ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI

1. Ectopic Pregnancy
Dr. Shashwat Jani.
M. S. ( Obs – Gyn ), F.I.A.O.G.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Ectopic pregnancy is a high-risk condition
wherein a fertilized ovum gets implanted
outside the uterine cavity.
This condition poses a significant threat to
women of reproductive age and is a leading
cause of maternal death during the first
trimester.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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3. Incidence
• Ectopic pregnancy still contributes significantly to the cause
of maternal mortality and morbidity.
• While there has been about fourfold increase in incidence
over the couple of decades, but the mortality has been slashed
down by 80%.
• Recognition of high-risk cases , early diagnosis (even
before rupture) with the use of TVS, serum Beta-hCG
and laparoscopy have significantly improved the
management of ectopic pregnancy.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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4. Safety First
AIM has changed from
"Saving The Mother's Life"
to Recently
"Saving The Woman's Fertility"
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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5. Current Scenario
•Incidence is increasing
( From 1 % to 2.5 % )
* Increasingly detected
* Detected early
95 – 98 % of all ectopic are tubal
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
5

6. Common Sites
Tubal
• Ampullary  70-80 %
• Isthmic  10-15%
• Fimbrial end  5 – 10 %
• Interstitial / Cornual  2 -3 %
Others
• Abdominal  1 %
• Ovarian  0.5 %
• Cervical  0.3 %
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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7. Risk Factors
P I D  Most important factor ( 50 % )
Prior Tubal Surgery Infertility, Reversal, Sterilization
Past H/O ectopic  15 % & linearly increasing
Infertility
A R T / Ovulation induction
Progesterone only contraceptives, Em.Contraceptives
I U C D
Congenital factors, Old age, smoking, Vaginal douching
No risk factor found in many cases
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
7

8. Course Of
Ectopic Pregnancy
Spontaneous resolution
 Tubal abortion (Ampullary, fimbrial)
Resolution, Pelvic hematocele
Hematosalpinx
 Tubal rupture (Isthmic, interstitial - at 12-16 wks )
Acute
Chronic
Secondary abdominal
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
8

9. Ectopic – Clinical
Presentation
Classical triad found in only 1/3rd cases
Pain  90 % cases
Amenorrhoea  80 % cases
Bleeding  70 % cases
Fainting attack typical but rare
Symptoms of shock in acute rupture
It can be asymptomatic also
Ectopic pregnancy is a great deceiver
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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10. Clinical Presentation
Signs variably present
Adenexal mass
Adenexal tenderness
Cervical movements tenderness !
Features of acute abdomen
Cullen’s sign !!
(Superficial edema and bruising in the subcutaneous fatty
tissue around the umbilicus )
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
10

11. Different Presentations
•Emergency presentation - Suddenly, without warning
a woman is very unwell, collapses and is taken to
hospital in stage of haemoperitoneum and hemorrhagic
shock.
•Subacute presentation - The most common
presentation is with a missed period, positive pregnancy
test, some abdominal pain, and irregular vaginal
bleeding
•High Risk Pregnancy Group - After previous ectopic,
tubal surgery or assisted conception ( IVF) → detection
rate is high → women are primary observed.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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12. 19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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13. Discriminatory Zone
• The discriminatory zone is based upon the
correlation between visibility of the gestational sac and
the hCG concentration.
• It is defined as the serum hCG level above which a
gestational sac should be visualized by ultrasound
examination if an intrauterine pregnancy is present .
• In most institutions, this serum hCG level is 1500 or
2000 IU/L with TVS [ the level is higher [6500 IU/L] with
TAS.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
13

14. hCG Above The Discriminatory Zone
• Serum hCG greater than 1500 IU/L without visualization of
intrauterine or extrauterine pathology may represent a
multiple gestation  repeat the TVS examination and hCG
concentration two days later.
• An ectopic pregnancy can be diagnosed if the serum hCG
concentration is increasing or plateaued. Treatment can be
instituted.
• A falling hCG concentration is most consistent with a failed
pregnancy (eg, arrested pregnancy, blighted ovum, tubal
abortion, spontaneously resolving ectopic pregnancy).
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
14

