1. Ectopic pregnancy Dr.F Mostajeran MD

2.  Ectopic pregnancy remains  Leading cause life/hreatening F- Trimester (morbidity)  Medical therapy method terexate as standard first line therop. Surgery  Hemorrhage?  Medical failures  Neglected cases  Medical contraindicated

3. Incidence E.P  Unprecedented sexual liberties.  ↑Ascertainment E.P  ↑ART  Leading cause maternal death U.S 5-6% all M. death

4. Pathogenesis Ability tube transport gametes embryos Clinical picture site E.P Most common site Tub 98-3% Ampoule – isthmus – fimbrial cornual. Rarely abdominal – ovarian – cervical.

5. Proliferating trophoblast Tubale wall Growth may extend luminal mucosa. Muscularis- serosa full thickness blood vessels Distorts tube stretches serosa → pain bleeding takes phase. 80% embryo degenerates. 50% often clinically silent. Tubal abortion self limited.

6. Risk factors  Needs aggressive monitoring pregnancy immediately after first missed menses  High risk Tubal surgery (21) Risk factors Tubal ligation Tubal Epithelial damage. Previous E.P (6-8) I U D, Morning after pill A R T

7. Moderate risk Infertility P I D Multiple sexual partners Salpingitis Low risk Cigarette Vaginal douching first intercourse <18

9. Signs and symptoms Many E.P never produce symptoms rather Timely diagnosed and treated (H.R) If diagnosis → delayed → classic triad. Amenorrhea, irregular V.B, lower ab- pain. Sudden sever ab pain 90-100% symptomatic patient. Pain radiating shoulder. Syncope shock → hemoperitaneum.( up to 20%)

10. Most common signs ab EX 90% tenderness,rebound tenderness in 70%. P.EX nonspecific. 2⁄3 C-motion tenderness. Adnexal mass 50%.

11. Diagnosis Diag as early as 4.5 WK. Visualization is frequently not possible. Traditional laparoscopic visualization rarely necessary. Routine diagnostic Tests. Serial 3HCG. U.S Progesterone levels. U - curettage.

12. Treatment for E.P Medical management. Methotrexate therapy. Folic acid antagonist DNA synthesis and cell multiplication. Single dose 50 mg/m 2 Blunts HCG increment (7) Drop progesterone, 17 × hydroxy progesterone prior to abortion Hemodiamically stable. E.P unruptured less 4cm Eligible for methatrexate therapy.

13. Multiple-dose: tailored weight-E.P responsiveness. Comparing multiple-dose-laparoscopic salpingostomy. Patent fallopian tubes. Subsequent IU pregnancy. Repeat E.P comparable. Single dose: Resent metaanalysis 26 studies. Based on clinical evidence presently available. Routine use methotrexate single dose IM not as Effective as multiple dose (tubal rupture↑)

14. Indication for systemic M-dose methotrexate No rupture Tubal size ≤4cm HCG ≤ 10,000 Positive F.H heartbeat proceed with caution.

15. Methotrexate by direct injection Methotrexate E. gestational sac TVS. Resolution within 2 weeks Higher concentrations site of implantation. Less systemic distribution drug 75.1% successfully treated Subsequent p–tubal patency (laparoscopic- systemic Mehta) Subsequent – P, recurrent E.P

16. Methotrexate failure  Pain is sever and persistent (>12h 4-12 3-7 after start therapy)  Falling HCT  Orthostatic hypotension.

17. Side effects High dose Bone marrow supp Hepatotoxicity Stomatitis Pulmonary fibrosis Alopecia Photosensitivity Infrequent in E.P therapy

18. Surgical Treatment 1884 E.P laparotomy salpingectom. 1953 salpingostomy Manual fimbrial expression Segmental resection.

19. Ruptured E.P Laparoscopy – laparotomy – salpingectomy. Inpatients hypovolemic shock. Surgery is choice.

20. Stable E.P If methotrexate contraindicated. Laparoscopic salpigostomy first surgical choice. Salpingectomy  Laparoscopy  Laparotomy

21. Expectant management E.P may resolve spontaneously 67.2% E.P resolved without surgery (over treats) Falling 3HCC under 1000 fallowed with conservative expectant management With low initial and falling HCG

22. Rare types of E.P Abdominal pregnancy 1⁄8000 birth prognosis poor M.M 5.1⁄1000 7.7 higher than other E.P (Higher due to delay in diagnosis)

23. Primary - Secondary Symptoms → normal for pregnancy to sever if time permits Abdominal pain intra abdominal hemorrhage shock Primary rare usually abort Secondary (reimplantation → abortion,rupture) U.S choice empty uterus If fetus near viability → hospitalization Adequate blood, bowel preparation Placenta removed unless major vessels, vital organ methotrexate

24. Ovarian pregnancy Most common form abdominal pregnancy less than 3% of E.P Clinical finding similar tubal E.P ab-pain,V.B Amenorrhea 30% hemodynamic instability → rupture Usually young multiparous cause Treatment → systectomy, wedge resection or oophorectomy

25. Cornual pregnancy or interstitial pregnancy 4.7% E.P 2.2% M. mortality Most frequent symptom menstrual aberration Abdominal pain V.B, shock → rapture uterine(9-12nk) Risk factor previous salpingectomy Repeat U.S with Doppler flow studies → early diagnosis Cornual resection lapa - resection systemic methatraxate local

26. Cervical pregnancy 1⁄12000 Most common risk factor  D.C  Previous CS  IVF Symptom most common V.B painless C.EP usually diagnosis incidentally during routine U.S or at time surgery for abortion Cervix enlarged- globular, distended it appears cyanotic hyperemic soft Diagnosis – US, MRI, GSOC below C.OS, Metha, U. Artery embolization, hysterectomy

27. Heterotopic pregnancy E.P + intrauterine pregnancy 1⁄6778 Most causes diagnosed after sign symptoms develop admitted for emergency surgery Lower abdominal pain serial 3HCG not helpful