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Ectopic Pregnancy

Ectopic Pregnancy. Peter L. Stevenson, MD, FACOG Associate Clinical Professor Wayne State University School of Medicine Obstetrics and Gynecology. Ectopic Pregnancy. Any Pregnancy Outside The Uterine Cavity Fallopian Tube is not Passive Conduit

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Ectopic Pregnancy

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  1. Ectopic Pregnancy • Peter L. Stevenson, MD, FACOG • Associate Clinical Professor • Wayne State University • School of Medicine • Obstetrics and Gynecology

  2. Ectopic Pregnancy • Any Pregnancy Outside The Uterine Cavity • Fallopian Tube is not Passive Conduit • Myoelectrical activity altered by age and hormones • Perimenopausal women have ↑ risk • E2 & PG which ∆ tubal motility • Subfertile women have ⇑ risk • WITHOUT Tubal Factor Infertility

  3. Ectopic Pregnancy • THINK ECTOPIC

  4. Ectopic Pregnancy-Rate • Increased rate: • Non-white population • Increased Maternal Age • Previous Ectopic • Previous Pelvic Infection (“PID”) • Previous Tubal Ligation

  5. Ectopic Pregnancy-Rate • 19.7 per 1000 pregnancies (CDC 1992, inpatients) • as high as 4% of all pregnancies (Currently) • Increased Incidence over last 40 years (↑ 3x) • Decreased Mortality (ca. 5 death/10,000 ectopic) • After first ectopic • 50 – 80 % next pregnancy intrauterine (IUP) • 10 – 25 % next pregnancy ectopic • ca. 30 % never conceive again

  6. Ectopic Pregnancy-Rate • THINK ECTOPIC

  7. Ectopic Pregnancy-Etiology • Tubal Damage & Tubal Dysfunction

  8. Ectopic Pregnancy-Etiology • Tubal Damage • Previous Documented Pelvic Infection (“PID”) • Previous Ectopic Pregnancy • Prior Surgery • Tubal Surgery • Infertility Surgery • Ruptured Viscus (Appendix) • Previous Occult Infection

  9. Ectopic Pregnancy-Etiology • Tubal Damage: Previous Pelvic Infection • Historically before antibx use – after infection • > 40 % pts ever able to concieve again • 5% risk of ectopic ( 6 X Increase) • Currently, after antibx treatment for infection • 70-80 % ABLE to conceive • 10-25 % risk of recurrent ectopic

  10. Ectopic Pregnancy-Etiology • Tubal Damage: Previous Pelvic Infection • Tubal Occlusion Occurs after Infection • 13 % after one infection of infection • 35 % after two episodes of infection • 75 % after three episodes of infection • Strong association with Clamydia • 30 % of ectopic culture positive • polymicrobial infections are the rule

  11. Ectopic Pregnancy-Etiology • Tubal Dysfunction • Ovulation Induction & Infertility • Extremes of Reproductive Age • Failures of Current Contraception: • Post Coital (“Morning After” Pill = OCP’s) < 4 % • Progesterone only OCP’s (“minipill”) 10% • Copper IUD’s 4% • Progesterone IUD’s 17% • Norplant 30%

  12. Ectopic Pregnancy-Etiology • Tubal Dysfunction • NOT Previous IUD users • No increased risk of ectopic after IUD removed • NOR Current Copper IUD users • IUD’s & Ectopics can be confusing: • IUD Pts are less likely to become pregnant • But if they conceive it is more likely an ectopic

  13. Ectopic Pregnancy-Etiology • THINK ECTOPIC

  14. Ectopic Pregnancy-Location • Tubal (Ampullary) • Interstitial • Abdominal • Primary – Implantation on viscera • Secondary – after Tubal Abortion • Cervical • Ovarian • Ligamentous • Heterotopic

  15. EctopicPregnancy THINK ECTOPIC

  16. Ectopic Pregnancy-Location • Tubal 95 % of all extra uterine pregnancies • Interstitial • Abdominal • primary • secondary • Cervical • Ovarian • Ligamentous • Heterotopic

  17. Ectopic Pregnancy-Location • Tubal 95 % of all extra uterine pregnancies • Ampullary 55 % • Isthmic 20 % • Fimbrial 17 % • Interstitial 4 % • All Others <5 % • Abdominal • Cervical • Ovarian • Ligamentous • Heterotopic

  18. Ectopic Pregnancy-Location • Ampullary • Tubal Abortion • Threatened (  Sx of ectopic: PAIN) • Incomplete • Complete • Blighted ova occur more commonly than IUP • 30 - 50 % of ectopic are non viable • without increase in aneuploidy as seen in IU AB’s

  19. Ectopic Pregnancy-Location • THINK ECTOPIC

  20. Ectopic Pregnancy-Diagnosis • Classic Triad ( B A P ) • Vaginal Bleeding  • Adnexal Mass • Pain • Classic Triad • Vaginal Bleeding  • Ammenorrhea ( = missed last menses) • Pain

  21. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal Bleeding  • Adenaxal Mass (or Ammenorrhea) • Pain • Abnormal Menses • ANY TIME YOU THINK ABOUT PREGNANCY • ANY TIME YOU THINK ABNL UTERINE BLEEDING

