2. Headings
• Definition
• Incidence and epidemiology
• Types of ectopic pregnancy
• Risk factors
• Clinical presentation
• Diagnosis
• Management
• Recent advances in management
3. Definition
“Any pregnancy where the fertilized ovum gets implanted & develops in a site
other than normal uterine cavity”.
Ectopic pregnancy occurs around 1-2% of all pregnancies
Recurrence rate 15% after 1st , 25 % after 2nd ectopic pregnancy.
The most recent MBRRACE report (2016) reveals almost 5% of all maternal
deaths in reporting period are directly related to ectopic pregnancy
Between 6-16% of women who attend emergency departments in the first
trimester with pain or vaginal bleeding with have an ectopic pregnancy
Incidence epidemiology
12. IF PREGNACY TEST TURNS Negative(-ve)
MBRRACE Report
Massive
pulmonary
embolus
Thrombolysis
13. Diagnosis
Proper history (cycle, pregnancy, PID, infertility, gynecological
surgery, contraception).
Clinical examination (Proper general,abdominal, vaginal and
vitalsigns).
Judicious use of investigation.
14. Investigations
• The mainstay for diagnosis of ectopic pregnancy
Transvaginal ultrasound
Quantitative serum HCG
• TV USS had a sensitivity 87-99% and specificity of 94 -99%
• Correlation of less conclusive scan findings with quantitative measurement
of serum Hcg can be helpful.
• Ectopic pregnancy in modern practice are diagnosed with a hcg under
1000iu/l.
• Serum progesterone level is not useful in predicting ectopic pregnancy .
15. • Ectopic pregnancy are associated with a below optimal < 66% rise Hcg
over 48 hours or a largely static HCG.
• Miscarriage may become clinically apparent due to the amount of
vaginal bleeding and would correspond to a fall in hcg levels, with a
50% decrease over 48hours meaning viable pregnancy is very
unlikely.
19. PREGNANCY OF UNKNOWN LOCATION
INTRAUTERINE
PREGNANCY
“It used to classify a pregnancy when a woman has
+ve pregnancy test but no pregnancy can be seen
on ultrasound’’
7-20% proved to be ectopic pregnancy.
20. In cases where
imaging is suboptimal
TRANSABDOMINAL
ULTRASOUND
Uterine fibroid Congenital uterine
abnormalities
22. Expectant Management
Criteria for selection….(RCOG-greentop-21-guideline)
Asymptomatic pt
Hemodynamically stable
Lower beta hcg value<1000IU/ml
Adnexal mass <3cm without cardiacactivity
Pregnancy of unknown location
SUCCESS RATE =57-100%
• Repeat B-HCG = weekly until <20iu/l or NIL
23. Medical Management
• Minimal symptoms/ hemodynamically stable
• No signs or symptoms ofactive bleeding / haemoperitoneum.
• HCG<3000(RCOG)
• Normal CBC,RFT,LFT
• Size<4cm
• Absence of cardiac activity
• Good compliance and follow up can be assured(RCOG)
• Women should be given clear information(preferably written)about
the possible need for further Tt and adverse effects following Tt
(RCOG)
24. Single dose regimen
If B-hcg levels drop by >15%
monitor B-hCG weeklyuntil non pregnant level
If b-hcg level drops by <15%
repeat dose of MTX on day 4 and if needed on D7
MTX 50mg/m2 on day 0
Measure B-hCG level on days 4 & 7
23-30% success rate
25. • Medical management of non tubal EP is preferred for cervical
pregnancy as surgery has high failure rate , it is also an option for
table women where the avoidance of surgery is preferred with an
interstitial pregnancy ,ovarian , and small abdominal pregnancy.
• Caesarean scar pregnancy is amenable to both medical an surgical
treatment.
26. Surgical management
• Aim of surgical management
Confirm the diagnosis
Stop intraperitoneal bleeding
Remove ectopic pregnancy tissue
28. • Salpingectomy
If no any future fertility
is desired
• Salpingectomy
Should the woman wish to
concave naturally &
contralateral tube appears
healthy
• Salpingotomy
If woman wish to conceive
naturally in future &
contralateral tube appears
unhealthy
31. • All unsensitised woman of rhesus –ve blood group with any form of
surgical management of EP, bleeding is repeated or is heavy …..
receive a prophylactic dose of Anti D ANTIBODIES 250IU I/M to avoid
in advertent rhesus sensitization
32. Take home massage and recent
advancements
• Refinements in risk stratification at first point of contact in antenatal
visit
• Tvs and quantitative serum hcg measurements are mainstay in
diagnosis
• Management is highly case dependant .
• A randomized controlled trial of placebo or gefitinb(on oral epidermal
growth factor receptor agent )used in combination with MTX to
hasten resolution of EP is underway