15. 19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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16. Management
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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17. Expectant Management
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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18. Medical Management
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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19. Multiple Dose MTX Regimen
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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20. Methotrexate Precautions
 No intercourse
 Report immediately if fainting, dizziness or severe pain
 Drug contraindications : B F , liver & renal dis.,
immunodeficiency
 LFT & Blood counts baseline & after one week
 Initial rise of HCG in some patients on day 4 occurs.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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21. Surgical Management
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
21

22. Laparotomy Vs Laparoscopy
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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Laparotomy Laparoscopy
Morbidity More Less
Post operative adhesions More Less
Risk of future ectopic More Less !
Future fertility Same Same
Persistent ectopic Less ! More
Experience/Instruments Routine Special
Cochrane Database Review 2007

23. Abdominal Ectopic
•Primary/Secondary
•Studdiford Criteria
•Diagnosis  Typical symptoms
 USG / MRI / Xray
Management
Laparotomy
Cut cord flush to placenta to leave it behind
Methotrexate not recommended
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
23

24. Ovarian Ectopic
•Spigelberg criteria
•Association with IUD 20-90%
•No case of recurrent ovarian ectopic
•Management
 MTX
 Partial oophorectomy
 Oophorectomy
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
24

25. Cervical Ectopic
•Palman & McElin clinical criteria
•Very very rare but increasing with IVF
•H/o D & C in most cases
Treatment
Cervical suture
Suction followed by tamponade
Embolization
 MTx
Hysterectomy
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
25

26. Heterotopic Ectopic
• 1 in 30000, Increasing due to ART 1 in 4000
• Problem with diagnosis
• Serial bHCG are not helpful
• Laparoscopy is required.
• No systemic medical management
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
26

27. Persistent Ectopic
•Persistence of viable Trophoblast
•Grow & produce symptoms
•2 – 20 % after medical & surgical Rx.
•Need to followup all cases with B HCG
•Treatment is single dose methotrexate
•Prophylactic Mtx after Rx in every
case not recommended
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
27

28. Recurrence…
 An ectopic mother has got every chance of a viable birth
in 1 in 3 and a chance of recurrence of ectopic in 1 in 10.
 Patient is asked to report after she misses her period to
confirm and to locate the new pregnancy.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
28

29.  Incidence of subsequent intrauterine pregnancy
(IUP) is 60–70%, in women with unruptured tubal
ectopic pregnancy treated by conservative surgery.
 The incidence of subsequent ectopic pregnancy is
about 10–20% and successful conception is about 60%.
 Salpingostomy done for unruptured tubal ectopic
pregnancy does not increase the risk of ectopic
pregnancy compared to salpingectomy. Conservative
surgery for unruptured tubal ectopic pregnancy is
beneficial.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
29

30. Take Home Message…
 In clinically stable women in whom a nonruptured
ectopic pregnancy has been diagnosed, laparoscopic surgery or
intramuscular methotrexate administration are safe and
effective treatments. The decision for surgical or medical
management of ectopic pregnancy should be guided by the
initial clinical, laboratory, and radiologic data as well as patient-
informed choice based on a discussion of the benefits and risks
of each approach.
 Surgical management of ectopic pregnancy is required
when a patient is exhibiting any of the following: hemodynamic
instability; symptoms of an ongoing ruptured ectopic mass
(such as pelvic pain); signs of intraperitoneal bleeding.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
30

31.  If the concept of the hCG discriminatory level is to
be used as a diagnostic aid in women at risk of ectopic
pregnancy, the value should be conservatively high
(eg, as high as 3,500 mIU/mL) to avoid the potential
for misdiagnosis and possible interruption of an
intrauterine pregnancy that a woman hopes to
continue.
 The single-dose protocol may be most
appropriate for patients with a relatively low initial
hCG level or a plateau in hCG values, and the two-
dose regimen may be considered as an alternative to
the single-dose regimen, particularly in women with
an initial high hCG value.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
31

32.  The decision to perform a salpingostomy or
salpingectomy for the treatment of ectopic
pregnancy should be guided by the …
- Patient’s clinical status,
- Her desire for future fertility, and
- The extent of fallopian tube damage.
19-11-2018
Dr Shashwat Jani.
+91 99099 44160.
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33. 19-Nov-18 33
Dr Shashwat Jani.
+91 99099 44160.