deaths.

  3. Incidence One in account Western countries. The incidence pregnancy is intrauterine & other is extrauterine ) in population is low (1:25,000 30,000), higher after in-vitro (1%) due to and aetiology pregnancies are 9 13% of world and 10 30% in 80 for ectopic. They maternal deaths in the low resource of a heterotopic pregnancy (one the general but significantly (IVF) treatment two blastocysts. fertilization the transfer of

  4. Classification Nearly 95 % of ectopic pregnancies are implanted in the various segments of the fallopian tubes .Of these, most are ampullary implantations. The remaining 5 % implant in the ovary, peritoneal cavity, or within the cervix.

  5. Tubal Pregnancy The fertilized ovum may lodge in any portion of the oviduct, giving rise to ampullary, isthmic, and interstitial tubal pregnancies). In rare instances, the fertilized ovum may implant in the fimbriated extremity. The ampulla is the most frequent site, followed by the isthmus. accounts for only About 2%.From these primary types, secondary forms of tubo-abdominal, tubo- ovarian, and pregnancies occasionally develop. Interstitial pregnancy

  6. Risk Factors 1-previous ectopic pregnancy 3-13% 2-Tubal corrective surgery 4% 3-Tubal sterilization 9% 4-Intrauterine device 1-4% 5-Documented tubal pathology 3.8 21% 6-Infertility 2.5 3% 7-Assisted reproductive technolog y 2 8% 8-Previous genital infection 2 4 % Chlamydia 2% Salpingitis 1.5 6.2%

  7. 9-Smoking 1.74% 10-Multiple sexual partners 1.6 3.5% 11-Prior cesarean delivery 1 2.1% 12-Maternal age (peak 25 to 34 years). Recurrence rate is about 10-15%

  8. Pathophysiology: In theory, any mechanical or functional factors that prevent or interfere with the passage of the fertilized egg to the uterine cavity may be etiological factor for an ectopic pregnancy. In general the main cause is a low grade infection- chronic PID. In an ectopic pregnancy, the uterine endometrium usually responds to the hormonal changes of pregnancy & undergoes focal decidual

  9. Natural history of untreated tubal pregnancy: The most common outcomes of established tubal pregnancies include the following: 1.Tubal rupture. 2.Pregnancy resorption. 3.Tubal abortion into the peritoneal cavity. Clinical presentation: a.Acute presentation (tubal rupture): 1.Acute abdominal pain referred to the shoulder tip. 2.Cardiovascular collapse. 3.Normal temperature. 4.Uterus slightly enlarged & there is a tender mass to one side. 5.Positive cervical excitation.

  10. b. Subacute presentation: Give rise to diagnostic confusion. 1.Abdominal pain which can be localized to one iliac fossa. 2.Delayed menstruation. 3.Episodes of vaginal bleeding. 4.There may be referred pain to shoulder. 5.Abdominal & pelvic examination reveal sign of peritoneal irritation less marked than in an acute situation. c. Asymptomatic (silent presentation). :discovered during assessment of early pregnancy or while investigating for other complain

  11. Diagnosis: Symptoms of ectopic pregnancy tend to have a poor positive predictive value to help discriminate between intra & extra uterine pregnancy. They may present as acute/ subacute or silent presentation. Signs: often have no specific signs: 1.Rapid heart rate, low BP may be noticed. 2.peritonism (due to intra abdominal blood if ruptured). 3.Gynecological examination: speculum or bimanual examination must be performed in an environment where facilities for resuscitation are available because may provoke tubal rupture.

  12. uterus usually normal size. cervical excitation & tenderness occasionally. adnexial tenderness. adnexial mass. Investigation: I.Ultrasound: transvaginal U/S : gestational sac of an intra uterine pregnancy should be detectable when serum B-hCG level exceeds 1000IU/L. The presence or absence of an intra uterine gestational sac is the principle point of distinction between intra uterine and tubal pregnancy. Morphology of ectopic pregnancy can be classified by U/S into 5 categories: 1.Gestational sac with a live embryo. 2.Sac with an embryo but no heart rate. 3.Sac containing yolk sac. 4.Empty gestational sac. 5.Solid tubal swelling

  13. The presence of fluid in the pouch of Douglas is a non specific sign of ectopic pregnancy. In 10 to 20% of ectopic pregnancy a pseudo gestational sac is seen as a small, central located endometrial fluid collection surrounded by a single echogenic rim of endometrial tissue undergoing decidual reaction. II. Biochemical measurements: 1.Serum hCG: Healthy normally developing pregnancies generally can be detected by a normal rate of increase of maternal serum B-hCG levels.

