Ectopic pregnancy

CS pregnancy national library of medicine Type EP Cause – best management ? Main objective. Prevention massive blood loss Conservation of uterus

Cause CSP ? Embryo implanation through a small dehicence or tract into uterine wall. First CSP and case Next 3 years 66 case

Expectant management woman desire to continue preg and us evidence, sac growing towards uterine cavity. termination recommended once diagnosis Ellective cs around wk

Conservative medical treatment Pain free Hemodynamically stable Less then 8 wk Myometrial thickness loss 2 mm CS bladder

Systemic methotrexate pregnancy < 9 wk Short half life MTX Fibrous tissue surrouding scar Can limit systemic absorption MTX Delaying disappearance G-sac Local MTX have greater success

MTX injected locally to G-sac TV ultrasound control gauge needle in case of concurrent embryo aspiration different embryocides kcl, hypertonic glucose Failed requiring MTX and uterine curretageVAE.

Combined treatment Hysterocopy : Identification G.sac, vessels coagulation Local injection techniques Rapid return to fertility Requires anesthesia, operative skills

Laparoscopy Laparotomy Uterine curretage An sac aspiration failure rate 70% inefective

Uterine artery embolization : UAE + cystemic MTX Well tolerated effective 64 blood loss 25 ml UAE + local MTX

212 ( ) Uterine arteery embolizatoin + intraarterial MTX h suction curretage Cystemic MTX 50mg if BHCG < 50% 50mg MTX abdominal guidance 5-6 months 2 wk BHCG

Uterine curettage and Sac aspiration blind uterine curettage + should be discouraged under US control G week < 7 wk Myometrial thickness > 3.5mm more reports documenting U-curettage ineffective

68 cases of CSP ( 40-28) TV Ultrasound guided embryo aspiration + MTX local 50 mg after on week 50 mg MTX IM Systemic MTX + curettage with hysteroscopy a week later 50 mg MTX IM 50% decreased BHCG, us indicate lower blood flow at the scare, curettage.

Figure 1. Ultrasound follow ‐ up at 5, 6 and 7 weeks gestation. At 5 and 6 weeks gestation (A and B), a midline sagittal transvaginal image demonstrating a gestational sac implanted at the isthmic region between the cervix and the empty uterine cavity (small arrows), i.e. anatomical location of a previous Caesarean section scar (large arrow). At 7 weeks gestation (C), a midline longitudinal transabdominal scan demonstrating an empty uterine cavity. The tip of the sac is bulging towards the bladder (large arrow).

Diagnosis Criteria interstitial EP Empty U-cavity G sac at least 1 cm lateral most borders U-cavity Myometrial bed thinning sac color Doppler us periphoblastic arterial flow

Interstitial pregnancy G-sac in uterin horn Hemodynamically stable conservative management sytemic methatrenate

Laparoscopic wedge resection Laparoscopy Laparoscopic salpingocentesis + MTX C-EP and I-EP systemic MTX+miferiston preserve fertility eliminate anesthesia

Cervical pregnancy 1/9000 pregnancy major predisposing factor D&C PCS IVF Asherman’s synd Prior EP Infertility Instrumentation on therapeutic – ab

Painless V-bleeding 1/3 lower ab – cramping Soft disproportionately large cervix an hour – glass shaped uterus US 81.8% correct diagnosis

Ushakou criteria ( C-preg ) G-sac in endocervix Intact portion C-canal between sac – endometrial Local invasion c-tissue Embryomic or fetal structures in sac Empty uterine cavity Hourglass uterus

On speculum examination Ex-os may be open fetal membranous, tissue pregnancy cystic lesion on cervical Lip.

Medical therapy : Hemodynamic stable Multidose MTX in very early cardiac activity, multidose MTX and intra Af and or intrafetal KCL Take a few months needle cc KCL 20%.

Surgical therapy main complication severe bleeding Transvaginal ligation cervical branches UA 3-9 o’clock Shirodkar cerclage, angiographic UA emb Intracervical vasopressin 20-30cc gauge needle 21 cervical stroma UAE

If implantation site bleeding Foley catheter (26) 30 ml balloon. After balloon deflated gradually hours to days and removed if bleeding picks up or recurs reinflated Angiographic embolization b-internal iliac artery ligation, U-A ligation, surgical evacuation several hours to 24 h. Hystrectomy

An ultrasonographic sagittal view shows the viable fetus within an ectopic gestational sac in the posterior cervical stroma.

A visible defect (black arrow) with prolapsing fetal membranes (black arrow) was seen in the posterior cervix.

This ultrasonographic image, obtained 1 week after direct instillation of methotrexate into the cervical ectopic gestational sac, shows the resolving ectopic pregnancy (white arrow).