1. DR. JOHARA AL-MUTAWA Asst. Prof. & Consultant Obstetrics & Gynecology Department

2. Definition: Definition: Implantation outside uterine cavity Implantation outside uterine cavity Most common site is within fallopian tube 98%, in the distal ampulla than in the proximal isthmus, followed by corneal 2% and abdominal1.4%, ovarian 0.15% and cervical os 0.15% Most common site is within fallopian tube 98%, in the distal ampulla than in the proximal isthmus, followed by corneal 2% and abdominal1.4%, ovarian 0.15% and cervical os 0.15% Incidence: I in 100 of all pregnancies and  to 1 in 30 in high risk population arising in the west in parallel with  number of cases of chlamydia infection

6. Risk Factor for Ectopic Pregnancy Previous PID – chlamydia infection Previous PID – chlamydia infection Previous ectopic pregnancy Previous ectopic pregnancy Tubal ligation Tubal ligation Previous tubal surgery Previous tubal surgery Intrauterine device Intrauterine device Prolonged infertility Prolonged infertility Diethylstilbestrol (DES) exposure in-utero Diethylstilbestrol (DES) exposure in-utero Multiple sexual partners Multiple sexual partners

7. THE OUTCOME OF ECTOPIC PREGNANCY THE OUTCOME OF ECTOPIC PREGNANCY The muscle wall of the tube has not the capacity of uterine muscles for hypertrophy and distention and tubal pregnancy nearly always end in rupture and the death of the ovum. The muscle wall of the tube has not the capacity of uterine muscles for hypertrophy and distention and tubal pregnancy nearly always end in rupture and the death of the ovum. Tubal abortion – usually in ampullary about 8 weeks – forming pelvic haematocele Tubal abortion – usually in ampullary about 8 weeks – forming pelvic haematocele Rupture into the peritoneal cavity Rupture into the peritoneal cavity Occur mainly from the narrow isthmus before 8 weeks or later from the interstitial portion of the tube. Haemorrhage is likely to be severe. Occur mainly from the narrow isthmus before 8 weeks or later from the interstitial portion of the tube. Haemorrhage is likely to be severe. Sometimes rupture is extraperitoneal between the leaves of the broad ligament – Broad ligament haematoma. Haemorrhage is likely to be controlled Sometimes rupture is extraperitoneal between the leaves of the broad ligament – Broad ligament haematoma. Haemorrhage is likely to be controlled

8. Tubal pregnancy – effect on uterus Tubal pregnancy – effect on uterus The uterus enlarge in first 3 months as if the implantation were normal, reach the size of a gravid uterus of the same maturity. The uterus enlarge in first 3 months as if the implantation were normal, reach the size of a gravid uterus of the same maturity. Uterine decidua grows abundantly and when the embryo dies bleeding occurs as the decidua degenerates due to effect of oestrogen withdrawal. Uterine decidua grows abundantly and when the embryo dies bleeding occurs as the decidua degenerates due to effect of oestrogen withdrawal.

9. Clinical Finding: Variable - Early diagnosis Variable - Early diagnosis - location of the implantation - location of the implantation - Whether rupture has occurred - Whether rupture has occurred  Classic symptom trait with unruptured ectopic pregnancy:  Amenorrhoea, abdominal pain, abnromal vagina bleeding  Classic signs – adnexal or cervical motion tenderness. tenderness.  With ruptured ectopic pregnancy, finding parallel with the degree of internal bleeding and hypovolemia – abdominal guarding and rigidity, shoulder pain and fainting attacks and shock.

10. Symptoms and Signs: Symptoms and Signs: Pain – constant Pain – constant - Cramp-like - It may be referred to the shoulder if blood tracks to the diaphragm and stimulate the phernic nerve and it may be severe as to cause fainting. - The pain caused by the distension of the gravid tube by its effort to contract and expel the ovum and by irritation of the peritoneum, by leakage of blood. - Vaginal bleeding – occur usually after death of the ovum and is an effect of oestrogen withdrawal. It is dark, scanty and its irregularity may lead the patient to confuse it with the menstrual flow and give misleading history. 25% of cases presents without any vaginal bleeding

11. Cont. Cont. - Internal blood loss – severe and rapid. The usual sign of collapse and chock and it is less common than the condition presenting by slow trickle of blood into the pelvic cavity. - Peritoneal irritation – muscle guarding - frequency of micturation - frequency of micturation - fever - fever - misleading of appendicitis - misleading of appendicitis - Pelvic examination – extreme tenderness - cystic mass may be felt - cystic mass may be felt - Abdominal - tenderness in one or other fossa. - General tenderness and resistance to palpation over whole abdomen.

12. Differential diagnosis: Differential diagnosis: 1. Salpingitis 2. Abortion 3. Appendecitis 4. Torsion of pedicle of ovarian cyst 5. Rupture of corpus luteum or follicular cyst 6. Perforation of peptic ulcer.