  14. Normal pregnancies show doubling of hCG levels every 48 hours in the first few weeks of pregnancy & sub optimal rise is suspicious of an ectopic pregnancy i.e. a prolonged hCG doubling time is an indicator of an abnormal pregnancy. 2. Serum progesterone: Serum progesterone levels will respond quickly to any decrease in hCG production. Serum progsterone <20 nmol/L reflects fast decreasing hCG levels and can be used to diagnose spontaneous resolving pregnancies. Progesterone level >60 nmol/L indicate normal increase in hCG level but those between 20 & 60 nmol/L are strongly associated with abnormal pregnancy

  15. Culdocentesis This simple technique was used commonly in the past to identify hemoperitoneum. The cervix is pulled toward the symphysis with a tenaculum, and a long detresni hguorht otni eht luc - ed - cas . fI ,tneserp diulf eruliaf ot od os si deterpretni ylno sa - ed - cas dna seod ton edulcxe na derutpur ro derutpurnu . diulF ,stolc ro ydoolb diulf taht seod ton sisongaid fo muenotirepomeh gnitluser eht doolb yltneuqesbus ,stolc ti yam tnecajda doolb lessev rehtar naht morf a gnideelb cipotce ycnangerp eldeen lanigav ,revewoh otni eht rehtie stnemgarf fo dlo htiw eht ycnangerp . fI morf na si eguag - 18 ro 16 eht nac - xinrof roiretsop ,detaripsa yrotcafsitasnu yrtne ,ycnangerp gniniatnoc elbitapmoc cipotce deniatbo eb luc cipotce si ,tolc morf evah na neeb

  16. Multimodality Diagnosis: Ectopic pregnancies are identified with the combined use of clinical findings along with serum analyte testing and transvaginal sonography. A number of algorithms have been proposed, but most include five key components: 1.Transvaginal sonography 2.Serum hCG level both the initial level and the pattern of subsequent rise or decline 3.Serum progesterone level 4.Uterine curettage 5.Laparoscopy and occasionally, laparotomy.

  17. Management In many cases, early diagnosis allows definitive surgical or medical management of unruptured ectopic pregnancy sometimes even before the onset of symptoms. In either case, treatment before rupture is associated with less morbidity and mortality and a better prognosis for fertility. D-negative women with an ectopic pregnancy who are not sensitized to D-antigen should be given anti-D immunoglobulin Surgical Management Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless the woman is hemodynamically unstable .

  18. The laparoscopy. compromised facilities. Fallopian or made extracted is recommended only absent or with a higher rate subsequently normal because the ipsilateral standard surgical treatment Laparotomy patients or The operation tube and some cases the site via this if visibly damaged, of remain high oocyte can or contralateral approach is is where there reserved for severely are of choice is removal of the EP within (salpingectomy), small opening can the EP and opening ( salpingostomy). Salpingostomy the contralateral and it subsequent EP. if the contralateral be picked up tube. no endoscopic the a of in over be the EP tube is associated Pregnancy rates is tube is by the

  19. Tubal surgery is considered conservative when there is tubal salvage. Examples include salpingostomy, salpingotomy, and fimbrial expression of the ectopic pregnancy . Radical surgery is defined by salpingectomy. Conservative surgery may increase the rate of subsequent uterine pregnancy but is associated with higher rates of persistently functioning trophoblast. Salpingostomy This procedure is used to remove a small pregnancy that is usually less than 2 cm in length and located in the distal third of the fallopian tube .A htiw edam si noisicni raenil mm eht revo redrob ciretnesemitna eht no yretuac eldeen ralopinu noisicni eht morf edurtxe lliw yllausu stcudorp ehT .ycnangerp hgih gnisu tuo dehsulf ro devomer ylluferac eb nac dna - erusserp eussit citsalbohport eht sevomer ylhguoroht erom taht noitagirri - 15 ot - 10