  22. Ectopic Pregnancy-Diagnosis • THINK ECTOPIC

  23. Ectopic Pregnancy-Diagnosis • First Pregnancy is ectopic • ca. 30% never pregnant again • 10 – 30% of future conceptions ARE ECTOPIC • morbidity increases with gestational age • 15 % ectopics rupture BEFORE missed menses • ca. 50 % ectopics have “NORMAL” menses

  24. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal bleeding, Pain & Adenexal Mass/Abnormal Menses • Serial ß-hCG’s • Serum Progesterone • Ultrasonography • Culdocentesis • Laparoscopy

  25. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal bleeding, Pain & Adenexal MassAbnormal Menses • Serial ß-hCG’s • Serum Progesterone • Ultrasonography • Culdocentesis • Laparoscopy

  26. Ectopic Pregnancy-Diagnosis • Serial ß-hCG’s • Expect ß-hCG’s to double every 2-3 days • (NL viable IUP Increases ≥ 66 %in 24 hrs) • 15 % of NL IUP DON’T, • 15 % of ectopics WILL • Doubling implies NL IUP • Stable or falling implies AB in progress • Rising, but not doubling

  27. Ectopic Pregnancy-Diagnosis • THINK ECTOPIC

  28. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal bleeding, Pain & Adenexal MassAbnormal Menses • Serial ß-hCG’s • Serum Progesterone • Ultrasonography • Culdocentesis • Laparoscopy

  29. Ectopic Pregnancy-Diagnosis • Serum Progesterone • Not a perfect test but helpful as adjunct • Pg > 25 ng/ml excludes most ectopic • 98.5 % of ectopic • NOT ectopic with FHM (> 7 wks) • Pg < 5.0 ng/ml excludes most viable IUP’s • Except 0.001%

  30. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal bleeding, Pain & Adenexal MassAbnormal Menses • Serial ß-hCG’s • Serum Progesterone • Ultrasonography • Culdocentesis • Laparoscopy

  31. Ectopic Pregnancy-Diagnosis • Ultrasonography: • GOAL find IUP, + FHM, w/o adnexal mass • ß-hCG > 2,000 mIU/ml IUP with vag probe • ß-hCG > 6,000 mIU/ml IUP with abd U/S • 5 wks LMP see gest sac • 6 wks LMP see embryo (“fetal pole”) • 7 wks LMP see + FHM • if no IUP seen ECTOPIC until proven otherwise

  32. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal bleeding, Pain & Adenexal MassAbnormal Menses • Serial ß-hCG’s • Serum Progesterone • Ultrasonography • Culdocentesis • Laparoscopy

  33. Ectopic Pregnancy Culdocentesis

  34. Ectopic Pregnancy-Diagnosis • Classic Triad • Vaginal bleeding, Pain & Adenexal MassAbnormal Menses • Serial ß-hCG’s • Serum Progesterone • Ultrasonography • Culdocentesis • Laparoscopy • DIAGNOSIS & TREATMENT

  35. Ectopic Pregnancy-Treatment • Medical • Surgical

  36. Ectopic Pregnancy-Treatment • Medical • Methotrexate 50mg/m2 ( ca. 85mg ) • Criteria: ß-hCG < 2000 • Sac size < 3 cm** ( 8 weeks LMP ) • No FHM & Unruptured gest sac • Contraindictions: • Abnl LFT’s ( > 2X NL) • Renal Function ( > 2X NL) • WBC < 1500 • Follow up ß-hCG Day 4 & 7 • Expect ß-hCG  15 % per week ** Some authors 3.4 or 4 cm

  37. Ectopic Pregnancy-Treatment • Medical • Methotrexate Therapy • 59% patients have PAIN, up to several weeks • Surgical intervention if: • Increased pain and dropping hemaglobin

  38. Ectopic Pregnancy-Treatment • Medical • Surgical • Laparotomy • Salpingectomy • Salpingostomy • Laparoscopy • Salpingostomy • Salpingectomy

  39. Ectopic Pregnancy-Treatment • Surgical • Salpingostomy

  40. Ectopic Pregnancy-Treatment • Surgical • Salpingectomy

  41. Ectopic Pregnancy-Diagnosis • A simple algorhythm • ANY woman of reproductive age • not more than 2 years after T/L • with a history of: • abnl bleeding • ammenorrhea • adnexal mass • pelvic pain • GETS A ß-hCG.

  42. Ectopic Pregnancy-Diagnosis • A simple algorhythm • Any women of reproductive age who is not more than 2 years after T/L with a history or ammenorrhea, abnl bleeding, pelvic pain or mass gets a ß-hCG. • If the ß-hCG is > 2000mIU/ml, she gets an U/S. • If the U/S is equivocal, repeat ß -hCG in 48 hrs • If the ß-hCG didn’t double or a mass noted • she goes for Laparoscopy. • If ANY CONCERN, Hospitalize for Observation, • get a PG, follow serial ß hCG’s and CBC’s

  43. EctopicPregnancy

  44. Ectopic Pregnancy • THINK ECTOPIC So you don’t miss an ectopic

  45. Ectopic Pregnancy • Peter L. Stevenson, MD, FACOG • Associate Clinical Professor • Wayne State University • School of Medicine • Obstetrics and Gynecology

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