Eldeeb W, Abd Elnaby M, Said T, Hazem A

2. Changing the Concept of TubalChanging the Concept of Tubal
Ectopic PregnancyEctopic Pregnancy
ByBy
Eldeeb W, Abd Elnaby M, Said T, Hazem AEldeeb W, Abd Elnaby M, Said T, Hazem A
20120177

3.  The incidence of ectopic pregnancy isThe incidence of ectopic pregnancy is
approximatelyapproximately 2%2% of all pregnancies.of all pregnancies.
 Over 95% of ectopic pregnancies areOver 95% of ectopic pregnancies are tubaltubal
pregnancies, and the remainders are non-pregnancies, and the remainders are non-
tubal pregnancies.tubal pregnancies.
Van Mello NM et al Fertil Steril. 2012Van Mello NM et al Fertil Steril. 2012

4.  The highest risk factor for ectopicThe highest risk factor for ectopic
pregnancy is a previous tubal pregnancypregnancy is a previous tubal pregnancy
followed by: previous tubal surgery, tubalfollowed by: previous tubal surgery, tubal
sterilization, tubal pathology, and currentsterilization, tubal pathology, and current
intrauterine device use.intrauterine device use.
Tulandi T et al, 2013Tulandi T et al, 2013

5.  The apparent increase in the incidence ofThe apparent increase in the incidence of
non-tubal ectopic pregnancy includingnon-tubal ectopic pregnancy including
heterotopic pregnancy may be attributed toheterotopic pregnancy may be attributed to
the increasing number of pregnanciesthe increasing number of pregnancies
because of IVF treatment and increasingbecause of IVF treatment and increasing
the rate of CS for infertile couples.the rate of CS for infertile couples.
Gunby J, et al Fertil Steril. 2011Gunby J, et al Fertil Steril. 2011

6.  Early diagnosis of intact ectopicEarly diagnosis of intact ectopic
pregnancies had increased due to highlypregnancies had increased due to highly
resolution ultrasound machines used andresolution ultrasound machines used and
improved skills of ultrasonographers byimproved skills of ultrasonographers by
continuous training.continuous training.
Belics et al. 2014.Belics et al. 2014.
Lozeau and Potter. 2005.Lozeau and Potter. 2005.

7.  In most cases, an ectopic pregnancy canIn most cases, an ectopic pregnancy can
be treated medically with a single dose ofbe treated medically with a single dose of
methotrexate.methotrexate.
Bachman and Barnhart, 2012.Bachman and Barnhart, 2012.
Dhar et al. 2011.Dhar et al. 2011.

8.  The rates of recurrent ectopic pregnancyThe rates of recurrent ectopic pregnancy
after single-dose methotrexate (MTX),after single-dose methotrexate (MTX),
salpingectomy, and linear salpingostomysalpingectomy, and linear salpingostomy
were 8%, 9.8%, and 15.4%, respectively.were 8%, 9.8%, and 15.4%, respectively.
After 2 previous ectopic pregnancies, theAfter 2 previous ectopic pregnancies, the
rate of a third ectopic pregnancy is aboutrate of a third ectopic pregnancy is about
30%30%
Yao M, et al Fertil Steril. 1997Yao M, et al Fertil Steril. 1997

9.  In view of IUD use, the risk of ectopicIn view of IUD use, the risk of ectopic
pregnancy among users of a norgestrel-pregnancy among users of a norgestrel-
containing IUD is lower than in those with acontaining IUD is lower than in those with a
copper IUD (0.3/1000 women and 2.5/ 1000,copper IUD (0.3/1000 women and 2.5/ 1000,
respectively; p = 0.02)respectively; p = 0.02)
 This might be related to the decreasedThis might be related to the decreased
overall pregnancy rate in women usingoverall pregnancy rate in women using
norgestrel-containing IUDsnorgestrel-containing IUDs
Juneau C et al Clin Obstet Gynecol. 2012Juneau C et al Clin Obstet Gynecol. 2012