  20. .Small electrocoagulation or laser, and the incision is left unsutured to heal by secondary intention,it is used if other tube is not healhty or absent Salpingotomy Seldom performed today, salpingotomy is essentially the same procedure as salpingostomy except that the incision is closed with delayed-absorbable suture. Salpingectomy Tubal resection may be used for both ruptured and unruptured ectopic pregnancies. When removing the oviduct, it is advisable to excise a wedge of the outer third (or less) of the interstitial portion of the tube. This so-called cornual resection is done in an effort to minimize the rare recurrence of pregnancy in the tubal stump. Even with cornual resection, however, a subsequent interstitial pregnancy is not always prevented bleeding sites are controlled with needlepoint

  21. Medical management Intramuscular methotrexate is a option for patients with minimal symptoms, an adnexal mass <40 mm in diameter and a serum hCG concentration 3,000 IU/l. treatment current under

  22. Methotrexate is inhibits particularly of methotrexate is patient s mg/m2. is usually 4, 7 undetectable (levels need to between day fall with treatment). therefore only present for acid antagonist acid (DNA) synthesis, trophoblastic cells. The calculated based on body surface area After methotrexate treatment routinely measured and 11, then weekly thereafter fall 4 and 7, Medical be offered if regular follow up a folic that deoxyribonucleic affecting dose the 50 and is serum hCG on days until by and treatment should facilities are visits. 15% continue to

  23. The (1) chronic (2) active infection; (3) immunodeficiency; (4) breastfeeding. (5) Fetal cardiac activity. this is a relative contraindication to medical therapy few treatment contraindications include: liver, renal or haematological to medical disorder; and

  24. There are also known side-effects such as stomatitis, conjunctivitis, gastrointestinal skin reaction, and about two-thirds suffer from non-specific abdominal pain. important to advise intercourse during treatment conceiving for 3 months because of the also important to alcohol and prolonged during treatment. upset and photosensitive of patients will It is women to avoid sexual to and avoid treatment after methotrexate risk of teratogenicity. advise them to exposure It is avoid to sunlight

  25. Patient Selection The best candidate for medical therapy is the woman who is asymptomatic, motivated, and compliant. With medical therapy, some classical predictors of success include: 1.Initial serum hCG level . 2.Ectopic pregnancy size .. A 93% success rate with single dose methottexate when the ectopic mass was < 3.5 cm ,

  26. Expectant Management In select cases, it is reasonable to observe very early tubal pregnancies . Expectant management is that a significant proportion resolve without any treatment. Expectant women with these criteria: 1.Tubal ectopic pregnancies only 2.Decreasing serial hCG levels 3.Diameter of the ectopic mass not <or=3.5 cm 4.No evidence of intra-abdominal bleeding or rupture by transvaginal sonography. based on of management the assumption all Eps will is indicated So,. haemodynamically so). The levels are undetectable. With expectant management, subsequent rates of tubal patency and intrauterine pregnancy are comparable management. This option is suitable for and asymptomatic hCG patients who are remain until stable (and patient requires serial measurements with surgery and medical

  27. Increasing Ectopic Pregnancy Rates A number of reasons at least partially explain the increased rate of ectopic pregnancies in the United States and many European countries. Some of these include: 1-Increasing prevalence of sexually transmitted infections, especially those caused by Chlamydia trachomatis 2-Identification through earlier diagnosis of some ectopic pregnancies otherwise destined to resorb spontaneously 3-Popularity of contraception that predisposes pregnancy failures to be ectopic 4-Tubal sterilization techniques that with contraceptive failure increase the likelihood of ectopic pregnancy 5-Assisted reproductive technology 6-Tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility

  28. Differential diagnosis of ectopic pregnancy: Gynecologic problems: Threatened or incomplete abortion. Ruptured corpus luteum cyst. Acute PID. Adnexal torsion. Degenerating leiomyoma (especially in pregnancy). Non- gynecologic problems: Acute appendicitis. Pyelonephritis. Pancreatitis.

  29. THANK YOU

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