Ectopic Pregnancy

Danielle E,et.al, Ectopic PregnancyFrom SurgicalEmergency to Medical Management. The Journal of the American Association of Gynecologic Laparoscopists. 2004 Feb;11(1):109-118 James Johnston Walker,MD, Ectopic pregnancy. Clinical Obstetrics and Gynecology.2007 Mar;50(1) 88-89 Mohamed Raheem.el al,Ectopic preganacy. The Middle East Journal of emergency medicine.2005 Mar ;5(1)

Epidemiology
A 2006 WHO analysis of cause maternal morbidity, pooled data from multiple geographic areas, the rate of death from ectopic pregnancy was 4.9%(0.4%-4.7%)

Epidemiology
With TVS and high sensitivity of hCG level, more than 80%can be diagnosed before rupture, 1970; 35.5/10,000 result in decline in the mortality rate

2000; 2.6/10,000

Epidemiology
Traditionally, rate of EP is around 1/100 pregnancies but over recent decades there has been rising ,associated with
Greater prevalence of STD Increase TS and reversal procedure Delay childbearing ART More successful clinical detection

Epidemiology
The risk for developing ectopic pregnancy
Black and other minority race (RR1.6), relate to socioeconomic factor Advance maternal age Impede the migration of conceptus
Anatomical defect Hormonal factor Pathologic factor

Presentation
Usually present between GA 6-10wk Main presenting feature are abdominal pain (69.3%) and vaginal bleeding(45.3%) Earlier diagnosis is important to allow intervention that will reduce morbidity and maximize further fertility

Presentation
Hx and PE do not reliably diagnosis to exclude EP, (9% no pain ,36% lack of adnexal tenderness) The present of risk factors should increase suspicion Tubal rupture is rarely sudden due to invasion of trophoblast , relative slow progress

Diagnosis
Serum hCG level
Diagnostic pregnancy
as early as 10 days following ovulation

Identifying abnormal pregnancy

Less than a 66% hCG levels during 48hr 15% of normal pregnancies would fall in the ectopic category, and 13% of the ectopic pregnancies would be missed.

Monitoring the resolution

Diagnosis
Progesterone
The usefulness is limited because significant number of tests fall in the intermediate range (5-25 ng/ml)

Diagnosis
TVS
TVS combine hCG level has improve the diagnostic accuracy At hCG 1500 IU/L ,IUP should be seen Heterotrophic pregnancy more common with the increased use ARTs (up to 1% of IVF versus 1/3,800 naturally conceived pregnancies)

Suspected ectopic (UPT positive) Clinical assessment Stable Laparotomy TVS Haemodynamically compromised

IUP

Empty Uterus

Empty uterus With adnexal mass/free fluid

Empty uterus

Empty uterus with adnexal mass/free fluid Laparoscopy

Serum hCG <1500

Serum hCG >1500

Repeat 48h later if stable

Rise by less than 66% Or condition worsens

66% or more rise

Repeat scan in 1 wk Unless condition changes

Treatment
Surgical option
Salpingotomy VS salpingectomy Laparotomy VS Laparoscopy

Nonsurgical treatment
Expectant management Metrotrexate

Combined medical-surgical treatment

Surgical option
In the past, laparotomy with salpingectomy was standard Recently, a more conservative surgical approach to unruptured ectopic pregnancy has been advocated to preserve tubal function.

Surgical option
Salpingectomy VS Salpingotomy
No RCT that specific compare laparoscopic salpingectomy and salpingotomy and the effects on subsequence fertility. Reviews of observational studies show no evidence that there is an increase in the rate of subsequence IUP

Surgical option
Salpingectomy VS Salpingotomy
Some studies show that the IUP rate were similar, other demonstrate a trend toward improved subsequence IUP rates with conservative surgery All studies suggest a trend towards an increased repeat ectopic rate with salpingotomy compares with salpingectomy

Surgical option
Salpingectomy VS Salpingotomy
Recent cohort studies suggesting that the future success has more to do with underlying pathology than the surgery undertaken

Surgical option
Salpingectomy VS Salpingotomy
If two or more of these prognostic factors ,
Hx of salpingitis / ectopic pregnancy/ tubal surgery, or presence of adhesions on the contralateral tube,

were present, the chances of a subsequent ectopic exceeded the chances of a successful pregnancy.

Surgical option
Salpingectomy VS Salpingotomy
Salpingectomy is the treatment of choice if the fallopian tube is extensively diseased or damaged as there is high risk of recurrent EP Salpingotomy is therapeutic option in an attempt to maintain fertility.

Surgical option
Salpingectomy VS Salpingotomy
Because of the risk of persistent trophoblast after salpingotomy ,close follow up is required with regular hCG assessment This results in short term cost of salpingotomy being greater ,however if need for assisted conception would make salpingotomy more cost-effective.

