Danforths Obstetrics and Gynecology Tenth edition Ectopic pregnancy the implantation of a fertilized ovum outside of the endometrial cavity a leading cause of lifethreatening firsttrimester morbidity ID: 272510
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Slide1
ECTOPIC PREGNANCY
Danforth’s Obstetrics and GynecologyTenth editionSlide2
Ectopic pregnancy, the implantation of a fertilized ovum outside of the endometrial cavity
a leading cause of life-threatening first-trimester morbidity
Incidence
Pathogenesis
Sites of implantation
Etiology and Risk FactorsSlide3
Tubal Damage and Infection
Salpingitis
Isthmica
Nodosa
Diethylstilbestrol
Cigarette Smoking
Contraception:
IUD
Tubal ligation
OCP
Barrier contraceptionSlide4Slide5
Risk Factor
Odds
Ratio
a
High risk
Tubal surgery
21.0
Tubal ligation
9.3
Previous ectopic pregnancy
8.3
In
utero
exposure to DES
5.6
Use of IUD
4.2–45.0
Tubal pathology3.8–21.0Assisted reproduction4.0
Moderate risk
I
infertility
2.5–21.0
Previous genital infections
2.5–3.7
Multiple sexual partners
2.1
Salpingitis
isthmica
nodosa
1.5
Low risk
Previous pelvic infection
0.9–3.8
Cigarette smoking
2.3–2.5
Vaginal douching
1.1–3.1
First intercourse <18 y
1.6Slide6
Clinical
Manifestations
Symptoms:
abdominal or pelvic pain
vaginal bleeding or spotting
a positive pregnancy test(
mensturation
delay)
Signs:
Abdominal tenderness
rebound tenderness
cervical motion tenderness
tender
adnexal
massSlide7
Diagnosis:
Ectopic pregnancy can be diagnosed as early as 4.5 weeks gestation
serial measurements of B
-
hCG
ultrasonography
uterine sampling via manual vacuum extraction or curettage
serum progesterone levelsSlide8
Human Chorionic
Gonadotropin
( B -
hCG
)
The B
-
hCG
, produced by
trophoblastic
cells in normal pregnancy, has long been accepted to rise at least 66% and up to twofold every 2 days
Eight-five percent of abnormal pregnancies, whether intrauterine or ectopic, have impaired B
-
hCG
production with an abnormal rate of B
-
hCG
riseSonographytransvaginal ultrasonography reliably detects intrauterine gestations when the B-hCG levels are between 1,500 and 2,500 mIU/mLDiagnosis of an ectopic pregnancy can be made with 100% sensitivity but with low specificity (15% to 20%) if an extrauterine gestational sac containing a yolk sac or embryo is identifiedSome sonographic images, such as the pseudogestational sac, may mislead even an experienced examiner to falsely diagnose a gestational sacUltrasonography
should be used to document the presence or absence of an intrauterine pregnancy when the B
-
hCG
levels have risen above the designated discriminatory cutoff zoneSlide9Slide10
Progesterone
Although progesterone levels are higher in intrauterine pregnancies than in ectopic pregnancies, there is no established cutoff to use to discriminate between these two entities
a low progesterone level of less than 5
ng
/
mL
can rule out a normal pregnancy with almost 100% accuracy but does not differentiate whether that pregnancy is an abnormal one in the uterus or at an ectopic site
Uterine Evacuation
necessary when a
transvaginal
ultrasonogram
and a rising or
plateauing
B-hCG level below the cutoff value are not sufficient for diagnosisSlide11Slide12
Treatment for Ectopic Pregnancy
Medical Management:
Methotrexate
therapy
The folic acid antagonist,
methotrexate
, inhibits de novo synthesis of
purines and pyrimidines, interfering with DNA synthesis and cell multiplication
1-unruptured ectopic pregnancy measuring less than or equal to 4 cm by
ultrasonography
2-Hemodynamically stable
3-B-HCG<10,000
4-Exist of FHR
Methotrexate
treatment regimens include:
methotrexate
directly impairs
trophoblastic production of hCG with a secondary decrement of corpus luteum progestin secretionthe multiple dose, single dose,two-dose protocolSlide13
Methotrexate
by Direct Injection
bone marrow suppression,
hepatotoxicity
,
stomatitis, pulmonary fibrosis, alopecia, and photosensitivity
Side Effects
Fortunately, the side effects reported with methotrexate used to treat ectopic pregnancy have mostly been minor
Direct Injection of
Cytotoxic
Agents
Prostaglandins,
hyperosmolar
glucose, potassium chloride, and saline by direct injection have been tried as therapeutic alternatives to
methotrexateSlide14
Surgical
TreatmentRuptured Ectopic Pregnancy
laparotomy
or laparoscopy with
salpingectomy
is the first choice for rupture
Stable Ectopic Pregnancy
If methotrexate
is contraindicated, laparoscopic
salpingostomy
is the first surgical choice
Persistent Ectopic Pregnancy Following
Salpingostomy
:
drop of <50% from the preoperative level of B-HCG on postoperative day 1
prophylactic
methotrexate
administration is recommendedSlide15
Other methods
segmental excision followed by intraoperative
or delayed microsurgical
anastomosis
Manual
fimbrial
expression
Ectopic Pregnancy and Assisted Reproductive Technology
Incidence
Location
Tubal Pathology
Ovulation InductionSlide16
Rare Types of Ectopic Pregnancy
Abdominal Pregnancy
Incidence
Clinical manifestations
Diagnosis
treatment
Ovarian Pregnancy
Cornual
Pregnancy
Cervical Pregnancy
Heterotopic
PregnancySlide17
Summary Points
In most circumstances, ectopic pregnancy can be diagnosed before symptoms develop and treated definitively with few complications.Quantitative B-hCG testing, ultrasonography, and curettage allow early diagnosis of ectopic pregnancy and use of medical therapy as the initial therapy option.
Conservative surgical therapy and medical therapy for ectopic pregnancy are comparable in terms of success rates and subsequent fertility. Medical therapy is the preferred choice because of the freedom from surgical complications and lower cost.
Surgery is the treatment of choice for hemorrhage, medical failures, neglected cases, and when medical therapy is contraindicated.
Multiple-dose
methotrexate
is preferable to single-dose methotrexate, direct injection, or tubal cannulation and is the first choice for
unruptured, uncomplicated ectopic pregnancy.Laparoscopic salpingostomy or
salpingectomy
is favored for cases of intra-abdominal hemorrhage, medical failure, neglected cases, and complex cases when medical therapy is contraindicatedSlide18