1. Early pregnancy complications-Early pregnancy complications-
Ectopic pregnancyEctopic pregnancy
Kapila GunawardanaMS,FRCOGKapila GunawardanaMS,FRCOG
B

2. MiscarriagesMiscarriages
Ectopic pregnancyEctopic pregnancy
Gestational Trophoblastic diseaseGestational Trophoblastic disease
``

3. IntroductionIntroduction
Ectopic pregnancy represent approximately 2% ofEctopic pregnancy represent approximately 2% of
all pregnancies. The risk of heterotopic pregnancyall pregnancies. The risk of heterotopic pregnancy
is approximately 1 in 10,000 to 1 in 30,000.is approximately 1 in 10,000 to 1 in 30,000.
However risk may increase up to 1 in 100 inHowever risk may increase up to 1 in 100 in
infertility clinics.infertility clinics.
Ectopic pregnancyEctopic pregnancy

4. Any pregnancy implanted outside the uterineAny pregnancy implanted outside the uterine
cavity.cavity.
Definition.Definition.

5. 5
The First Trimester
Implantation
in uterine wallFig. 2
Cleavage and
blastocyst
formation
cleavage
implantation
placentation
embryogenesis

6. Fertilization of the ovum occurs in the ampularyFertilization of the ovum occurs in the ampulary
part of the fallopian tube. As the zygote divides , itpart of the fallopian tube. As the zygote divides , it
becomes first a morula and then a blastocyst,becomes first a morula and then a blastocyst,
normally arriving in the uterine cavity andnormally arriving in the uterine cavity and
beginning implantation on day 6beginning implantation on day 6thth
after theafter the
fertlization. Anything that delays or impedes tubalfertlization. Anything that delays or impedes tubal
transport may allow implantation to begin whiletransport may allow implantation to begin while
the blasocyst is still in the tube or it can getthe blasocyst is still in the tube or it can get
dislodge out of the fimbrial end in to the peritonealdislodge out of the fimbrial end in to the peritoneal
cavity.cavity.
Patho-physiologyPatho-physiology

7. It is strongly associated with conditions that causeIt is strongly associated with conditions that cause
alterations to the normal mechanism of fallopian tubalalterations to the normal mechanism of fallopian tubal
transport. It has been postulated more damage that occurstransport. It has been postulated more damage that occurs
to the fallopian tube , higher the risk of ectopic pregnancy.to the fallopian tube , higher the risk of ectopic pregnancy.
InfectionInfection
Surgery (Tubal and non tubal pelvic surgery)Surgery (Tubal and non tubal pelvic surgery)
 congenital anomaliescongenital anomalies
TumorsTumors
Past history of ectopicPast history of ectopic
An IUCD( relative increase)An IUCD( relative increase)
Risk actorsRisk actors

8. Fallopian tube (95%)Fallopian tube (95%)
Ampula(12%)Ampula(12%)
Fimbriya(11%)Fimbriya(11%)
Cornua(2.4%)Cornua(2.4%)
Ovarian (3.2%)Ovarian (3.2%)
Abdominal(1.3%)Abdominal(1.3%)
Cervical(<1%)Cervical(<1%)
Locations of the ectopic pregnancyLocations of the ectopic pregnancy

10. Classic triadClassic triad
Abdominal painAbdominal pain
AmenorrheaAmenorrhea
Abnormal vaginal bleedingAbnormal vaginal bleeding
ExaminationExamination
Tachycardia, hypotensionTachycardia, hypotension
Cervical excitationCervical excitation
Adnexal tendernessAdnexal tenderness
Palpable massPalpable mass
UnremarkableUnremarkable
PresentationPresentation

11. History, Examination & InvestigationsHistory, Examination & Investigations
InvestigationsInvestigations
a) Transvaginal Ultrasounda) Transvaginal Ultrasound
b)Serum beta HCG levelsb)Serum beta HCG levels
c) Combination of above twoc) Combination of above two
have Sensitivity & specificityhave Sensitivity & specificity
of 90- 100%of 90- 100%
d) Laparoscopyd) Laparoscopy
DiagnosisDiagnosis

