1. E CTOPIC P REGNANCY Dr.Najwa.B.Eljabu Arab & Libyan Board Msc reproductive and Maternal sciences Glasgow University

2. D EFINITION Ectopic pregnancy is implantation occurring outside the uterine cavity. Either implanted outside the uterus (fallopian tube, ovary and abdominal cavity) or in abnormal position within the uterus (cornua, cervix). Combined tubal and uterine (Heterotopic) pregnancies are uncommon) It is a major cause of maternal mortality in the first trimester.

3. O VERVIEW Incidence Increasing (16/1000 Pregnancies in UK) 95-98% tubal 50% ampulla 20% isthmus 12% fimbrial 10% interstitial Mortality Decreasing With Better Detection Surgical and Medical Treatment Available Recurrence Rate ~ 10-15%

4. R ISK F ACTORS Maternal age Number of sexual partners Cigarette smoking Previous Ectopic Pregnancy PID (Gonorrhea, Chlamydia) Tubal Surgery or pelvic surgery Infertility and infertility treatment ICUD IVF

5. S ITES Ampulla (50%) Isthmus (20%) Cornua (< 2%) Ovary (< 2%) Abdomen (< 2%) Cervix (< 2%)

6. Simultaneous intrauterine and ectopic pregnancies (heterotopics) occur in 1/3000 to 1/30000 pregnancies

7. S YMPTOMS Amenorrhea (typically 6-8 weeks) Abdominal Pain Vaginal Bleeding (small amount) Syncope Pelvic Mass Shoulder tip pain

8. 15% of the cases present acutely with abdominal pain, amenorrhea and haemodynamic compromise In most cases the history will be more chronic Arias-stella reaction

9. E VALUATION AND D IAGNOSIS History and Physical Exam Blood investigations (CBC, blood group) Serial Quantitative HCG Ultrasound Laparoscopy

10. E VALUATION AND D IAGNOSIS Clinical: O/E: look for signs of intra-peritoneal hemorrhage Abdominal tenderness(95%) Peritonism Abdominal distension Pain on movement of the cervix (cervical excitation (50%) Adnexal mass (63%) Cervix ----closed

11. S ERIAL B-HCG HCG Levels Double Every 48 Hrs 66% Rise / 48 Hrs Consistent With Ectopic Single Determination Not Helpful Best If Done Within Same Laboratory At HCG of 1000 IU/L gestational sac of an intrauterine pregnancy should be detected by US

12. U LTRASOUND May or May Not Be Helpful Discriminatory Zone: TV: 1500-2000 mIU/ml TA: 6500 mIU/ml +IUP: Generally Excludes Ectopic Free fluids in POD Adnexal mass

13. T REATMENT Observation Laparoscopy Laparotomy Medical MTX Hyperosmolar Glucose PG

14. O BSERVATION Many Tubal Pregnancies Abort Needs simple follow up Criteria for selection of patients Serial HCG levels and US

15. M ANAGEMENT OF ACUTE HEMORRHAGE - Urgent hospital assessment - Resuscitation - Intravenous access and two large cannula - Start IVF (colloid) - Send for blood group, CBC and cross match - Serum BHCG - Transfer to theater - Anti D should be given to all RH negative women

16. L APAROSCOPY Allows Diagnosis and Treatment Lower post op morbidity and quicker recovery Salpingotomy Salpingectomy (Total / Partial) Cornual Resection Minimally Invasive, Unlike Laparotomy Few Contraindications: Unstable Patient (Possibly)

17. M INI - LAPAROTOMY Salpingectomy Salpingotomy Needed in acute intra-peritoneal haemorrhage-------for immediate ligation of the bleeding point

18. M EDICAL TREATMENT Suitable patients are: Haemodynamically stable serum BHCG less than 10000IU/L no extrauterine fetal heart by US compliant patient

19. M ETHOTREXATE Toxic to Trophoblast Cells Minimal Side Effects May Preserve Fertility in Cases of Cervical Pregnancy Requires Compliant Patient, Time Pain Not Uncommon BHCG May Rise Initially

20. P ERSISTENT T ROPHOBLAST Most Often after Salpingostomy Laparoscopic Minilap Most Easily Treated With MTX

21. O UTCOMES 15% Repeat Ectopic Rate 60-70% intra-uterine pregnancy after single ectopic

22. S UMMARY Ectopic Pregnancy is a Common, Treatable Problem Sensitive Assays Allow Early Detection Surgical and Medical Options Exist Ruptured Ectopics should be Unusual with Compliant Patients and Appropriate Medical Care

23. T HANKS