the management of ectopic pregnancy in women

1. Clinical manifestations, diagnosis,
and management of ectopic
pregnancy
Military Maternity Hospital
Dr.Kahtan Sbeqi
25 february 2013

2. INTRODUCTION
The diagnosis of ectopic pregnancy is based
on a combination of quantitative assay for
human chorionic gonadotropin (hCG) and
findings on high resolution transvaginal
ultrasonography (TVUS)
CLINICAL MANIFESTATIONS
History — The classic symptoms of ectopic
pregnancy
• Abdominal pain
• Amenorrhea
• Vaginal bleeding
Physical examination

3. Risk factors for ectopic pregnancy
High
 Previous ectopic pregnancy
 Previous tubal surgery
 Tubal ligation
 Tubal pathology
 In utero DES exposure
 Current IUD use
Moderate
 Infertility
 Previous cervicitis (gonorrhea, chlamydia)
 History of pelvic inflammatory disease
 Multiple sexual partners
 Smoking
Low
 Previous pelvic/abdominal surgery
 Vaginal douching
 Early age of intercourse (<18 years)

4. Differential diagnosis :
 urinary tract infection
 kidney stones
 diverticulitis
 appendicitis
 ovarian neoplasms
 endometriosis
 endometritis
 leiomyomas
 pelvic inflammatory disease
 pregnancy-related conditions
Recommended diagnostic tests
 TVUS
 hCG
 Other diagnostic tests (eg, serum progesterone level,
curettage, laparoscopy, culdocentesis)

5. 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
transabdominal ultrasound).
HCG above the discriminatory zone
 serum hCG greater than 1500 IU/L without
visualization of intrauterine or extrauterine
pathology may represent a multiple gestation

6.  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)
HCG below the discriminatory zone
 A serum hCG concentration less than 1500
IU/L should be followed by repetition of hCG
in three days to follow the rate of rise

7.  A normally rising hCG concentration should be
evaluated with TVS when the hCG reaches the
discriminatory zone. At that time, an intrauterine
pregnancy or an ectopic pregnancy can be
diagnosed
 If the hCG concentration does not double over 72
hours , then the pregnancy is abnormal (an
ectopic gestation or intrauterine pregnancy that is
destined to abort). The clinician can be reasonably
certain that a normal intrauterine pregnancy is not
present
 A falling hCG concentration is most consistent
with a failed pregnancy (eg, arrested pregnancy,
blighted ovum, tubal abortion, spontaneously
resolving ectopic pregnancy)

8. Ancillary diagnostic tests
Progesteron
a level less than 5 ng/mL (15.9 nmol/L) was highly
unlikely to be associated with a viable pregnancy
Curettage
 the use of curettage as a diagnostic tool is limited
by the potential for disruption of a viable
pregnancy
 false negatives results can occur
 it recommended performing curettage only on
women with both a hCG concentration below the
discriminatory zone and a low doubling rate
Doppler
Doppler examination can be performed when an
adnexal mass is seen

9. Laparoscopy
Laparoscopy is rarely required for diagnostic
purposes only
Culdocentesis
a culdocentesis positive for blood is nondiagnostic
Magnetic resonance imaging
It is not a cost effective approach
UNCOMMON TYPES OF ECTOPIC PREGNANCY
Heterotopic pregnancy
Combined intrauterine and extrauterine pregnancy
(heterotopic pregnancy) is rare, except among
women conceiving through IVF
Early diagnosis of heterotopic pregnancy is difficult
because of lack of symptoms

10.  Surgery (salpingectomy) is the standard treatment
of
heterotopic pregnancy with a tubal component
 Cervical pregnancy, Ovarian pregnancy, Interstitial
pregnancy, Abdominal pregnancy, Intramural
pregnancy
NATURAL HISTORY
 Rupture : Salpingectomy is the most common
surgical approach when the tube has ruptured.
 Tubal abortion may be accompanied by severe
intraabdominal bleeding, necessitating surgical
intervention, or by minimal bleeding, not requiring
further treatment.
 The incidence of spontaneous resolution of an
ectopic pregnancy is unknown

11. MANAGEMENT
 expectant
 medical
 surgical
Specific indications for surgical therapy
include:
• Hemodynamic instability
• Impending or ongoing ectopic mass rupture
• Not able or willing to comply with medical
therapy posttreatment follow-up
• Lack of timely access to a medical institution
for management of tubal rupture
• Failed medical therapy

