Ectopic pregnancy Vaishali Mody, M.D. Incidence 16/1,000 reported pregnancies (CDC, 1989) Five fold increase over 1970 rates Age - highest 35-44 yrs (27.2/1,000) Race- AAF (20/1K) > CF (13/1K) 15 % of all maternal deaths (1989) Sites of Ectopic pregnancies Tubes Ovaries Cervix Cornua Abdominal Risk Factors Tubal damage (inflammation/ infection/ surgery) Previous PID, 13% (1 episode), 35% (2), 75% (3) Previous ectopic, 10-25% Previous tubal surgery for infertility Previous tubal sterilization, 5-16% (50% fulguration) Tubal sterilization reversal Risk Factors Congenital Segmental atresia, tubal diverticula, in-utero DES Hormonal E (increases tubal motility), P (decreases) IUD use 0.4 to 0.8 x more likely than no contraception 6-10 x more likely tubal if pregnant Risk factors Other causes: Abortion (illegal abortions, 10-fold) Infertility (age, Rx -meds, surgery, IVF) Smoking (> 2-fold, nicotine effect) Fibroids, Endometriosis- no association Symptoms Risk factor assessment - menstrual pattern, prev.pregnancies, infertility/ Rx of, current contraceptive use Symptoms - Triad: pain, amenorrhea, vaginal bleeding Hemodynamic instability : dizzy, light headed, unconscious Signs VS: unreliable if normal Abdomen: tender, rebound, Cullen’s sign Pelvis: Uterus - slightly enlarged Cervix - c.m.t. Adnexa - mass (50%) Clinical accuracy <50% Lab tests bHCG - doubling time (66% rise 48 hrs) 15% normal IUP <66% rise in 48 hrs 15% ectopics >66% rise in 48 hrs progesterone (>25 ng/ml, <5 ng/ml) >25 : 70% viable IUP, 1.5% ectopic <5 : Abnormal preg (normal preg in 1:1,500) Ultrasound Normal IUP- g.sac (4 wks TVU)- eccentric thick ring, double decidual sac sign(DDSS) Ectopic pregnancy Psuedogestational sac (8-29%), central Empty uterus Adnexal mass (g.sac, fetal pole, cardiac activity-17%, adnexal ring-35%-50%) Free fuid in peritoneum US D/D: bHCG >2,000, must see IUP if present. If no IUP seen, abnormal IUP or ectopic <2,000, D/D: normal early IUP, abnormal IUP, ectopic, recent abortion Adnexal mass: complex or solid, CL, hydrosalpinx, endometrioma, ovarian neoplasm (dermoid), fibroid. D&C Ectopic ? nonviable IUP ? recent abortion D&C material -- place in a cup w/ saline Float: Chorionic villi Does not float: Decidual tissue ? sensitivity & specificity (95% in some lit.) confirm w/ frozen section if any doubt Culdocentesis Used widely prior to bHCG + US Rarely used now 6% false positive tap 10-20% false negative tap Laparoscopy Gold standard Missed in 3-4% very small ectopic False positive - tortuous, distorted tube that is distended or discolored. Laparoscopic Images of Ectopic Tubal Pregnancies A right tubal ectopic pregnancy as seen at laparoscopy The swollen right tube containing the ectopic pregnancy is on the right at E The stump of the left tube is seen at L - this woman had a previous tubal ligation Treatment Surgical Laparoscopy, Laparotomy Medical Methotrexate Both are equally effective Surgical Rx Salpingectomy vs. salpingostomy Linear Salpingostomy- preferred Unruptured, future fertility unchanged Milking the tube For Fimbrial ectopics 2-fold increase future ectopic vs linear sal’ostomy when ectopic at ampullary region Laparotomy vs Laparoscopy Surgeon expertise Hemodynamic stability Size and site of the ectopic (cornual, interstitial) Hemoperitoneum- NOT a contraindication for L/S Future reproductive outcome - same Medical management Methotrexate Other: KCl, hyperosmolar glucose, PG, RU486 Future fertility outcome same as surgery Criteria for medical therapy Hemodynamically stable, no hemoperitoneum Size <3.5 cm, No cardiac activity bHCG <15,000 (<10,000, 93% success rate) Unreliable patient, no future fertility desired Methotrexate D#1 Labs- bHCG, CBC, LFT, renal panel MTX 50 mg/ m2 IM x 1 D#4 labs - bHCG D#7 labs - bHCG, CBC, LFT Repeat MTX on D#7 if <15% decrease in bHCG from D4 to D7 90% success rate Heterotopic pregnancy IUP + EUP 1: 30,000 Fertility Rx, IVF Always look at the adnexa even when normal IUP is seen Serial bHCG not helpful Rx- surgical removal of the EUP Ovarian ectopics 0.5% to 1% of all ectopics Most common non-tubal ectopic upto 1:7,000 deliveries Spiegelberg criteria Cervical pregnancy 1: 2,400 to 1:50,000 pregnancies Risk factors- prev abortions, Asherman’s syndrome, previous c/s, DES exposure, fibroids, IVF. Catastrophic bleeding - spont or at surgery T&C , large IV x 2, prepare for TAH Non surgical- MTX (IM or local) Abdominal ectopics 1:372 to 1:9,714 live births High maternal mortality and morbidity Rare term pregnancies (case reports) Perinatal morbidity/ mortality: IUGR, cong. Anomalies, pulmonary hypoplasia, pressure deofrmities, facial and limb asymmetry Rx - surgical, leave placenta back if vascular supply not identified. MTX - C/I , sepsis, death Other Rare ectopic Interstitial/ Cornual ectopic1% of ectopics Uterine rupture, massive h’hage, mortality Laparotomy, cornual resection. Interligamentous ectopic Preg. After hysterectomy Multiple ectopics
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