10. Clinical Picture and DiagnosisClinical Picture and Diagnosis
 However, an ectopic pregnancy could still be missed.However, an ectopic pregnancy could still be missed.
The estimated rate of missed ectopic pregnancies atThe estimated rate of missed ectopic pregnancies at
the initial presentation was 12%the initial presentation was 12%
RobsonSJ, et al J Obstet Gynaecol 2011RobsonSJ, et al J Obstet Gynaecol 2011

11. Transvaginal UltrasoundTransvaginal Ultrasound
 Transvaginal ultrasound (TVUS) is the most usefulTransvaginal ultrasound (TVUS) is the most useful
diagnostic test to locate the gestation either intra- ordiagnostic test to locate the gestation either intra- or
extra-uterine.extra-uterine.
 An intrauterine gestational sac could be detected withAn intrauterine gestational sac could be detected with
TVUS at serum human chorionic gonadotropin (hCG)TVUS at serum human chorionic gonadotropin (hCG)
levels of 1500 to 2000 IU/L; this level is called thelevels of 1500 to 2000 IU/L; this level is called the
discriminatory threshold of hCG It corresponds to 4.5discriminatory threshold of hCG It corresponds to 4.5
weeks of gestationweeks of gestation

12. Transvaginal UltrasoundTransvaginal Ultrasound
 A yolk sac is usually observed at 5 weeks of gestationA yolk sac is usually observed at 5 weeks of gestation
and a fetal pole at 5.5 weeks of gestation.and a fetal pole at 5.5 weeks of gestation.
Barnhart KT, et al Obstet Gy- necol. 2003Barnhart KT, et al Obstet Gy- necol. 2003

13. Transvaginal UltrasoundTransvaginal Ultrasound
 In diagnosing an ectopic pregnancy, TVUS has aIn diagnosing an ectopic pregnancy, TVUS has a
sensitivity of 87% to 99%sensitivity of 87% to 99%
Kirk E, et al Obstet Gynaecol. 2009Kirk E, et al Obstet Gynaecol. 2009

14. CornualCornual ectopic

15. Corpus luteumCorpus luteum

16. Ectopic fetal poleEctopic fetal pole

17. Ectopic fetal pole, empty uterusEctopic fetal pole, empty uterus

18. Ectopic tubal ringEctopic tubal ring

19. Ectopic pregnancyEctopic pregnancy

20. Sac or pseudo-sacSac or pseudo-sac

21. Tubal ringTubal ring

22. Serum hCG LevelSerum hCG Level
 In a normal intrauterine pregnancy, the serum hCGIn a normal intrauterine pregnancy, the serum hCG
level doubles every 2 days until about 40 days oflevel doubles every 2 days until about 40 days of
gestation. In most ectopic and nonviable intrauterinegestation. In most ectopic and nonviable intrauterine
pregnancies, the in- crease in the hCG level is muchpregnancies, the in- crease in the hCG level is much
slower.slower.
 A decreased or plateauing hCG level is most likelyA decreased or plateauing hCG level is most likely
associated with a failed pregnancy.associated with a failed pregnancy.

23.  In the absence of definitive ultrasound findings and aIn the absence of definitive ultrasound findings and a
serum ß-hCG level of less than1500 IU/L, a repeatserum ß-hCG level of less than1500 IU/L, a repeat
hCG mea surement every 3 days should behCG mea surement every 3 days should be
performed.performed.
 If the hCG level does not double over 72 hours, thenIf the hCG level does not double over 72 hours, then
the pregnancy is abnormal (i.e., an ectopic gestationthe pregnancy is abnormal (i.e., an ectopic gestation
or failed intrauterine pregnancy).or failed intrauterine pregnancy).
Tulandi T et al Journal of Minimally Invasive Gynecology,Tulandi T et al Journal of Minimally Invasive Gynecology,
2013.2013.

24. Clinical Picture and DiagnosisClinical Picture and Diagnosis
 Besides the usual signs and symptoms of pregnancy,Besides the usual signs and symptoms of pregnancy,
women with ectopic pregnancies usually present withwomen with ectopic pregnancies usually present with
abdominal pain, vaginal bleeding, and amenorrhea ofabdominal pain, vaginal bleeding, and amenorrhea of
6 to 8 weeks.6 to 8 weeks.
 Ectopic pregnancy should be suspected in all womenEctopic pregnancy should be suspected in all women
of reproductive age with these symptoms, especiallyof reproductive age with these symptoms, especially
in those with risk factors. This will lead to an earlyin those with risk factors. This will lead to an early
diagnosis and will allow medical treatment.diagnosis and will allow medical treatment.

