The lecture has been given on Dec. 20th, 2010 by Dr. Muhabat Salih Saeid.

1. Ectopic pregnancy Dr. MuhabatSalihSaeid MRCOG LONDON UK

2. When a woman presents with an early pregnancy… Ask yourself two questions… Where is this pregnancy? Is it viable?

3. Where is this pregnancy? In a woman with an early pregnancy you must determine if the pregnancy is intrauterine or an ectopic, because her life could depend on it!

4. Ectopic Pregnancy 􀂄 Pregnancy anywhere outside uterine cavity 􀂄 Fallopian tube most common location 􀂄 Second leading cause of maternal mortality Risk Factors 􀂋 Pelvic inflammatory disease, Age, Previous Ectopic, Previous tubal ligation Symptoms 􀂋 Abdominal pain, vaginal bleeding, syncope, amenorrhea 􀂋 Occurs 5-8 weeks after last menstrual period

6. Ectopic Pregnancy 95% are in the fallopian tube (70% ampulla, 12% isthmus, 11% fimbria, 2% interstitial/cornual) Ovarian occurs about 3% of the time, abdominal 1% of the time cervical <1% of the time Seeber 2006

7. How to you determine location of the pregnancy? First determine dating by LMP Then perform ultrasound If you can see location of the pregnancy, you are done! If you cannot…it becomes more complicated…

8. Early pregnancy with unknown location Check a serum BHCG If it is above the discriminatory zone (DZ)—(this is different at every hospital) an intrauterine pregnancy should be seen Then do an ultrasound to see if you see the pregnancy

9. Early pregnancy with unknown location If BHCG>DZ and pregnancy seen in the uterus, you are done If BHCG>DZ and no pregnancy seen in the uterus, it is an ectopic until proven otherwise!

10. Early pregnancy with unknown location If BHCG< DZ and you do not see the pregnancy on the ultrasound consider your patient… Is she…. Unstable or stable Have pain? Have risk factors for ectopic? Your differential diagnosis is :intrauterine pregnancy just too small to see on ultrasound vs ectopic

12. If the patient is stable you can have her return in 48 hours for repeat BHCG

13. If is doubling appropriately, likely normal intrauterine pregnancy and can order ultrasound when >DZ

19. Ectopic with FHR

20. Tubal Ectopic Pregnancy

21. Ectopic Pregnancy Management-determine hemodynamic stability Medical Methotrexate-unruptured, small, no cardiac activity, compliant patient Surgical Laparoscopy • Salpingostomy • Salpingectomy Laparotomy

23. The patient must be hemodynamically stable

24. no signs or symptoms of active bleeding or hemoperitoneum.

25. she must be reliable, compliant, and able to return for follow-up.

26. size of the gestation, which should not exceed 3.5 cm at its greatest dimension on ultrasound (US) measurement.

28. documented hypersensitivity to methotrexate

29. breastfeeding

30. immunodeficiency

31. alcoholism

32. alcoholic liver disease or any liver disease

33. blood dyscrasias

34. leukopenia

35. thrombocytopenia

36. anemia

37. active pulmonary disease

38. peptic ulcer disease

40. patients with cornual ectopic pregnancies.

42. in a patient with a history of an ectopic pregnancy in the same tube.

44. Ectopic Pregnancy- Unusual Variants Heterotopic Pregnancy. Simultaneous IUP and ectopic gestations. Rare- 1 in 30,000 pregnancies Abdominal Pregnancy-can occur anywhere, in peritoneal cavity (1 in 3000) Cervical Pregnancy (1 in 10,000), May need hysterectomy Ovarian Pregnancy (1 in 7,000), Oophorectomyusually required

45. Prognosis for Subsequent Fertility Overall subsequent pregnancy rate is 60%, other 40% are infertile One-third of pregnancies after an ectopic pregnancy are another ectopic pregnancy, one-sixth are spontaneous abortions Only 33% of women with ectopic pregnancy will have a subsequent live birth