12. IUP rules out an ectopic pregnancy except the rareIUP rules out an ectopic pregnancy except the rare
possibility of hetertopic pregnancypossibility of hetertopic pregnancy
At POA of 5.5 weeks first maker of an IUP is aAt POA of 5.5 weeks first maker of an IUP is a
gestational sac with a double echogenic ringsgestational sac with a double echogenic rings
around the sacaround the sac
York sac appears at 5-6w and disappear at 10wYork sac appears at 5-6w and disappear at 10w
Embryo pole and cardiac activity first seen at 5-Embryo pole and cardiac activity first seen at 5-
6ws6ws
Psuedo sac may be seenPsuedo sac may be seen
Diagnosis cont..Diagnosis cont..

13. What is a Psuedo sac ?What is a Psuedo sac ?
Collection of fluid with in the endometrialCollection of fluid with in the endometrial
cavitycavity
Usually located centrally where as gestationalUsually located centrally where as gestational
sac is away from the centre.sac is away from the centre.
This is due to desidual bleeding in theThis is due to desidual bleeding in the
endometriumendometrium
This can be mistaken for an IUPThis can be mistaken for an IUP
Diagnosis cont..Diagnosis cont..

14. Serum Beta HCG levels and the TVSSerum Beta HCG levels and the TVS
findingsfindings
When Beta HCG level is > 6500mIU it is possible to see the IUP viaWhen Beta HCG level is > 6500mIU it is possible to see the IUP via
abdominal scanabdominal scan
When Beta HCG level is 1500- 2500mIU it is possible to see the IUPWhen Beta HCG level is 1500- 2500mIU it is possible to see the IUP
via TVS and if we cannot see IUP at this point, it is stronglyvia TVS and if we cannot see IUP at this point, it is strongly
suggestive of an ectopic. An exception would be early Multiplesuggestive of an ectopic. An exception would be early Multiple
pregnancypregnancy
Diagnosis cont..Diagnosis cont..

15. Predictive values of SerumPredictive values of Serum
Beta HCGBeta HCG
In normal pregnancy the doubling time of the BetaIn normal pregnancy the doubling time of the Beta
HCG would be 2 days. Usually after 48h there willHCG would be 2 days. Usually after 48h there will
be an increase of 60% in normal pregnancy.be an increase of 60% in normal pregnancy.
A rise lower than this is highly likely of anA rise lower than this is highly likely of an
abnormal pregnancy including an ectopic.abnormal pregnancy including an ectopic.
However , normal rise donot rule out ectopicHowever , normal rise donot rule out ectopic
pregnancy as well.pregnancy as well.
Diagnosis cont..Diagnosis cont..

16. When there is no conclusive evidence of TVS andWhen there is no conclusive evidence of TVS and
beta HCG levels ( specially HCG levels are in thebeta HCG levels ( specially HCG levels are in the
normal pregnancy level ) to diagnose an ectopicnormal pregnancy level ) to diagnose an ectopic
pregnancy , it is advisable to do a diagnosticpregnancy , it is advisable to do a diagnostic
curettage to see the histology.curettage to see the histology.
Continue with serial TVS and Beta HCG levels . IfContinue with serial TVS and Beta HCG levels . If
levels are declining can follow up conservatively. Iflevels are declining can follow up conservatively. If
rising or remains the same better to treat withrising or remains the same better to treat with
Metho- trexateMetho- trexate
Serum Progesterone levels > 25ng/ml is consistenceSerum Progesterone levels > 25ng/ml is consistence
of IUP.<5ng/ml is suspicious of an abnormalof IUP.<5ng/ml is suspicious of an abnormal
pregnancy.pregnancy.
Diagnosis cont..Diagnosis cont..