25.  Usually surgical treatment can beUsually surgical treatment can be
performed by laparoscopy.performed by laparoscopy.
 Laparotomy is rarely needed even inLaparotomy is rarely needed even in
women with intraperitoneal bleeding.women with intraperitoneal bleeding.
Oron and Tulandi, 2013.Oron and Tulandi, 2013.

26. Medical TreatmentMedical Treatment
 Early diagnosis allows medical treatment in theEarly diagnosis allows medical treatment in the
majority of cases of ectopic pregnancy. The mainmajority of cases of ectopic pregnancy. The main
medical treatment is a single dose intramuscularmedical treatment is a single dose intramuscular
MTX.MTX.
 A second dose of MTX is sometimes needed.A second dose of MTX is sometimes needed.
Menon S et al Fertil Steril. 2007Menon S et al Fertil Steril. 2007

27. Medical TreatmentMedical Treatment
 The best candidates for MTX treatment are womenThe best candidates for MTX treatment are women
who are hemodynamically stable, have compliancewho are hemodynamically stable, have compliance
for follow-up, have a hCG concentration of <=5000for follow-up, have a hCG concentration of <=5000
mIU/mL, and have no fetal cardiac activity.mIU/mL, and have no fetal cardiac activity.
 The most important predictor associated withThe most important predictor associated with
treatment failure is a high hCG concentration.treatment failure is a high hCG concentration.
Menon S et al Fertil Steril. 2007Menon S et al Fertil Steril. 2007

28. Contraindications to MTX treatmentContraindications to MTX treatment
 Breast-feeding; immunodeficiency; alcoholism;Breast-feeding; immunodeficiency; alcoholism;
chronic liver disease; preexisting blood dyscrasia;chronic liver disease; preexisting blood dyscrasia;
known sensitivity to MTX; active pulmonary disease;known sensitivity to MTX; active pulmonary disease;
peptic ulcer disease; and hepatic, renal, orpeptic ulcer disease; and hepatic, renal, or
hematologic dysfunction.hematologic dysfunction.
 Side effects of a single dose of MTX are mild and self-Side effects of a single dose of MTX are mild and self-
limiting.limiting.
 The most common side effects are conjunctivitis orThe most common side effects are conjunctivitis or
aphthous stomatitisaphthous stomatitis

29.  If the patient is Rh(D)-negative, Rh(D) immuneIf the patient is Rh(D)-negative, Rh(D) immune
globulin should be administered.globulin should be administered.
 Folic acid intake interferes with MTX efficacy andFolic acid intake interferes with MTX efficacy and
should be avoided.should be avoided.

30.  After MTX injection, the patient should be followedAfter MTX injection, the patient should be followed
until the serum hCG level is undetectable.until the serum hCG level is undetectable.
Approximately 15% to 20% of patients need a secondApproximately 15% to 20% of patients need a second
dose of MTX, and less than 1% need over 2 dosesdose of MTX, and less than 1% need over 2 doses
Kelly H, et al Obstet Gynecol. 2006Kelly H, et al Obstet Gynecol. 2006

31. Surgical TreatmentSurgical Treatment
 The indications for surgery include hemodynamicThe indications for surgery include hemodynamic
instability, impending or ongoing rupture of aninstability, impending or ongoing rupture of an
ectopic mass, contraindications to MTX, a coexistingectopic mass, contraindications to MTX, a coexisting
intrauterine pregnancyintrauterine pregnancy

32.  Surgical treatment is still needed in womenSurgical treatment is still needed in women
who are hemodynamically unstable and inwho are hemodynamically unstable and in
those who do not fulfill the criteria forthose who do not fulfill the criteria for
methotrexate treatment.methotrexate treatment.
Stock and Milad, 2012.Stock and Milad, 2012.

