1. Rukset Attar, MD, PhD Obstetrics and Gynecology Department
ECTOPIC PREGNANCY
Rukset Attar, MD, PhD
Obstetrics and Gynecology Department

2. is a complication of pregnancy in which the pregnancy implants outside the uterine cavity
1.4-2 %
With rare exceptions, ectopic pregnancies are not viable.
About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes
The classic symptoms of ectopic pregnancy include:
abdominal pain,
the absence of menstrual periods (amenorrhea),
vaginal bleeding.

3. The pain is caused by
prostaglandins released at the implantation site, and
free blood in the peritoneal cavity, which is a local irritant.
If left untreated, about half of ectopic pregnancies will resolve without treatment

5. An intrauterine sac should be visible by transvaginal ultrasound when the β-hCG is approximately 1000 mIU/mL, and by transabdominal ultrasound approximately 1 week later, when the β-hCG is 1800–3600 mIU/mL.

6. Classification Tubal pregnancy Pregnancies can grow in
the fimbrial end (5% of all ectopics),
the ampullary section (80%),
the isthmus (12%),
and the cornual and interstitial part of the tube (2%).
Isthmic pregnancies rupture earliest, at 6 to 8 weeks’- due to the small diameter of this portion of the tube.
Ampullary pregnancies rupture later, generally at 8–12 weeks.
Interstitial pregnancies are the last to rupture, usually at 12–16 weeks, as the myometrium allows more room to grow than the tubal wall

7. Nontubal ectopic pregnancy
Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal
Heterotopic pregnancy
The survival rate of the uterine fetus of an ectopic pregnancy is around 70%

8. Persistent ectopic pregnancy
refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy.
After a conservative procedure such as a salpingotomy some trophoblastic tissue perhaps deeply embedded may escape removal and continues to growth, generating a new rise in hCG levels.

9. The most effective way to identify persistent ectopic pregnancies is to monitor serum b-hCG levels during the postoperative period.
Recommendations have varied from every 3 days to 2 weeks
Women in whom the serum b-hCG concentration falls less than 50% are more than 3 times as likely to have a persistent ectopic pregnancy
serum b-hCG on postoperative day 1 and every 3–7 days thereafter, depending on the rate of decline, until levels are undetectable.
For those who exhibit evidence of persistent ectopic pregnancy (rising or slowly falling postoperative b-hCG concentrations), the single-dose methotrexate treatment regimen (50 mg/m2 i.m.) is highly effective.

10. Causes
one third to one half of ectopic pregnancies, no risk factors can be identified.
Risk factors include:
pelvic inflammatory disease,
infertility,
use of an intrauterine device (IUD),
those who have been exposed to DES,
tubal surgery,
smoking,
previous ectopic pregnancy, and
tubal ligation

11. Symptoms
Early signs include:
Pain
Vaginal bleeding

12. Diagnosis
An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test
ultrasound
β-hCG
Serum progesteron levels
laparoscopy or laparotomy
Culdocentesis
Cullen's sign

14. Treatment Expectant management Medical methotrexate Surgical
laparoscopy or laparotomy
salpingostomy
salpingectomy

15. Expectant management Tubal ectopic pregnancies only
Decreasing serial -hCG levels
Diameter of the ectopic mass not >3.5 cm
No evidence of intra-abdominal bleeding or rupture by transvaginal sonography

16. Medical treatment
hCG < 5,000
No cardiac activity
Mass < 4cm

17. Absolute Requirements
Hemodynamic stability
No evidence of acute intra-abdominal bleeding
Reliable commitment to comply with required follow-up care
No contraindications to methotrexate treatment

18. Contraindications to Methotrexate Treatment
Breastfeeding
Immunodeficiency states
Hematologic abnormalities (severe anemia, leukopenia, thrombocytopenia)
Known sensitivity to methotrexate
Active pulmonary disease
Active peptic ulcer disease
Alcoholism
Clinically important hepatic or renal dysfunction

19. Preferred Characteristics
Absent or mild symptoms (pain)
Serum concentration less than 5,000 IU/L
Absent embryonic heart activity
Ectopic mass measuring less than 4 cm in diameter

20. Pre-treatment evaluation:
Complete blood count
Blood type and Rh(D)
Serum creatinine
Liver function tests
Transvaginal ultrasonography

21. patients should be advised to
discontinue any folic acid supplements they may be taking
to avoid
sun exposure (to decrease risk of methotrexate dermatitis),
use of non-steroidal antiinfl ammatory drugs (interaction with methotrexate may cause bone mar-row suppression or gastrointestinal toxicity), and
intercourse or strenuous physical activity (to decrease the risk of tubal rupture).

22. “single-dose” treatment regimen
methotrexate is administered in a single dose (50 mg/m2, day 1)
if the serum b-hCG declines 15% or more between days 4 and 7, treatment is deemed successful and b-hCG concentrations are monitored weekly thereafter until undetectable.
In the majority of women (85%), serum b-hCG concentrations rise somewhat between days 1 and 4- normal

23. Any subsequent further increase in b-hCG levels, or a decrease of less than 15% between days 4 and 7, is indication for a second dose (on day 7), using the same criteria for judging response (on day 11).
If required, a third dose can be administered on day 11 and the response evaluated by measuring b-hCG again on day 14.
Although a fourth dose can be administered (on day 14), surgical treatment generally is recommended after 2 weeks of failed medical treatment.

24. 2-dose treatment regimen
Methotrexate is administered on days 1 and 4 (50 mg/m2)
If the serum b-hCG declines 15% or more between days 4 and 7, levels are monitored weekly until levels become undetectable
If b-hCG concentrations decreases by less than 15% between days 4 and 7, a third dose of methotrexate is administered (on day 7) and the same criterion is applied in judging the response to treatment on day 11.
If necessary, a fourth dose is administered (on day 11) and the serum b-hCG concentration is assessed again on day 14.

25. Multi-dose treatment regimen
Methotrexate (1 mg/kg i.m.) and leukovorin (0.1 mg/kg i.m.) are administered on alternate days, up to a maximum of four doses, until the serum b-hCG level declines by 15% from the previous value.
Thereafter, b-hCG concentrations are monitored on a weekly basis until levels become undetectable.

26. Indications for surgical treatment
Hemodynamic instability
Rupture of an ectopic mass
Coexisting viable intrauterine pregnancy
Unwillingness or inability to comply with required follow-up after medical treatment
Lack of ready access to a hospital for management of tubal rupture
Desire for permanent sterilization
Contraindications to medical treatment
Failed medical treatment