ECTOPIC PREGNANCY Dr FAHMI ISHAQ EL-URI MRCOG FRCOG

ECTOPIC PREGNANCY Dr FAHMI ISHAQ EL-URI MRCOG, FRCOG. A. PROF OB/GYN

DEFINITION; • It is a gestation that implants outside ‘ • • • endometrial cavity. It is a serious hazard requiring prompt recognition & early aggressive intervention. >95% of ectopic pregnancies implant in various anatomic segment of ‘ fallopian tube including ‘ interstitial 1%, isthmic 5%, ampullary 85%, & infundibular+ fimbrial portion 9%. Other less common sites of ectopic are ‘ovary, cervix, & ‘ peritoneal cavity.

INTRODUCTION; • The diagnosis & management of ectopic pregnancy has undergone a revolution a century after Lawson Tait successfully performed a laparotomy to ligate ‘ broad ligament & remove a ruptured tube in 1883 (Tait 1884 ). Improved technology allows to diagnosis ectopic pregnancy before it ruptures , thus making lessinvasive treatment possible , resulting in reduced mortality & morbidity.

Incidence & Risk factors ; • In USA deaths due to ectopic pregnancy • was 9% of all maternal deaths in 1992 & its incidence has apparently increased fourfold (from 4. 5 to 20 / 1000 pregnancies) between 1970 and 1992(Centers for Disease Control 1995). In UK it represent 4. 2% of maternal deaths in 1991 -93, its incidence apparently doubling between 1973 -75 & 1991 -93(from 4. 9 to 9. 6 per 1000 pregnancy) (Department of Health 1994).

Mortality from Ectopic ; • The mortality , has decreased tenfold in the USA & fivefold in the UK during these timeframes. The increase in incidence has not been paralleled by a similar increase in ‘ incidence of STDs & other contributing factors such as reconstructive tubal surgery & assisted reproduction, the most important contributing factor is probably earlier & more accurate diagnosis.

Clinical presentation; • It can vary from vaginal spotting of old blood to vasomotor shock with haematoperitoneum ; the classic triad of delayed menses, irregular vaginal bleeding & abdominal pain is not commonly encountered (Speroff et al. 1994).

General Examination ; • Pulse rate & Blood pressure , because in vascular instability BP is low , fainting, dizziness & rapid heart rate. • Shoulder pain , occurs due to blood irritating ‘ diaphragm as a result of rupture ectopic pregnancy causing intra-abdominal bleeding.

Gynaecological Examination; • Speculum or bimanual examination must be performed in hospital because it may lead to rupture of ‘ tube.

Laparoscopy & uterine curettage; • These will confirm or exclude the diagnosis of extra-uterine pregnancy. • In ectopic pregnancy , ‘ uterine endometrium will undergoes focal decidual changes as a response to ‘ hormonal changes in pregnancy (Arias Stella reaction ). If ectopic pregnancy miscarries, as in cornual or cx ectopic , ‘ decidua will slough off as a cast.

Culdocentesis; • This test is used to exclude hemoperitoneum which is associated with ruptured ectopic pregnancy , therefore it is not useful in detecting an early ectopic pregnancy.

Human Chorionic Gonadotrophin(h. CG)& vaginal US. • (h. CG) can be detected in ‘ urine as early as 14 days postconception ; by sensitive enzyme-linked immunosorbent assays (detection limits 2550 IU/L; sensitivity 98%-100%). It can be detected in ‘ serum 5 -9 days postconception by immuno-radio active assays.

h. CG (continue) ; • Between 2 -4 weeks after ovulation serum h. CG levels double approximately every 2 days in normal pregnancy ; a lesser increase ( <66% over 48 hours ) is associated with ectopic pregnancy & spontaneous abortion. However , 15% of normal pregnancy will have an abnormal doubling time &13% of ectopic pregnancies will have a normal doubling time.

Continue ; • Therefore in order to increase ‘ sensitivity of quantitative h. CG , a discriminatory zone has been described whereby a titre of 1000 -1500 IU/L will be associated with ‘ presence of an intrauterine sac on transvaginal US ( 6000 -6500 IU/L for trans -abdominal US ). In mutiple pregnancy ‘ discriminatory zone would be a little higher , requiring an extra 2 -3 days for a sac to become visible.

Continue; • The demonstration of a viable intrauterine • pregnancy does not exclude ‘ possibility of heterotopic pregnancy (frequency 1/3000 -4000 spontaneously to 1%-3% after assisted reproduction). Transvaginal US; has resulted in’diagnosis of normal&abnormal pregnancy approximately 1 wk earlier than using transabdominal US. In ectopic , there an empty uterus, pseudo-sac , a tubal ring(doughnut or bagelsign) with fluid in ‘ pouch of douglas.

Management; • The classical treatment of ectopic pregnancy has always been surgical ie salpingectomy or salpingostomy, either by laparotomy or laparoscopy. Early diagnosis by US is now possible before ‘ onset of symptoms.

Non-Surgical approaches ; • Such as puncture & aspiration of ectopic • • sac. Local injections of prostaglandins, KCL, hyperosmolar glucose or methotrexate. Methotrexate has been used successfully in Japan & in USA, both by multiple IM doses or by single doses & both regimens have reported 95% success rate with a non- response rate and/ or tubal rupture of 3%-4%.

Conclusion: • The technological advances should ensure early diagnosis & less-invasive therapy, leading to a reduction in the mortality & morbidity of ectopic pregnancy