Definition

  • Implantation of conceptious outside uterine cavity
  • When Women in reproductive age present with pelvic pain and positive pregnancy test à Ectopic pregnancy until proven otherwise
 

Incidence

20:1000 pregnancies

  • Increasing from 11:1000 pregnancies
  • May due to improved technology (US resolution), increased Assisted reproduction, increase PID
  • Contribute to most significant death in 1st Trimester
 

Classification

Tubal (95% are in Fallopian tube)

  • Ampullary – 55%
  • Isthmic – 25%
  • Fimbrial – 17%
  • Interstitial – 2%

Others – <5%

  • cervical, ovarian, scar

Heterotopic

  • Ectopic pregnancy with combination of Intrauterine pregnancy
 

Risk Factors

  • only evidence in 25-50% cases
  • History of infertility
  • Assisted conception
  • History of PID (especially Chlamydia trachomatis)
  • Endometriosis
  • Prev Pelvic/ tubal surgery
  • Previous ectopic (recurrent 10-20%)
  • IUCD in situ
  • Smoking
  • Prior induced abortion

Symptoms

  • Pain (unilateral/ generalised)
  • amenorrhea (6-8 weeks)
  • PV bleed (occur up to 75% cases)
  • may be asymptomatic
  • shoulder tip pain (from intra-abdominal irritation secondary to haemoperitonium)
  • Collapse!

Signs

Acute abdomen

  • Peritonism
  • Guarding
  • Tenderness @ adnexa
  • Distension (in case of ruptured)

Cerical excitation

  • During VE
  • may indicate blood in pelvis
  • Adnexa mass
  • If ectopic large

Shock ! à This is emergency

  • Hypotension
  • tachycardia
  • Tachypnoea
  • GCS dropping
  • Cold peripheries
  • deteroriate end-organ perfusion

non specific signs

  • normal size uterus

Investigations

Pregnancy test

  • to confirm pregnancy

TVS

  • pick up 90% case
  • location
  • adnexal mass
  • presence of free fluid
  • If hCG >1500IU à should see IUP (Intrauterine Pregnancy) /EP (ectopic pregnanacy)

Progesterone

  • know whether pregnancy failing/ not
  • <20 nmol/L – suggestive failing
  • >60mmol/l – ongoing pregnancy

hCG

  • repeat 48 hours later
  • pattern ; doubling every 48 hours in normal pregnancy
  • rise >66% indicate IUP
  • suboptimal rise à suggest Ectopic Pregnancy
  • If serum b-hCG <5 mIU/ml à ectopic is excluded
  • if serum hCG >1500IU, US scan should visualise Intrauterine /Ectopic pregnancy

Laparoscopy

  • gold standard

FBC

  • To know degree of blood loss
  • Look at Hct, Hb

Group& Save/ Crossmatch

Management

Expectant

  • Need strict criteria for selection, also fulfilling Medical management criteria
  • Patient understand consequences, complications
  • Patient live close to hospital and can attend Hospital instantly during emergency
  • patient can attend follow up
  • Need to monitor serum hCG, initially and then every 48 hours until level fall, then weekly until <15IU
  • Also moniotr using Transvaginal Ultrasound weekly
  • serum progesterone <20mmol/l suggest ectopic that should resolve spontaneously
  • More successful if initial serum hCG <1000IU

Medical

  • Methotrexate (Folate antagonist) à destroys trophoblastic tissue
  • Success rate : up to 90%
  • Suitable for:
    • clinically stable
    • minimal symptoms
    • ectopic <3cm
    • no fetal cardiac activity
    • no evidence of haemoperitonium
    • hCG <3000IU
  • Dose
    • 50mg/m2
    • Around 75-90 mg for most women
  • Follow up hCG to check resolution
    • Should fall >15% between day 4 and 7 after treatment
    • If fall <15% à second dose Methotrexate will be given
    • At least 15% patiet treat medically need second dose Methotrexate
  • Contraindicated in Liver disease, renal diseease
  • Advise
    • Side Effect of Methotrexate
    • Avoid sexual intercourse during treatment
    • Keep ample fluid intake
    • Use contraception after treatment (for 3 months)

Surgical

Laparoscopy/ Laparatomy

  • Gold standard
  • Laparoscopy is preferable than laparotomy in haemodinamically stable patient

Salpingectomy

  • lower rate persistent trophoblast
  • Indicated when:
    • The tube is severely damaged
    • If contralateral tube healthy/ normal
    • No plan for future pregnancy/ complete family
    • Ectopic pregnancy >5cm size/ recurrent ectopic

Salpingotomy

  • increase risk residual trophoblast/ residual bleeding
  • Follow up hCG to ensure resolution
  • Suitable for those with contralateral tube disease/ desire future pregnancy (preferably laparoscopic salpingotomy)

Anti-D immunoglobulin

  • For rhesus negative mother with confirmed or suspected ectopic pregnancy
  • Dose of 250IU (50 microgrammes)
 

Post-Ectopic

  • 70% women will have intrauterine pregnancy
  • risk recurrent around 10-20%
  • If conceived, need to have early pregnancy scan to confirm the location of pregnancy

References

  • Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and gynaecology. Oxford University Press. 2nd edition 2008.
  • Sarris I, Bewley S, Agnihtori S. Training in Obstetrics And Gynaecology the essential curriculum. Oxford university Pres. 2009.
  • Green Top Guideline No. 21. RCOG. May 2004.
  • Dulay AT. Merk Manual: Ectopic Pregnancy. Feb 2010. [Online]

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