Surgical option
Persistent trophoblast
This is mostly a problem after salpingotomy Incidence around 8% More likely if the preoperative serum hCG are above 3000 IU/L There are insufficient data to recommended the correct definition and units needs to develop their criteria

Surgical option
Persistent trophoblast
Suggested criteria for starting the treatment are if hCG level fail to fall below 65% at 48hr postop or hCG level is greater than 10% at 10days postop. If diagnosed, MTX 50mg/m2 is preferable to repeat surgical procedure

Surgical option
Laparotomy VS Laparoscopy
In case where is rupture of tube and hemodynamically unstable ,laparotomy is preferred The decision on approach should be made by clinical state and skill of operator

Surgical option
Laparotomy VS Laparoscopy
Laparotomy is also associated with lower subsequent pregnancy rate but this may be due to the relative severity of cases In the small number of RCT, there is no difference in tubal patency and subsequence IUP but developed significantly less adhesions trend toward lower EP if laparoscopy was used.

Surgical option
Laparoscopy
Main benefits
shorter operation times Less intraoperative blood loss Shorter hospital stays Lower anesgesic requirement Shorter convalescence

Surgical option
In the surgical management, one must consider the patients desire for further childbearing. The couple is fully informed of the possibility of laparotomy with salpingectomy or more extirpative surgery. Even if neither tube can be saved, effort to preserve the uterus and at least one ovary to keep alive with the use of the IVF

Nonsurgical treatment
Expectant management
Many EPs will resolve spontaneously The range of success in observational studies is 44%-69%

Nonsurgical treatment
Expectant management
The success depend on the USG appearance and the level of hCG level
Adnexal mass 4 cm. Absence of a GS Free fluid <100ml hCG < 1000 IU/L and by fall at least 15% in first 24hr ;most predictive factor But no cut-off value has been found below which expectant management is uniformly safe

Nonsurgical treatment
Expectant management
Need serial hCG measurements twice a week and weekly TVS to ensure resolution,
(marked by a rapidly decrease hCG to less than 50% of initial level and reduction in size of mass by 7day)

Thereafter ,weekly hCG and TVS should be carried out until serum levels are less than 20 IU/L

Nonsurgical treatment
Expectant management
Should be counseled about the importance of compliance with follow-up and should have easy access to hospital However, tubal patency rates have been reported to be the same with either expectant or salpingotomy

Nonsurgical treatment
Metrotrexate
Folic antagonist, has been used for over 20years Aimed at patients before ectopic ruptures and who hemodynamically stable

Nonsurgical treatment
Metrotrexate
Metroxate can be successful at
small GS(<4cm) , lower serum hCG (<3000 IU/L) absence of blood in the peritoneal cavity and absent fetal heart activity.

High failure rate if progesterone>10ng/mL or hCG >5000IU/L or presence cardiac activity or yolk sac are seen

Nonsurgical treatment
Metrotrexate
Abdominal pain is common (75%) and some need to admit if rupture is suspected Should be advises to avoid SI ,maintain ample fluid intake during treatment and need to understand treatment and potential problem Contraception 3 mo after MTX has been given

Nonsurgical treatment
Metrotrexate
Benefit of single dose MTX is associate cost saving due to outpatient management However in RCT, cost saving were only seen when hCG below 1500 IU/L due to increased need for further treatment and prolong follow-up

Nonsurgical treatment
Metrotrexate
In a multicenter RCT found that patients treated with MTX had more limitations in physical and social functioning, worse health perceptions, less energy, more pain, more physical symptoms a worse overall quality of life, than surgically treated patients

Nonsurgical treatment
Metrotrexate
Systemic methotrexate therapy is contraindicated
hemodynamically unstable have signs of bone marrow depression liver or renal dysfunction, evidenced by leukopenia and/or thrombocytopenia,

Nonsurgical treatment
Metrotrexate
Work up prior to therapy should include CBC, LFT,BUN/Cr and coagulation S/E of MTX are rare and usually mild and include: nausea, vomiting, diarrhea, stomatitis, reversible alopecia, neutropenia, and pneumonitis.in high risk patient

Combined medical-surgical therapy

Local injection of MTX into the ectopic under USG or laparoscopy Although the local levels are high, the circulating levels of MTX are not decreased. In fact they are the same as if injected IM, as one would expect given the rapid systemic absorption of the antimetabolite.

Combined medical-surgical therapy

Laparoscopic salpingotomy VS Laparoscopic local MTX injection
Equally effective and with balanced advantages/disadvantages Local MTX injection
shorter operation time less need for surgical expertise

The salpingotomy
shorter hospitalization reduced risk of persistent trophoblastic activity

Combined medical-surgical therapy

Prophylactic MTX has been successfully used to reduce the risk of persistent ectopic pregnancy following the salpingotomy,
MTX1mg/kg IM, the rate was reduced from 14.5% to 1.9% in the study Group MTX 1 mg/kg, in the affected tube,reduced from 15.8% to 0% in the treatment group.

Combined medical-surgical therapy

Heterotopic pregnancies
Laparoscopic removal of the eccyesis had previously been the standard treatment A less invasive and safer is the local injection of KCl or hyperosmolar glucose directly into the ectopic GS MTX should not be used since its systemic absorption would endanger the IUP

Comparison between treatment methods

Pregnancy rate Expectant management Medical treatment 80%-88% 66% Recurrent EP 4.2%-5% 10%

starting hCG levels < 3000IU/L , the results are comparable with laparoscopic surgery 65% within a year over 80% in the long term 10-15%

Surgical treatment

outcome in the next pregnancy is as much to do with underlying pathology as the therapeutic option chosen.