ECTOPIC PREGNANCY Baher Bashity Salama Awadalla Haythm Shehabir Mahmoud Al-Shawaf

 Leading cause of maternal deaths in the first trimester 1- 2%  Constituting 1- 2% of all conceptions  13%  13% of all maternal deaths. 13%  The rate of repeat ectopic pregnancy after a single ectopic pregnancy 13% 35%  Nulliparous women who have an ectopic pregnancy 35% 90%  After two ectopic pregnancies, infertility rates as high as 90% have been reported

 Ectopic pregnancy can be diagnosed as early as 4.5 weeks gestation  serial measurements of B-hCG  ultrasonography

 The B-hCG, produced by trophoblastic cells in normal pregnancy, has long been accepted to rise at least 66% and up to twofold every 2 days  85% of abnormal pregnancies, whether intrauterine or ectopic, have impaired B-hCG production with an abnormal rate of B- hCG rise

 transvaginal ultrasonography reliably detects intrauterine gestations when the B-hCG levels are between 1,500 and 2,500 mIU/mL  Diagnosis of an ectopic pregnancy can be made with 100% sensitivity but with low specificity (15% to 20%) if an extrauterine gestational sac containing a yolk sac or embryo is identified

Ectopic pregnancy can be treated : 1)conservative (expectant ). 2)medical. 3)surgical According to: 1)Clinical presentation. 2)Ultrasound finding. 3)B-HCG titer.

Anti-D Immunoglobulin D-negative women with an ectopic pregnancy who are not sensitized to D-antigen should be given anti-D immunoglobulin

 Criteria : 1.Ultrasound diagnosis of ectopic pregnancy 2.Clinically stable, Asymptomatic 3.Initial hCG is < 1000 IU/L and Rapidly decreasing 4.No identifiable extra uterine sac 5.No evidence of blood in the pouch of Douglas

 Women should be followed up twice weekly to ensure a rapid decrease in serum hCG and there after weekly until serum hCG is < 20 IU/L.  Success rates in these conditions are up to 88%

Methotrexate therapy o The folic acid antagonist, methotrexate, inhibits de novo synthesis of purines and pyrimidines, interfering with DNA synthesis and cell multiplication o methotrexate directly impairs trophoblastic production of hCG with a secondary decrement of corpus luteum progestin secretion Dose : 1 mg/kg Intramuscular Injection

 Diagnosis of unruptured ectopic pregnancy   -HCG <3000 IU/L  Adnexal mass ≤ 3.5 cm  No fetal heart in adnexae  Minimal free fluid on US  Haemodynamically stable  Normal FBC, LFTs, creatinine

 HCG > 5000 IU/L  Breastfeeding  Immunodeficiency / active infection  Chronic liver disease  Active pulmonary disease  Active peptic ulcer or colitis  Blood disorder  Hepatic, Renal or Haematological dysfunction

 Significantly worsening abdominal pain  Hemodynamic instability  Level of HCG do not decline by at least 15% between Day 4 & 7 post treatment  or plateauing HCG level after first week of treatment

Ruptured Ectopic Pregnancy laparotomy or laparoscopy with salpingectomy is the first choice for rupture, performed if the fallopian tube is extensively diseased or damaged Stable Ectopic Pregnancy If methotrexate is contraindicated, laparoscopic salpingostomy is the first surgical choice and Gold standard surgical method for unruptured ectopic pregnancy Ectopic Pregnancy Following Salpingostomy: drop of <50% from the preoperative level of B-HCG on postoperative day 1 prophylactic methotrexate administration is recommended

1. Positive pregnancy test Lower abdominal pain + Minimal Vaginal bleeding Asymptomatic with factors for ectopic pregnancy Risk factors Previous ectopic pregnancy Previous PID Tubal surgery Tubal Surgery Tubal pathology (PID, endometriosis Infertility, ovarian stimulation IUCD failure Sterilization failure Previous abdominal surgery DES exposure in utero Multiple sexual partners 2. History + clinical examination MANAGEMENT OF ECTOPIC PREGNANCY

If sure of date of LMP and /or Regular cycle, i.e. >6 wks. gestation, Arrange TV ultrasound If unsure of date of LMP and /or irregular cycle, Measure serum hCG If hCG <100 (?early Intrauterine/ ? Ectopic pregnancy If Hcg >1000, use protocol for suspected Ectopic pregnancy 3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000 Meet criteria for Methorexate treatment Does not meet criteria for methotrexate treatment Use methotrexate protocol Laproscopic /salpingotomy/ Salpingectomy ?Proceed to laparotomy OR Laparotomy if haemodynamically unstable

23 identified case of ectopic pregnancy between 1/1/2015 – 1/10/2015 incidance of ectopic pregnancy in hospital 0.46% Data collected from only 20 case. Factors considered: Mother Age, RF, primi or multi Gestational Age Symptom, Diagnosis management

Results 4 of the 20 cases were offered expectant / medical management although their beta hCG was too high as a violation of the protocol All but one of the cases for medical management needed second methotrexate dose

Conclusions Record Keeping was very poor in all cases The majority of cases were managed conservatively or medically The rate of 2 nd dose methotrexate was very high No major complications were reported

1.Not written Not done – improve medical record keeping 2.Use data collection sheet to improve data collection from cases 3.Re-audit after 6 months Please help me in this ???????

Thank you.