Danforth’s Obstetrics and Gynecology Tenth edition ECTOPIC PREGNANCY Danforth’s Obstetrics and Gynecology Tenth edition

Etiology and Risk Factors Ectopic pregnancy, the implantation of a fertilized ovum outside of the endometrial cavity a leading cause of life-threatening first-trimester morbidity Incidence Pathogenesis Sites of implantation Etiology and Risk Factors

Tubal Damage and Infection Salpingitis Isthmica Nodosa Diethylstilbestrol Cigarette Smoking Contraception: IUD Tubal ligation OCP Barrier contraception

Previous ectopic pregnancy 8.3 In utero exposure to DES 5.6 Use of IUD Risk Factor Odds Ratioa High risk Tubal surgery 21.0 Tubal ligation 9.3 Previous ectopic pregnancy 8.3 In utero exposure to DES 5.6 Use of IUD 4.2–45.0 Tubal pathology 3.8–21.0 Assisted reproduction 4.0 Moderate risk Iinfertility 2.5–21.0 Previous genital infections 2.5–3.7 Multiple sexual partners 2.1 Salpingitis isthmica nodosa 1.5 Low risk Previous pelvic infection 0.9–3.8 Cigarette smoking 2.3–2.5 Vaginal douching 1.1–3.1 First intercourse <18 y 1.6

Clinical Manifestations Symptoms: abdominal or pelvic pain vaginal bleeding or spotting a positive pregnancy test(mensturation delay) Signs: Abdominal tenderness rebound tenderness cervical motion tenderness tender adnexal mass

Diagnosis: serial measurements of B-hCG ultrasonography Ectopic pregnancy can be diagnosed as early as 4.5 weeks gestation serial measurements of B-hCG ultrasonography uterine sampling via manual vacuum extraction or curettage serum progesterone levels

Sonography Human Chorionic Gonadotropin ( B -hCG) 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 Eight-five percent of abnormal pregnancies, whether intrauterine or ectopic, have impaired B-hCG production with an abnormal rate of B-hCG rise Sonography 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 Some sonographic images, such as the pseudogestational sac, may mislead even an experienced examiner to falsely diagnose a gestational sac Ultrasonography should be used to document the presence or absence of an intrauterine pregnancy when the B-hCG levels have risen above the designated discriminatory cutoff zone

Progesterone Uterine Evacuation Although progesterone levels are higher in intrauterine pregnancies than in ectopic pregnancies, there is no established cutoff to use to discriminate between these two entities a low progesterone level of less than 5 ng/mL can rule out a normal pregnancy with almost 100% accuracy but does not differentiate whether that pregnancy is an abnormal one in the uterus or at an ectopic site Uterine Evacuation necessary when a transvaginal ultrasonogram and a rising or plateauing B-hCG level below the cutoff value are not sufficient for diagnosis

Treatment for Ectopic Pregnancy Medical Management: Methotrexate therapy The folic acid antagonist, methotrexate, inhibits de novo synthesis of purines and pyrimidines, interfering with DNA synthesis and cell multiplication methotrexate directly impairs trophoblastic production of hCG with a secondary decrement of corpus luteum progestin secretion 1-unruptured ectopic pregnancy measuring less than or equal to 4 cm by ultrasonography 2-Hemodynamically stable 3-B-HCG<10,000 4-Exist of FHR Methotrexate treatment regimens include: the multiple dose, single dose,two-dose protocol

Methotrexate by Direct Injection Side Effects bone marrow suppression, hepatotoxicity, stomatitis, pulmonary fibrosis, alopecia, and photosensitivity Fortunately, the side effects reported with methotrexate used to treat ectopic pregnancy have mostly been minor Direct Injection of Cytotoxic Agents Prostaglandins, hyperosmolar glucose, potassium chloride, and saline by direct injection have been tried as therapeutic alternatives to methotrexate

Surgical Treatment Ruptured Ectopic Pregnancy laparotomy or laparoscopy with salpingectomy is the first choice for rupture Stable Ectopic Pregnancy If methotrexate is contraindicated, laparoscopic salpingostomy is the first surgical choice Persistent Ectopic Pregnancy Following Salpingostomy: drop of <50% from the preoperative level of B-HCG on postoperative day 1 prophylactic methotrexate administration is recommended

Ectopic Pregnancy and Assisted Reproductive Technology Other methods segmental excision followed by intraoperative or delayed microsurgical anastomosis Manual fimbrial expression Ectopic Pregnancy and Assisted Reproductive Technology Incidence Location Tubal Pathology Ovulation Induction

Rare Types of Ectopic Pregnancy Abdominal Pregnancy Incidence Clinical manifestations Diagnosis treatment Ovarian Pregnancy Cornual Pregnancy Cervical Pregnancy Heterotopic Pregnancy

Summary Points In most circumstances, ectopic pregnancy can be diagnosed before symptoms develop and treated definitively with few complications. Quantitative B-hCG testing, ultrasonography, and curettage allow early diagnosis of ectopic pregnancy and use of medical therapy as the initial therapy option. Conservative surgical therapy and medical therapy for ectopic pregnancy are comparable in terms of success rates and subsequent fertility. Medical therapy is the preferred choice because of the freedom from surgical complications and lower cost. Surgery is the treatment of choice for hemorrhage, medical failures, neglected cases, and when medical therapy is contraindicated. Multiple-dose methotrexate is preferable to single-dose methotrexate, direct injection, or tubal cannulation and is the first choice for unruptured, uncomplicated ectopic pregnancy. Laparoscopic salpingostomy or salpingectomy is favored for cases of intra-abdominal hemorrhage, medical failure, neglected cases, and complex cases when medical therapy is contraindicated