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 less-invasive 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 / 1000pregnancies) 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(hCG)& vaginal US. (hCG) can be detected in ‘ urine as early as 14 days postconception ; by sensitive enzyme-linked immunosorbent assays (detection limits 25-50IU/L;sensitivity 98%-100%). It can be detected in ‘ serum 5-9 days postconception by immuno-radio active assays .

hCG (continue) ; Between 2-4 weeks after ovulation serum hCG 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 hCG , 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 are 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 early diagnosis & less-invasive therapy, leading to a reduction in the mortality & morbidity of ectopic pregnancy