12. SURGICAL TREATMENT
SURGICAL PROCEDURE
Salpingostomy versus salpingectomy
salpingostomy is performed in women who are
hemodynamically stable and appear to have a
reasonable probability of future normal tubal function
in the affected tube
salpingectomy is performed in the following situations:
 Uncontrolled bleeding from the implantation site
 Recurrent ectopic pregnancy in the same tube
 Severely damaged tube
 Large tubal pregnancy (ie, greater than 5 cm)
 Women who have completed childbearing (with or
without a tubal sterilization procedure), or who will be
treated with in vitro fertilization
The disadvantage of salpingostomy is the potential risk
of persistent or recurrent ectopic pregnancy

13. Laparoscopy versus laparotomy
Laparoscopic surgery is the standard
surgical approach for ectopic pregnancy
Laparoscopic salpingostomy resulted in:
 significantly shorter operation time
 less perioperative blood loss
 shorter duration of hospital stay
 shorter convalescence time
 lower costs.

14. OUTCOME AND PROGNOSIS
Persistent ectopic pregnancy
 is 4 to 15 percent
 is generally higher after laparoscopic
salpingostomy than after open procedures
 weekly measurement of serum beta-hCG
concentration after laparoscopic salpingostomy
 a single serum beta-hCG measurement one week
after surgery
 A level that is less than 5 percent of the
preoperative value is consistent with complete
resolution of the ectopic pregnancy
 administer a single dose of methotrexate (50
mg/m2 intramuscularly

15.  prophylactic treatment with one dose of
methotrexate can be given after all salpingostomies
Medical treatment
 While surgical approaches are the mainstay of
treatment
 advances in early diagnosis facilitated the introduction
of medical therapy with methotrexate (MTX)
CANDIDATES FOR MEDICAL TREATMENT
Optimal candidates
 hemodynamically stable,
 willing and able to comply with posttreatment follow-
up,
 have a human chorionic gonadotropin beta-subunit
(hCG) concentration ≤5000 mIU/mL,
 and no fetal cardiac activity. Ectopic mass size less
than 3 to 4 cm

16. Contraindications
 Hemodynamically unstable
 Signs of impending or ongoing ectopic mass
rupture (ie, severe or persistent abdominal pain or
>300 mL of free peritoneal fluid outside the pelvic
cavity)
 Clinically important abnormalities in baseline
hematologic, renal or hepatic laboratory values
 Immunodeficiency, active pulmonary disease,
peptic ulcer disease
 Hypersensitivity to MTX
 Coexistent viable intrauterine pregnancy
 Breastfeeding
 Unwilling or unable to be compliant with post-
therapeutic monitoring
 Do not have timely access to a medical institution

17. Relative contraindications
 High hCG concentration
 Fetal cardiac activity
 Large ectopic size
 Peritoneal fluid
 Other:: sonographic evidence of a yolk sac
, isthmic location of ectopic mass (rather
than ampullary), high pretreatment folic
acid level ,and rate of hCG rise or fall prior
to and within several days following
treatment

18. Efficacy of single versus multidose
 The two most commonly used protocols for MTX
administration are single dose and multiple dose
(four MTX doses which alternate with oral
leucovorin).
 is used multidose MTX therapy for interstitial
pregnancies
Precautions during therapy
 Avoid vaginal intercourse and new conception
until hCG is undetectable
 Avoid pelvic exams during surveillance of MTX
therapy due to theoretical risk of tubal rupture
 Avoid sun exposure to limit risk of MTX dermatitis
 Avoid foods and vitamins containing folic acid
 Avoid nonsteroidal antiinflammatory drugs, as the
interaction with MTX may cause bone marrow

19. Pretreatment testing and instructions
 hCG concentration
 Transvaginal ultrasound
 Blood group and Rh(D) typing; give anti
Rh(D) immune globulin 300 mcg IM, if
indicated
 Complete blood count
 Liver and renal function tests
 Discontinue folic acid supplements
 Counsel patient to avoid nonsteroidal
antiinflammatory medications, recommend
acetaminophen if an analgesic is needed
 Advise patient to refrain from sexual
intercourse and strenuous exercise