13. Diagnosis: Diagnosis: -Careful history about LMP its timing and appearance. -Always think of tubal pregnancy women with lower abdomen pain in whom there is possibility of pregnancy should be regarded as having an ectopic until proved otherwise. -Pregnancy test nearly always be found by the time of clinical presentation. -Pregnancy test nearly always be found by the time of clinical presentation. -Ultrasound to exclude intrauterine pregnancy -Laparoscopy: for identifying an unruptured tubal pregnancy which is producing equivocal symptoms and for exclude salpingitis and bleeding from small ovarian cyst. -For operative treatment using minimally invasive methods.

14. Treatment: Treatment: If haemorrhage and shock present If haemorrhage and shock present Restore blood volume by the transfusion of red cells or volume expander Restore blood volume by the transfusion of red cells or volume expander Proceed with Laparotomy Proceed with Laparotomy The earlier diagnosis of tubal pregnancy has allowed a more conservative approach to management where the tube is less damage. The earlier diagnosis of tubal pregnancy has allowed a more conservative approach to management where the tube is less damage. Pregnancy removed from the tube by laparoscopy (salpingostomy) hopefully retaining tubal function. Pregnancy removed from the tube by laparoscopy (salpingostomy) hopefully retaining tubal function. Trophoblast destroyed by chemotherapeutic agent such as methotrexate Trophoblast destroyed by chemotherapeutic agent such as methotrexate

15. DIAGNOSIS: DIAGNOSIS: BHCG level BHCG level TVU TVU Medical Managment Medical Managment Methotrexate 1 mg/kg body weight Methotrexate 1 mg/kg body weight Indicationss: Indicationss: Haemodynamically stable, no active bleeding, No haemoperitneum, minimal bleeding and no pain Haemodynamically stable, no active bleeding, No haemoperitneum, minimal bleeding and no pain No contra indication to methotrexate No contra indication to methotrexate Able to return for follow up for several weeks Able to return for follow up for several weeks Non laparoscopic diagnosis of ectopic pregnancy Non laparoscopic diagnosis of ectopic pregnancy General anaesthesia poses a significant risk General anaesthesia poses a significant risk Unruptured adenexal mass < 4cm in size by scan Unruptured adenexal mass < 4cm in size by scan No cardiac activity by scan No cardiac activity by scan

16. HCG does not exceed 5000 IU/L HCG does not exceed 5000 IU/L Contraindications: Contraindications: Breastfeeding Breastfeeding Immunodeficiency / active infection Immunodeficiency / active infection Chronic liver disease Chronic liver disease Active pulmonary disease Active pulmonary disease Active peptic ulcer or colitis Active peptic ulcer or colitis Blood disorder Blood disorder Hepatic, Renal or Haematological dysfunction Hepatic, Renal or Haematological dysfunction

17. Side Effects: Side Effects: Nausea & Vomiting Nausea & Vomiting Stomatitis Stomatitis Diarrhea, abdominal pain Diarrhea, abdominal pain Photosensitivity skin reaction Photosensitivity skin reaction Impaired liver function, reversible Impaired liver function, reversible Pneumonia Pneumonia Severe neutropenia Severe neutropenia Reversible alopecia Reversible alopecia Haematosalpinx and haematoceles Haematosalpinx and haematoceles

18. Treatment Effects: Treatment Effects:  Abdominal pain (2/3 of patient)  Abdominal pain (2/3 of patient)  HCG during first 3 days of treatment  HCG during first 3 days of treatment Vaginal bleeding Vaginal bleeding Signs and Treatment failure and tubal rupture: Signs and Treatment failure and tubal rupture: Significantly worsening abdominal pain, regardless of change in serum HCG (Check CBC) Significantly worsening abdominal pain, regardless of change in serum HCG (Check CBC) Haemodynamic instability Haemodynamic instability Level of HCG do not decline by at least 15% between Day 4 & 7 post treatment 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  or plateauing HCG level after first week of treatment

19. Follow-Up: Follow-Up: Repeat HCG on Day 5 post injection if <15 % decrease – consider repeat dose Repeat HCG on Day 5 post injection if <15 % decrease – consider repeat dose If BHCG >15  recheck weekly until 15  recheck weekly until <25 ul/l Surgery should also considered in all women presenting with pain in the first few days after methotrexate and careful clinical assessment is required. If these is significant doubt surgery is the safest option Surgery should also considered in all women presenting with pain in the first few days after methotrexate and careful clinical assessment is required. If these is significant doubt surgery is the safest option SURGICAL MANAGEMENT:  Laparoscopy approach – salpingostomuy  Laprotomy – salpingostomy  salpingectomy

20. 1. Positive pregnancy test Lowe 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

21. 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