By: Marie Zelle K. Vergel

DEFINITION  any implantation of a fertilized ovum at a site other than the endometrial lining of the uterus  Most common cause of maternal mortality

Intrauterine implantation

Ectopic implantation

LOCATIONS Sites and frequencies of ectopic pregnancy. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

LOCATIONS

TUBAL ECTOPIC

RISK FACTORS  Pelvic Inflammatory Disease (6-9%)  Endometriosis  History of prior ectopic pregnancy  History of tubal surgery and conception after tubal ligation  Use of fertility drugs (clomiphene citrate or injectable gonadotropin therapy)

RISK FACTORS  Use of assisted reproductive technology (in vitro fertilization and gamete intrafallopian transfer)  In utero exposure to diethylstilbestrol  Use of progesterone intrauterine device  Increasing age  Cigarette smoking

PATHOPHYSIOLOGY Dysfunction of the cilia which normally propel the fertilized ovum through the tube into the uterine cavity Disruption or scarring of fallopian tube Blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus Fertilized egg attaches to an area outside of the uterus (ampullary area of the fallopian tube) where it implants Sudden severe abdominal pain and abnormal bleeding from the vagina, usually scanty amounts or spotting

CLINICAL PRESENTATION  Remains asymptomatic until it ruptures  Usually present between GA 6-10wk  Symptoms:  Classical triad:  Amenorrhea  Abdominal pain  Vaginal bleeding  Other presentations  Syncope  Pelvic mass

CLINICAL PRESENTATION  Signs  Normal or slightly enlarged uterus  Pelvic pain with movement of cervix  Adnexal mass  Hypoactive bowel sounds  Hypotension  Acute abdomen

DIAGNOSIS  Complete Blood Count  Ultrasonography  Beta-HCG levels  Serum progesterone levels  Uterine curettage  Culdocentesis

CBC  hemoglobin  hematocrit  WBC

ULTRASONOGRAPHY  diagnostic test of choice  Ectopic pregnancy:  transabdominal ultrasonography  (-) intrauterine gestational sac  beta-hCG > 6,500 mIU per mL (6,500 IU per L)  transvaginal ultrasonography  (-) intrauterine gestational sac  beta-hCG => 1,500 mIU per mL (1,500 IU per L)

Red:uterine outline Green: uterine lining Yellow: ectopic pregnancy Blue: pseudosac

BETA-hCG LEVELS  36 % sensitive and 65 % specific  < 66% rise every 48 hours = ectopic

SERUM PROGESTERONE LEVELS  < 11 ng/ml = ectopic

UTERINE CURETTAGE

CULDOCENTESIS  (+) non-clotting blood = ruptured ectopic

 Combined transvaginal ultrasonography and serial quantitative beta-hCG measurements are approximately 96 % sensitive and 97 % specific for diagnosing ectopic pregnancy.  Therefore, transvaginal ultrasonography followed by quantitative beta-hCG testing is the optimal and most cost-effective strategy for diagnosing ectopic pregnancy

TREATMENT  Surgical  Laparoscopy vs laparotomy  Medical  Methotrexate

SURGERY  General anesthetic  Laparotomy vs. Laparoscopy  X-lap  hemodynamically unstable  large hemoperitoneum

SURGERY  Salpingostomy  <2cm in the distal third of fallopian tube  unsutured  Salpingotomy  <2cm in the distal third of fallopian tube  sutured  Salpingectomy

SURGERY  Hysterectomy

Medical Management  Advantages  Avoidance of surgery  Preservation of tubal patency  Lower cost  Chemical Agents  Previously studied  Hyperosmolar glucose, urea, prostaglandins, mefepristone (RU486), actinomycin,  Most commonly used  Methotrexate (MTX)

Methotrexate  Folinic acid antagonist  Inhibits dihydrofolic acid reductase  Toxic effects are related to does and duration of therapy

Criteria for receiving MTX  AOG < 6 weeks  Unruptured mass <3.5cm in diameter  No Fetal Cardiac motion detected  BHCG <10,000 mlU/mL  Some advocate for BHCG <5,000 mlU/mL  Hemodynamically stable patient  Patient desires future fertility  No active bleeding or signs of hemoperitoneum  Patient is reliable and able to return for followup care  Patient has no contraindications to MTX

Contraindications to MTX  Breastfeeding  Evidence of Immunodeficiency  Alcoholism, or chronic liver disease  Pre-existing blood dyscrasias  Active Pulmonary disease  Peptic Ulcer disease  Hepatic or Renal dysfunction  Known sensitivity to MTX  Gestational sac > 3.5cm  Embryonic cardiac motion