17. OptionsOptions
EExpectantxpectant
SurgicalSurgical
a) Laparotomya) Laparotomy
b)Laparoscopyb)Laparoscopy
MedicalMedical
TreatmentTreatment

18. Treatment will depend onTreatment will depend on
Stability of the patientStability of the patient
AgeAge
Fertility wishesFertility wishes
Patient wishesPatient wishes
Available facilitiesAvailable facilities
Skills of the attending doctorSkills of the attending doctor
Treatment cont…Treatment cont…

19. Surgical optionsSurgical options
If the patient is unstable immediate surgery viaIf the patient is unstable immediate surgery via
laparotomy or laparoscopy.laparotomy or laparoscopy.
When medical treatment is failed or undesirable.When medical treatment is failed or undesirable.
If the size of the ectopic is >5cm or live fetus seenIf the size of the ectopic is >5cm or live fetus seen
Refusal of the patient for medical or expectantRefusal of the patient for medical or expectant
management.management.
Treatment cont..Treatment cont..

20. Surgical optionsSurgical options
Pre operative assessment be carried outPre operative assessment be carried out
Preoperative i.v fluid be commenced via a widePreoperative i.v fluid be commenced via a wide
bore canulabore canula
An urgent blood investigation be sent (FBC)An urgent blood investigation be sent (FBC)
Pre operative counseling and reassurance be donePre operative counseling and reassurance be done
Appropriate surgical technique will be decidedAppropriate surgical technique will be decided
often in the operative suite (Salingostomy versusoften in the operative suite (Salingostomy versus
Salpingectomy)Salpingectomy)
Treatment cont…Treatment cont…

21. {{ {{
SalpingostomySalpingostomy
Wishes to preserveWishes to preserve
fertilityfertility
Contralaterar tube isContralaterar tube is
un healthyun healthy
Patient’s desire toPatient’s desire to
retain the tuberetain the tube
 SalpingectomySalpingectomy
 Recurrent ectopic in the sameRecurrent ectopic in the same
tubetube
 Severly damage tubeSeverly damage tube
 Uncotrolled bleedingUncotrolled bleeding
 Heterotopic pregnancyHeterotopic pregnancy
 Lack of desire to have furtherLack of desire to have further
fertilityfertility
 Persistent ectopic afterPersistent ectopic after
salpingostomy or expectantsalpingostomy or expectant
managementmanagement
Treatment cont…Treatment cont…
Salpingectomy vs salpingotomySalpingectomy vs salpingotomy

22. Make the incision on the antimesentric borderMake the incision on the antimesentric border
Incision will be made at the point of maximalIncision will be made at the point of maximal
distensiondistension
Remove the products of conception byRemove the products of conception by
hydrodesectionhydrodesection
Avoid excessive handlingAvoid excessive handling
Avoid excessive cautery at the siteAvoid excessive cautery at the site
Follow up with TVS and BetaHCG weekly isFollow up with TVS and BetaHCG weekly is
recommendedrecommended
Some have recommended prophylactic methotrexateSome have recommended prophylactic methotrexate
How do we do salpingostomy?How do we do salpingostomy?

23. One of the hazards of conservative managementOne of the hazards of conservative management
The risk is about 2-20%The risk is about 2-20%
This is common with an inexperienced operatorsThis is common with an inexperienced operators
If the Beta HCG is rising, it is recommended toIf the Beta HCG is rising, it is recommended to
go ahead with salpingectomygo ahead with salpingectomy
If the Beta HCG is plateaus, methotrexate isIf the Beta HCG is plateaus, methotrexate is
ecomendedecomended
Persistent ectopic or trophoblastsPersistent ectopic or trophoblasts

