1. Management of ectopic pregnancy Dr.V.Ravimohan

2. Incidence 11.1/1000 pregnancies Treatment options 1.Expectant 2.Medical 3.Surgical

3. Ruptured ectopic with collapse Get help- call senior SPR/Consultant on call and anaesthetist ABC of resuscitation give facial oxygen Site two IV lines (at least 16g), commence IV fluids (crystalloid) Send blood for FBC, Clotting screen and cross-match at least 4 units of blood. insert indwelling catheter arrange theatre for laparotomy whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive monitoring of haemodynamic state do not wait for BP and pulse to normalise prior to transfer-resuscitation and surgery need to go hand in hand. Pfannensteil incision, locate tube directly and clamp salpingectomy and wash out of abdomen assess bloods consider CVP / HDU discuss with anaesthetist record operative findings including the state of the remaining tube/pelvis Anti – D immunoglobulin (250 IU)to be given to Rhesus negative women

4. Surgical Management

5. Salpingectomy Vs Salpingotomy No randomised controlled studies available Evidence from observational studies Case series Cohort Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contra lateral tubal disease and the desire for future fertility.

7. Persistent trophoblast When salpingotomy is done, protocols should be in place for the identification and treatment of women with persistent trophoblast. Monitoring serum HCG levels would help to identify the pesistenttrophoblast.

8. Criteria for medical therapy Selection criteria Minimal symptoms HCG <3,000 Absence of fetal heart beat Normal FBC,U&E(urea & electrolytes),LFT(liver function tests) Exclusion creiteria Any hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood dyscrasia(WCC <2000 cells cm3). Difficulty or unwillingness of patient for prolonged follow-up (average follow-up 35days). Ectopic mass >3.5mm The presence of cardiac activity in an ectopic pregnancy Women on concurrent corticosteroid therapy

10. Anti-D should also be given if required

11. Rest up to one hour after the injection.

12. Check for any local reaction.

14. Medical management.... Patient should be given information on(preferably written) Need for further treatment Adverse effects Women should be able to return easily for assessment at any time during follow-up Advice avoid sexual intercourse during treatment to maintain ample fluid intake use reliable contraception for three months after methotrexate has been given, because of a possible teratogenic risk.(barrier or hormonal) side effects of the drug are minimal but may include nausea, vomiting and stomatitis. avoid alcohol or folic acid containing vitamins during treatment. Avoid exposure to sunlight. Outcome 90% successful treatment with single dose regime. Recurrent ectopic pregnancy rate 10 – 20%. Tubal patency approximately 80%.

15. Medical management.... Day 1- Do FBC, LFTs, U &Es, serum hCG and give Methotrexate Day 4 – Do serum hCG Day 7 – Do serum hCG, FBC, LFTs and U&Es On day 4 and day 7 blood results should be reviewed by the doctor with regard to resolution, need for a second dose or surgical treatment. Then blood tests should be repeated once or twice weekly until levels of hCG drop below 20 IU/L.

16. Cost benefit Medical management is cheap in the initial period but considering the cost of follow up & the loss of work time for patient & carers no cost saving was seen at serum hCG levels above 1500 iu/l due to the increased need for further treatment and prolonged follow-up.

17. Expectant management of pregnancy of ectopic pregnancy Criteria for selection asymptomatic women with an ultrasound diagnosis of ectopic pregnancy. less than 100 ml fluid in the pouch of Douglas decreasing hCG levels that are less than hCG 1000 iu/l at initial presentation Adnexal mass less than 4 or 5 cm was the cut off for the studies assessing expectant management.

18. Monitoring Initial follow up twice weekly with serial hCGmeasurements weekly by transvaginal examinations By the first week drop in HCG level more than 50% Adnexal mass size more than 50% Otherwise reassess the options (Medical/Surgical) If the fall of HCG & reduction in size of adnexal mass satisfatory weekly hCG and transvaginal ultrasound examinations Till the HCG falls less than <20 IU

19. Expectant management of pregnancy of unknown location Selection criteria Clinically stable patient with minimal symptoms initial upper level of serum hCG of 1000–1500 iu/l Explain the possibility ectopic pregnancy to the patient. 44–69% of pregnancies of unknown location resolve spontaneously with expectant management Ectopic pregnancy was subsequently diagnosed in 14–28% of cases of pregnancy of unknown location Intervention has been shown to be required in 23–29% of cases.

20. Anti-D immunoglobulin Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin. Dose 250 IU

21. Follow up Women must be made aware of the risk of a further ectopic pregnancy My Web site www.mrcogexam.net Twitter: www.twitter.com/ravimohanv http://about.me/Ravimohan2 Source: Royal college of Obstetericians & Gynaecologists Guideline