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ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI

ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI

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ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI

  1. 1. Ectopic Pregnancy Dr. Shashwat Jani. M. S. ( Obs – Gyn ), F.I.A.O.G. Diploma in Advance Laparoscopy. Consultant Assistant Professor, Smt. N.H.L. Municipal Medical College. Sheth V. S. General Hospital , Ahmedabad. Mobile : +91 99099 44160. E-mail : drshashwatjani@gmail.com
  2. 2. Ectopic pregnancy is a high-risk condition wherein a fertilized ovum gets implanted outside the uterine cavity. This condition poses a significant threat to women of reproductive age and is a leading cause of maternal death during the first trimester. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 2
  3. 3. Incidence • Ectopic pregnancy still contributes significantly to the cause of maternal mortality and morbidity. • While there has been about fourfold increase in incidence over the couple of decades, but the mortality has been slashed down by 80%. • Recognition of high-risk cases , early diagnosis (even before rupture) with the use of TVS, serum Beta-hCG and laparoscopy have significantly improved the management of ectopic pregnancy. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 3
  4. 4. Safety First AIM has changed from "Saving The Mother's Life" to Recently "Saving The Woman's Fertility" 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 4
  5. 5. Current Scenario •Incidence is increasing ( From 1 % to 2.5 % ) * Increasingly detected * Detected early 95 – 98 % of all ectopic are tubal 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 5
  6. 6. Common Sites Tubal • Ampullary  70-80 % • Isthmic  10-15% • Fimbrial end  5 – 10 % • Interstitial / Cornual  2 -3 % Others • Abdominal  1 % • Ovarian  0.5 % • Cervical  0.3 % 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 6
  7. 7. Risk Factors P I D  Most important factor ( 50 % ) Prior Tubal Surgery Infertility, Reversal, Sterilization Past H/O ectopic  15 % & linearly increasing Infertility A R T / Ovulation induction Progesterone only contraceptives, Em.Contraceptives I U C D Congenital factors, Old age, smoking, Vaginal douching No risk factor found in many cases 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 7
  8. 8. Course Of Ectopic Pregnancy Spontaneous resolution  Tubal abortion (Ampullary, fimbrial) Resolution, Pelvic hematocele Hematosalpinx  Tubal rupture (Isthmic, interstitial - at 12-16 wks ) Acute Chronic Secondary abdominal 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 8
  9. 9. Ectopic – Clinical Presentation Classical triad found in only 1/3rd cases Pain  90 % cases Amenorrhoea  80 % cases Bleeding  70 % cases Fainting attack typical but rare Symptoms of shock in acute rupture It can be asymptomatic also Ectopic pregnancy is a great deceiver 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 9
  10. 10. Clinical Presentation Signs variably present Adenexal mass Adenexal tenderness Cervical movements tenderness ! Features of acute abdomen Cullen’s sign !! (Superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus ) 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 10
  11. 11. Different Presentations •Emergency presentation - Suddenly, without warning a woman is very unwell, collapses and is taken to hospital in stage of haemoperitoneum and hemorrhagic shock. •Subacute presentation - The most common presentation is with a missed period, positive pregnancy test, some abdominal pain, and irregular vaginal bleeding •High Risk Pregnancy Group - After previous ectopic, tubal surgery or assisted conception ( IVF) → detection rate is high → women are primary observed. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 11
  12. 12. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 12
  13. 13. Discriminatory Zone • The discriminatory zone is based upon the correlation between visibility of the gestational sac and the hCG concentration. • It is defined as the serum hCG level above which a gestational sac should be visualized by ultrasound examination if an intrauterine pregnancy is present . • In most institutions, this serum hCG level is 1500 or 2000 IU/L with TVS [ the level is higher [6500 IU/L] with TAS. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 13
  14. 14. hCG Above The Discriminatory Zone • Serum hCG greater than 1500 IU/L without visualization of intrauterine or extrauterine pathology may represent a multiple gestation  repeat the TVS examination and hCG concentration two days later. • An ectopic pregnancy can be diagnosed if the serum hCG concentration is increasing or plateaued. Treatment can be instituted. • A falling hCG concentration is most consistent with a failed pregnancy (eg, arrested pregnancy, blighted ovum, tubal abortion, spontaneously resolving ectopic pregnancy). 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 14
  15. 15. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 15