24. Criteria for medical treatmentCriteria for medical treatment
Absolute indicationsAbsolute indications
a) Haemodynamicaly stable without activea) Haemodynamicaly stable without active
bleeding or signs of haemoperitoneumbleeding or signs of haemoperitoneum
b) Desire for future fertilityb) Desire for future fertility
c) Non laparoscopic diagnosisc) Non laparoscopic diagnosis
d) Follow up can be done reliablyd) Follow up can be done reliably
e) Anesthesia posses riske) Anesthesia posses risk
f) No contra indication for methotrexatef) No contra indication for methotrexate
g) Unruptured mass < 3.5cmg) Unruptured mass < 3.5cm
i) No fetal cardiac activityi) No fetal cardiac activity
Treatment cont…Treatment cont…
Medical optionMedical option

25. Methotrexate has been the most successful drugMethotrexate has been the most successful drug
of choice.of choice.
Methotrexate is a folinic acid antagonistMethotrexate is a folinic acid antagonist
interfering with the synthesis of DNAinterfering with the synthesis of DNA
Two regimens have been describedTwo regimens have been described
a) Multiple doses + citrovorum rescuea) Multiple doses + citrovorum rescue
b) Single dose+ citrovorum rescueb) Single dose+ citrovorum rescue
Treatment cont…Treatment cont…
Medical optionMedical option

26. Multiple dose regimenMultiple dose regimen
 Methotrexate 1mg/kg/im EODMethotrexate 1mg/kg/im EOD
 Citrovorum rescue factor 0.1mg/kg EODCitrovorum rescue factor 0.1mg/kg EOD
 This be continued until there is a 15% decline inThis be continued until there is a 15% decline in
the level of HCGthe level of HCG
Treatment cont…Treatment cont…
Medical optionMedical option

27. Single dose regimenSingle dose regimen
Day 0 HCG +or – D&CDay 0 HCG +or – D&C
Day 1 HCG,FBC,LFT& Methotrexate 50mg/sqmDay 1 HCG,FBC,LFT& Methotrexate 50mg/sqm
Day 4 HCGDay 4 HCG
Day 7 HCGDay 7 HCG
Treatment cont…Treatment cont…
Medical optionMedical option

28. {{ {{ Predictor ofPredictor of
successsuccess
 Beta HCG levelsBeta HCG levels
 10001000
 2000-49992000-4999
 5000-99995000-9999
 >10,000>10,000
Success rateSuccess rate
98%98%
87%87%
87%87%
68%68%
Treatment cont…Treatment cont…
Medical optionMedical option

29. SurveillanceSurveillance
 Day 1 HCGDay 1 HCG
 Day 4 HCG level can plteau or rise and abdominalDay 4 HCG level can plteau or rise and abdominal
painpain
 Day 7 HCG levelDay 7 HCG level
 With the Successful treatment there will be .15%With the Successful treatment there will be .15%
decline of HCG from day 4-day 7decline of HCG from day 4-day 7
 Then weekly HCG levels are measured until HCGThen weekly HCG levels are measured until HCG
levels are <15mIUlevels are <15mIU
 If the decline is < than 15% from day4-day 7 andIf the decline is < than 15% from day4-day 7 and
patient is stable, a second dose can be givenpatient is stable, a second dose can be given
 If the response is poor may need explorationIf the response is poor may need exploration
Treatment cont…Treatment cont…
Medical optionMedical option

30. If the serum Beta HCG levels are <175mIU andIf the serum Beta HCG levels are <175mIU and
no evidence of progress of the pregnancy can beno evidence of progress of the pregnancy can be
manage conservatively with regularmanage conservatively with regular
surveillance. In successful cases usually the HCGsurveillance. In successful cases usually the HCG
levels will fall by at least 15% in the next 24hlevels will fall by at least 15% in the next 24h
Expectant managementExpectant management

31. Advise to avoid pregnancy for the next 3mAdvise to avoid pregnancy for the next 3m
Hysterosalphingogram after 3mHysterosalphingogram after 3m
In case if she misses her periods to see anIn case if she misses her periods to see an
obstetrician for confirmation of the pregnancyobstetrician for confirmation of the pregnancy
and its locationand its location
Long term follow upLong term follow up