Ectopic pregnancy Vaishali Mody, M.D.

Ectopic pregnancy
Vaishali Mody, M.D.
Incidence
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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
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Tubes
Ovaries
Cervix
Cornua
Abdominal
Risk Factors
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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
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Congenital
Segmental atresia, tubal diverticula, in-utero
DES
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Hormonal
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E (increases tubal motility), P (decreases)
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IUD use
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0.4 to 0.8 x more likely than no contraception
6-10 x more likely tubal if pregnant
Risk factors
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Other causes:
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Abortion (illegal abortions, 10-fold)
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Infertility (age, Rx -meds, surgery, IVF)
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Smoking (> 2-fold, nicotine effect)
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Fibroids, Endometriosis- no association
Symptoms
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Risk factor assessment - menstrual
pattern, prev.pregnancies, infertility/ Rx
of, current contraceptive use
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Symptoms - Triad: pain, amenorrhea,
vaginal bleeding
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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%
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Lab tests
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bHCG - doubling time (66% rise 48 hrs)
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15% normal IUP <66% rise in 48 hrs
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15% ectopics >66% rise in 48 hrs
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progesterone (>25 ng/ml, <5 ng/ml)
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>25 : 70% viable IUP, 1.5% ectopic
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<5 : Abnormal preg (normal preg in 1:1,500)
Ultrasound
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Normal IUP- g.sac (4 wks TVU)- eccentric
thick ring, double decidual sac sign(DDSS)
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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:
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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
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Ectopic ? nonviable IUP ? recent abortion
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D&C material -- place in a cup w/ saline
Float:
Chorionic villi
Does not float:
Decidual tissue
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? sensitivity & specificity (95% in some lit.)
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confirm w/ frozen section if any doubt
Culdocentesis
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Used widely prior to bHCG + US
Rarely used now
6% false positive tap
10-20% false negative tap
Laparoscopy
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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
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Surgical Rx
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Salpingectomy vs. salpingostomy
Linear Salpingostomy- preferred
Unruptured, future fertility unchanged
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Milking the tube
For Fimbrial ectopics
2-fold increase future ectopic vs linear
sal’ostomy when ectopic at ampullary region
Laparotomy vs Laparoscopy
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Surgeon expertise
Hemodynamic stability
Size and site of the ectopic (cornual,
interstitial)
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Hemoperitoneum- NOT a
contraindication for L/S
Future reproductive outcome - same
Medical management
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Methotrexate
Other: KCl, hyperosmolar glucose, PG, RU486
Future fertility outcome same as surgery
Criteria for medical therapy
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Hemodynamically stable, no hemoperitoneum
Size <3.5 cm, No cardiac activity
bHCG <15,000 (<10,000, 93% success rate)
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Unreliable patient, no future fertility desired
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Methotrexate
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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
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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
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0.5% to 1% of all ectopics
Most common non-tubal ectopic
upto 1:7,000 deliveries
Spiegelberg criteria
Cervical pregnancy
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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
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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
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Rx - surgical, leave placenta back if vascular
supply not identified.
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MTX - C/I , sepsis, death
Other Rare ectopic
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Interstitial/ Cornual ectopic1% of ectopics
Uterine rupture, massive h’hage, mortality
Laparotomy, cornual resection.
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Interligamentous ectopic
Preg. After hysterectomy
Multiple ectopics