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Women Ectopic Pregnancy PowerPoint Presentation

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Slide 1 - Ectopic Pregnancy Dr. Yasir Katib MBBS, FRCSC, Perinatologist
Slide 2 - Introduction Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity The most common extra-uterine location is the fallopian tube, which accounts for 98%
Slide 3 - Types of EP
Slide 4 - Sites of EP Heterotopic Pregnancies: 1 in 30 000
Slide 5 - Epidemiology 2nd leading cause of overall maternal mortality in US Leading cause of pregnancy-related deaths during T-1 1-2% of all diagnosed pregnancies
Slide 6 - Epidemiology Incidence is   incidence of salpingitis d/t chlamydia or other STI Improved diagnostic techniques  age Blacks >non-whites>whites Most occur in multigravid women > 50% in women with  3 pregnancies 10-15% in nulligravid women
Slide 7 - Mortality Causes 15% of maternal deaths Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion Cause of death due blood loss (80%)I infection (3%) anesthesia (2%) Interstitial & abdominal 5X > risk of death than other sites
Slide 8 - Of Historical Note……. 1693 1st documentation of unruptured ectopic 1752 Infertility linked to EP mid 19th century Path reports stressed pelvic inflammation as cause of EP 1800s 30 abd operations in (5 women survived) If not treated, 1 out of 3 survived (better!)
Slide 9 - Risk Factors for EP Definite (high risk) Previous EP Any tubal surgery or sterilization procedure In-utero DES exposure
Slide 10 - Risk Factors for EP Probable (modrate risk) PID Infertility “Superovulating agents” Pergonal, Clomiphene citrate Multiple sexual partners  Smoking
Slide 11 - Risk Factors for EP Uncertain Association (low risk) IUCD Vaginal douching  Maternal age (extremes) Use of reproductive techniques In vitro fertilization Gamete intrafallopian transfer Embryo transfer
Slide 12 - Classic TRIAD of EP Delayed menses Irregular vaginal bleeding Abdominal pain Most commonly NOT encountered
Slide 13 - Symptoms of Ectopic Pregnancy
Slide 14 - Signs of EP * 20% of masses occur on the side opposite the EP.
Slide 15 - Differential Diagnosis Complication of IUP Abortion Early pregnancy plus uterine fibroid or ovarian tumour Conditions causing acute abd pain Torsion of ovarian tumour, FT, or subserous pedunculated fibroid Salpino-oophoritis Pelvic pain with an IUCD in situ Appendicitis
Slide 16 - Differential Dx – cont’d Conditions causing hemoperitoneum Ruptured corpus luteum Ruptured follicular cyst Ruptured endometriotic cyst Conditions simulating a pelvic hematocele Retroverted gravid uterus Pelvic or tubo-ovarian abcess
Slide 17 - Management of EP Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50% 20% of EP occur as surgical emergencies Delay is justified only to correct shock
Slide 18 - Acute Management of EP Remember your ABCs Oxygen Large bore IV(s)  crystalloids Blood Labs CBC, coagulation studies, T & C -hCG
Slide 19 - Usefulness of Quantitaive -hCG Assessment of pregnancy viability Serial rise usually indicates a normal pregnancy Correlation with ultrasonography With titers > 1500 IU/L, TVUS should ID an IUP With multiple gestation, a gestational sac will not be apparent until titer rises a little higher Assessment of treatment results Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD
Slide 20 - The Importance of TVUS Documentation of an intrauterine sac A viable IUP should be identified when -hCG > 1500 IU/ml Adnexal mass An EP > 2 cm should be identified Adnexal cardiac activity Detectable when -hCG is ~ 15 000 – 20 000
Slide 21 - U/S – Is it EP or miscarriage?
Slide 22 - Surgical Management of EP Radical Salpingectomy with/out oophorectomy Conservative Salpingotomy Salpingostomy or segmental resection  does not  repeat EP rate fimbrial evacuation (traumatizes the endosalphinx & is assoc with  rate of recurrent EP (24%) compared with salpingectomy
Slide 23 - Medical Management of EP Methotrexate (MTX) 1st used in Japan in 1982 Antimetabolite that interferes with dihydrofolate reductase Considered for low -hCG Success rate 67%-94% Indications Hemodynamically stable pt good F/U Recurrent EP following Sx intervention
Slide 24 - Methotrexate – cont’d Contraindications Evidence of rupture Serum -hCG > 5 000 IU/L (varies) FH detected on U/S Adnexal mass> 3.5 cm on U/S Unreliable pt F/U unavailable Laparoscopy required to make dx Solid adnexal masses (germ cell tumour) Free fluid > 30ml
Slide 25 - Methotrexate Protocol Exclude contraindications as well as No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST,ALT, urea, Cr, CBC) Informed consent 5% risk of hematoperitoneum 2° to rupture of EP following MTX MTX 50mg/m² body surface area (~1mg/kg) given IV or IM
Slide 26 - Methotrexate Protocol – cont’d Pt F/U repeat serum quantitative -hCG in 3-4 days, 7days, then weekly until < 10 IU/L If > day-4 level at day-7  repeat MTX If -hCG fails to fall by at least 25%/week at any time repeat dose U/S not required routinely Pt should avoid Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)
Slide 27 - Methotrexate Protocol – cont’d What to expect Majority experience some degree of abd pain (occurs in ~ 50% at day-6) Shedding of a decidual cast Moderate vaginal bleeding Side effects (usually at higher doses) Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx
Slide 28 - Expectant Mx of EP Anticipates spontaneous regression of EP Occurs in ~ 57% Symptoms, HCG titers, & U/S findings followed Risk of tubal rupture is 10% if HCG levels < 1000 Criteria include Sonographic diameter < 3cm Initial -hCG < 1 000 IU/ml, no  in 2-day period, subsequent levels  asymptomatic
Slide 29 - Future Fertility following EP Subsequent conception rate is ~ 60% Incidence of recurrent EP is 15% Other factors influencing include: Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis No difference b/t laparoscopy vs laparotomy
Slide 30 - Prevention of EP Treat salpingitis early & correctly MTX management lowers rate of subsequent EP Risk of EP is  with all methods of contraception, except progesterone containing IUCDs Remember Rh Sensitization Rhogam for the Rh-neg woman
Slide 31 - The End
 

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