Ectopic Pregnancy

When implantation of the embryo occurs outside the uterine cavity is called ectopic pregnancy. Common site of ectopic is in the fallopian tube.

Earlier the diagnosis better is the prognosis with conservation of the reproductive capacity. Chances of a subsequent successful pregnancy are reduced in these women.

Risk factors for ectopic pregnancy

Ø PID- chlamydia infection has been estimated to account for 40 % of ectopic pregnancies.’

Ø Previous ectopic pregnancy

Ø Endometriosis

Ø IUCD use

Ø Progesterone only contraceptive pill use

Ø Pregnancy after tubal ligation, tubal surgery

Ø ovulation induction and assisted reproduction techniques,

Ø subfertility

Investigations:

1. Serum beta HCG

When serum level is more than 1500IU/L intra uterine pregnancy must be visible.

If pregnancy is viable its concentration rapidly increases and double every 48 hours.

Ectopic or non-viable pregnancy shows sub optimal rise.

However 10- 15 % of viable pregnancies can have sub optimal rise.

2. Transvaginal ultrasound  

·        absent intrauterine pregnancy

·        Presense of adenexial mass /ectopic sac

·        Free fluid if ruptured

3. Blood grouping crossmatching and reservation

4. Histopathological examination of the operative specimen to confirm diagnosis.

Management:

·        Expectant

·        Medical

·        Surgical

Expectant management

Criteria for expectant management

·        Beta hCG at initial presentation < 1000IU/L

·        Adenexal mass < 4cm on transvaginal scan

·        Less than 100 mL free fluid in the pelvis

·        Dedicated unit with facilities available for TV scan and Beta hCG monitoring.

Medical management

Systemic methotrexate, a folic acid antagonist, inhibit DNA synthesis in trophoblastic cells.

Dose 50 mg/m2 – calculated for body surface area

Contra indications

·        Chronic liver ,renal and hematological disorders

·        Active infections

·        Immunodeficiency

·        Breastfeeding

Criteria for medical management

·        Haemodynamically stable patient

·        Beta HCG <3000IU/L

·        No contra indications for methotrexate

·        Adenexal mass < 4cm

·        No fetal cardiac activity in the ectopic sac

·        Patient compliance with follow up visits

Follow up plan

Beta hCG measurement on day 4 and 7 after methotrexate .

If beta hCG has not fallen by >25% by day 7 , a repeat dose is administered

If the fall is satisfactory weekly blood tests are performed until Beta hCG is under 25IU/L.

Medical treatment in appropriately selected patient is as effective as laparascopic treatment.

Surgical treatment

Advantages

·        Confirm the diagnosis

·        No need of prolonged follow up

·        Immediately patient attempt for pregnancy following treatment

Salpingostomy

Removal of ectopic pregnancy with the preservation of fallopian tube. Indicated when contralateral tube is diseased with fertility wish.

Salphingectomy

Removal of tube with ectopic sac

Can be done either via Laparoscopy or Laparotomy

Laparascopy is the preferred  method except in the situation of hamodynamically unstable patient.

Advantages of laparascopy

·        Less blood less

·        Shorter hospital stay

·        Shorter operating time

·        Less analgesia requirement

·        Shortery convelance period