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 • Myoelectrical activity altered by age and hormones • Perimenopausal women have ↑ risk • E2 & PG which ∆ tubal motility • Subfertile women have ⇑ risk • WITHOUT Tubal Factor Infertility

Ectopic Pregnancy • THINK ECTOPIC

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

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

Ectopic Pregnancy-Rate • THINK ECTOPIC

Ectopic Pregnancy-Etiology • Tubal Damage & Tubal Dysfunction

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

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

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

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%

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

Ectopic Pregnancy-Etiology • THINK ECTOPIC

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

EctopicPregnancy THINK ECTOPIC

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

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

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

Ectopic Pregnancy-Location • THINK ECTOPIC

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

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

Ectopic Pregnancy-Diagnosis • THINK ECTOPIC

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

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

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

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

Ectopic Pregnancy-Diagnosis • THINK ECTOPIC

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%

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

Ectopic Pregnancy Culdocentesis

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

Ectopic Pregnancy-Treatment • Medical • Surgical

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

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

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

Ectopic Pregnancy-Treatment • Surgical • Salpingostomy

Ectopic Pregnancy-Treatment • Surgical • Salpingectomy

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.

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

EctopicPregnancy

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

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

Ectopic Pregnancy