20. Multiple dose protocolSingle dose protocolTreatment
day
hCG concentrationhCG concentration1
MTX 1 mg/kg bodyweight IMMTX 50 mg/m2 body surface area IM
LEU 0.1 mg/kg PO2
hCG3
If <15 percent hCG decline from day 1
to 3, give MTX 1 mg/kg IM
If ≥15 percent decline from day 1 to 3,
begin weekly hCG
LEU 0.1 mg/kg PO*hCG (protocols vary, see day 7)4
hCG5
If <15 percent hCG decline from day 1
to 3, give MTX 1 mg/kg IM
If ≥15 percent decline from day 1 to 3,
begin weekly hCG
LEU 0.1 mg/kg PO*6
hCGhCG7
If <15 percent hCG decline from day 1
to 3, give MTX 1 mg/kg IM
If <15 percent hCG decline from day 4 to 7 (OR <25
percent decline from day 1 to 7), give additional dose
of MTX 50 mg/m2 IM
If ≥15 percent decline from day 1 to 3,
begin weekly hCG
If ≥15 percent hCG decline from day 4 to 7 (OR ≥25
percent decline from day 1 to 7), draw hCG
concentration weekly until hCG is undetectable

21. MEDICAL VERSUS SURGICAL TREATMENT
compared methotrexate therapy with laparoscopic
salpingostomy
 Intramuscular MTX therapy (single or multiple
dose) and salpingostomy yielded similar treatment
success rates
 Adverse effects and complications were more
common in women treated with systemic MTX
than with surgery
 Physical and psychological functioning after
treatment was improved for patients treated with
single dose MTX
 The time required for hCG concentrations to reach
undetectable levels is faster after laparoscopic
surgery,

22.  Posttreatment tubal patency and
intrauterine pregnancy rates were similar
 Risk of recurrent ectopic pregnancy did
not differ by treatment approach.

23. Expectant management of ectopic pregnancy
CANDIDATES FOR EXPECTANT MANAGEMENT
Selection criteria
when we suspect ectopic pregnancy, but TVUS fails to
reveal extrauterine findings suggestive of ectopic
pregnancy and the beta-human chorionic
gonadotropin (hCG) concentration is low (≤200
mIU/mL) and declining
Contraindications
• Hemodynamically unstable
• Signs of impending or ongoing ectopic mass rupture
(ie, severe or persistent abdominal pain or >300 mL of
free peritoneal fluid outside the pelvic cavity)
• hCG that is greater than 200 mIU/mL, is increasing, or
is not declining
• Unwilling or unable to comply with monitoring
• Does not have timely access to a medical institution

24.  Success rates for expectant management of
ectopic pregnancy is 70 percent
FOLLOW-UP
 We suggest following the hCG level every 48
hours for three measurements to confirm that
it continues to decline, and then weekly until
it is undetectable
SUMMARY AND RECOMMENDATIONS
 For women with suspected ectopic
pregnancy, we recommend avoiding
expectant management if the serum beta-
human chorionic gonadotropin concentration
is >200 mIU/mL (Grade 1B). We treat these
women with methotrexate or surgical therapy.

25.  Women with ectopic pregnancy who are
hemodynamically unstable require surgery
 In women with tubal ectopic pregnancy, who are
good candidates for MTX therapy
(hemodynamically stable, able to comply with
follow-up, hCG <5000 mIU/mL, no fetal cardiac
activity), we suggest MTX therapy rather than
laparoscopic surgery (Grade 2B). In stable women
who do not meet these criteria, we suggest
laparoscopic surgery rather than MTX (Grade 2C)
 We suggest a single dose over multiple dose
regimen (Grade 2B)
 , we use a multidose regimen for interstitial
pregnancy.
 We suggest not using mifepristone with MTX

26.  We recommend laparoscopic salpingostomy
rather than an open surgical procedure (Grade
1B). A disadvantage of laparoscopic
salpingostomy is that it is associated with a
higher rate of persistent trophoblast than open
salpingostomy.
 After an ectopic pregnancy,. Recurrent ectopic
pregnancy occurs in 15 percent ,the
recurrence risk rises to 30 percent following
two ectopic pregnancies.
 If the woman does not conceive in the first 12
to 18 months after surgical therapy of ectopic
pregnancy, or her contralateral tube is
damaged or absent, referral for in vitro
fertilization is appropriate.

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