  16. 16. Management 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 16
  17. 17. Expectant Management 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 17
  18. 18. Medical Management 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 18
  19. 19. Multiple Dose MTX Regimen 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 19
  20. 20. Methotrexate Precautions  No intercourse  Report immediately if fainting, dizziness or severe pain  Drug contraindications : B F , liver & renal dis., immunodeficiency  LFT & Blood counts baseline & after one week  Initial rise of HCG in some patients on day 4 occurs. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 20
  21. 21. Surgical Management 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 21
  22. 22. Laparotomy Vs Laparoscopy 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 22 Laparotomy Laparoscopy Morbidity More Less Post operative adhesions More Less Risk of future ectopic More Less ! Future fertility Same Same Persistent ectopic Less ! More Experience/Instruments Routine Special Cochrane Database Review 2007
  23. 23. Abdominal Ectopic •Primary/Secondary •Studdiford Criteria •Diagnosis  Typical symptoms  USG / MRI / Xray Management Laparotomy Cut cord flush to placenta to leave it behind Methotrexate not recommended 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 23
  24. 24. Ovarian Ectopic •Spigelberg criteria •Association with IUD 20-90% •No case of recurrent ovarian ectopic •Management  MTX  Partial oophorectomy  Oophorectomy 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 24
  25. 25. Cervical Ectopic •Palman & McElin clinical criteria •Very very rare but increasing with IVF •H/o D & C in most cases Treatment Cervical suture Suction followed by tamponade Embolization  MTx Hysterectomy 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 25
  26. 26. Heterotopic Ectopic • 1 in 30000, Increasing due to ART 1 in 4000 • Problem with diagnosis • Serial bHCG are not helpful • Laparoscopy is required. • No systemic medical management 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 26
  27. 27. Persistent Ectopic •Persistence of viable Trophoblast •Grow & produce symptoms •2 – 20 % after medical & surgical Rx. •Need to followup all cases with B HCG •Treatment is single dose methotrexate •Prophylactic Mtx after Rx in every case not recommended 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 27
  28. 28. Recurrence…  An ectopic mother has got every chance of a viable birth in 1 in 3 and a chance of recurrence of ectopic in 1 in 10.  Patient is asked to report after she misses her period to confirm and to locate the new pregnancy. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 28
  29. 29.  Incidence of subsequent intrauterine pregnancy (IUP) is 60–70%, in women with unruptured tubal ectopic pregnancy treated by conservative surgery.  The incidence of subsequent ectopic pregnancy is about 10–20% and successful conception is about 60%.  Salpingostomy done for unruptured tubal ectopic pregnancy does not increase the risk of ectopic pregnancy compared to salpingectomy. Conservative surgery for unruptured tubal ectopic pregnancy is beneficial. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 29
  30. 30. Take Home Message…  In clinically stable women in whom a nonruptured ectopic pregnancy has been diagnosed, laparoscopic surgery or intramuscular methotrexate administration are safe and effective treatments. The decision for surgical or medical management of ectopic pregnancy should be guided by the initial clinical, laboratory, and radiologic data as well as patient- informed choice based on a discussion of the benefits and risks of each approach.  Surgical management of ectopic pregnancy is required when a patient is exhibiting any of the following: hemodynamic instability; symptoms of an ongoing ruptured ectopic mass (such as pelvic pain); signs of intraperitoneal bleeding. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 30
  31. 31.  If the concept of the hCG discriminatory level is to be used as a diagnostic aid in women at risk of ectopic pregnancy, the value should be conservatively high (eg, as high as 3,500 mIU/mL) to avoid the potential for misdiagnosis and possible interruption of an intrauterine pregnancy that a woman hopes to continue.  The single-dose protocol may be most appropriate for patients with a relatively low initial hCG level or a plateau in hCG values, and the two- dose regimen may be considered as an alternative to the single-dose regimen, particularly in women with an initial high hCG value. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 31
  32. 32.  The decision to perform a salpingostomy or salpingectomy for the treatment of ectopic pregnancy should be guided by the … - Patient’s clinical status, - Her desire for future fertility, and - The extent of fallopian tube damage. 19-11-2018 Dr Shashwat Jani. +91 99099 44160. 32
  33. 33. 19-Nov-18 33 Dr Shashwat Jani. +91 99099 44160.

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