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ECTOPIC PREGNANCY ECTOPIC PREGNANCY

ECTOPIC PREGNANCY - PowerPoint Presentation

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ECTOPIC PREGNANCY - PPT Presentation

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

ectopic pregnancy methotrexate hcg pregnancy ectopic hcg methotrexate therapy medical dose choice ultrasonography surgical risk abdominal sac diagnosis injection

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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 contraceptionSlide4
Slide5

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 zoneSlide9
Slide10

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 diagnosisSlide11
Slide12

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