34. Hemoperitonium ectopicHemoperitonium ectopic

35. Salpingectomy VersusSalpingectomy Versus
SalpingostomySalpingostomy

36.  The reproductive outcome afterThe reproductive outcome after
salpingostomy or salpingectomy issalpingostomy or salpingectomy is
comparable.comparable.
Hajenius PJ, et al. Lancet. 1997Hajenius PJ, et al. Lancet. 1997

37. Salpingostomy or SalpingectomySalpingostomy or Salpingectomy
 In women who have completed their family or in thoseIn women who have completed their family or in those
with recurrent ectopic pregnancies, severe tubalwith recurrent ectopic pregnancies, severe tubal
damage, or hemodynamic instability, salpingectomydamage, or hemodynamic instability, salpingectomy
is the appropriate surgical treatment.is the appropriate surgical treatment.
 Otherwise, linear salpingostomy can be performed.Otherwise, linear salpingostomy can be performed.

38. Salpingostomy or SalpingectomySalpingostomy or Salpingectomy
 Salpingostomy might be associated with a 4% to 15%Salpingostomy might be associated with a 4% to 15%
risk of persistent ectopic pregnancy and a 15%risk of persistent ectopic pregnancy and a 15%
incidence of recurrent ectopic pregnancy.incidence of recurrent ectopic pregnancy.
 In cases in which there is a possibility of leavingIn cases in which there is a possibility of leaving
trophoblastic tissue inside the Fallopian tube or introphoblastic tissue inside the Fallopian tube or in
the abdominal cavity, 1 dose of MTX can bethe abdominal cavity, 1 dose of MTX can be
administered in the immediate postoperative period.administered in the immediate postoperative period.
Mol F, et al. Hum Reprod Update. 2008Mol F, et al. Hum Reprod Update. 2008

39. Salpingostomy or SalpingectomySalpingostomy or Salpingectomy
 A serum level of hCG 7 days after surgery of less thanA serum level of hCG 7 days after surgery of less than
5% of the preoperative value indicates complete5% of the preoperative value indicates complete
resolution of the ectopic pregnancy.resolution of the ectopic pregnancy.

40. Use of sutures in neosalpingostomyUse of sutures in neosalpingostomy
 No data to recommend either use or non use ofNo data to recommend either use or non use of
sutures in salpingostomysutures in salpingostomy

41.  For most tubal ectopic pregnancies (EP) surgery isFor most tubal ectopic pregnancies (EP) surgery is
the treatment of first choice.the treatment of first choice.
 Whether surgical treatment should be performedWhether surgical treatment should be performed
conservatively (salpingostomy) or radicallyconservatively (salpingostomy) or radically
(salpingectomy) in women wishing to preserve their(salpingectomy) in women wishing to preserve their
reproductive capacity, is a subject of debate.reproductive capacity, is a subject of debate.
Mol et al. 2008.Mol et al. 2008.

42. ConclusionConclusion
 Ectopic pregnancy is still the leading cause of deathEctopic pregnancy is still the leading cause of death
in the first trimester of pregnancy.in the first trimester of pregnancy.
 A high index of suspicion is required for an earlyA high index of suspicion is required for an early
diagnosis because signs and symptoms are notdiagnosis because signs and symptoms are not
specific.specific.
 Expectant management is suitable in a limitedExpectant management is suitable in a limited
number of cases.number of cases.

43. ConclusionConclusion
 Most ectopic pregnancies can be treated medicallyMost ectopic pregnancies can be treated medically
with a single dose of MTX, and surgical managementwith a single dose of MTX, and surgical management
is reserved for those who do not fulfill the criteria ofis reserved for those who do not fulfill the criteria of
MTX treatment or who have failed medical treatment.MTX treatment or who have failed medical treatment.
 Most surgical treatment can be performed byMost surgical treatment can be performed by
laparoscopy either salpingostomy or salpingectomylaparoscopy either salpingostomy or salpingectomy
and laparotomy is rarely needed even in women withand laparotomy is rarely needed even in women with
intra-peritoneal bleeding.intra-peritoneal bleeding.