Ectopic Pregnancy

Chongdong liu MD

Learning Objectives

You should understand:
– Why and how ectopic pregnancy remains a cause of – – –

maternal death Why tubal damage is a risk factor for ectopic pregnancy How to interpret serial measurement of serum hCG Why ectopic pregnancy can be managed in a variety of ways The implication of an ectopic pregnancy to future fertility

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Conception A pregnancy in which the fertilized ovum implants on any tissue other than the endometrium is considered an ectopic pregnancy (EP) .

Morbidity & Risk of Death   Morbidity: ≥1% (USA).4% (China) The risk of death: ≥10 times for vaginal delivery. 50 times for an induced abortion .

000 in 1970 to 16.Current incidence  4.000 in 1989 to 19.7 per 1.000 in 1992. .5 per 1.8 per 1.

Current incidence       Higher causes: A continued increase in the risk factors associated with ectopic pregnancy. 13% of maternal deaths. accounting for 5-6% of all maternal deaths in the United States. . this dropped to 9%. Increasing use of ART for treatment of infertility Between 1979 and 1986. by 1992. Ectopic pregnancy continue to be the leading causes of maternal deaths in the first trimester. Increased ascertainment of ectopic from use of more sensitive and specific diagnostic methods.

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Risk Factors        Tubal damage and infection Salpingitis isthmica Nodosa Diethylstibestrol Cigarette smoking Contraception Previous operation history on the tube Assisted reproduction .

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5 fold common adjusted odds ratio for ectopic pregnancy. . previous tubal infection → destruction of cilial lining & intratubal adhension → transport mechanism↓ → EP  Tubal pathology carries a 3.Salpingitis  Destruction of tubal anatomy.

5% after two infections.7%) Microscopic evidence of salpingitis is present in 38% of ectopic pregnancy cases.Salpingitis  Patients with pelvic infections.(4%:0. have two-fold to four-fold higher risk of developing an ectopic pregnancy. and non-specific pelvic inflammatory disease. and 75% with three or more infections. 35. 12.8% after one infection.   .

< 30% can become pregnant after tubal sterilization. 15%-50% of these pregnancies are ectopic .Previous operation history on the tube  Previous operation for an EP. conservation tubal procedures → EP  e.g. previous tubal ligation.

Previous operation history on the tube  Patients with a previous ectopic pregnancy are six to eight times more likely to experience another ectopic pregnancy. and 8% to 14% of patients experience more than one ectopic pregnancy.  Patients with a history of tubal surgery have a 21fold common adjusted odds ratio of ectopic pregnancy .  The recurrent ectopic pregnancy rate is about 13% after a history of one ectopic and 28% after two previous ectopics.

Salpingitis isthmica nodosa  Salpingitis isthmica nodosa is a disease defined by an anatomic thickening of the proximal portion of the fallopian tubes at the junction with the uterus and is histological characterized by multiple luminal diverticula. .

GIFT.Assisted reproduction Ovulation induction. IVF → heterotypic tubal pregnancy  GIFT. IVF → tubal pregnancy  Ovulation induction. IVF → abdominal pregnancy  IVF → cervical pregnancy  IVF → ovarian pregnancy  .

Diethylstilbestrol  Prenatal exposure to diethylstilbestrol (DES) alters fallopian tubal development. resulting in absent or minimal fimbrial tissue. a small tubal os.  This abnormal tubal anatomy is associated with a five-fold increase in the risk for ectopic pregnancy. and decreased length. and caliber of the tube. .

IUD. laparoscopic fulguration → EP . such as: tubal sterilization. minipills.Failed contraception  Contraceptive failure.

4 for ectopic pregnancy in current IUD users compared with pregnant control. there is increased likelihood that the pregnancy will be ectopic. but if pregnancy does occur in a women using an IUD.  IUDs effectively prevent pregnancy.5 when comparison was made with non-pregnant controls. .IUD   IUDs associated with ectopic pregnancy. whereas the odds ratio was only 0. A multicenter case-controlled study conducted by the WHO in ten countries found an odds ratio of 6.

.Tubal sterilization  Tubal sterilazation by using Eletrocoagulation procedures are associated with higher ectopic pregnancy risk than other methods of tubal sterilization.

.  Emergency OC after fertilization are at substantial risk for an ectopic pregnancy.Oral contraceptive  Oral contraceptive associated with a reduced risk of ectopic pregnancy when compared with nonpregnant controls but with elevated risk when compared with pregnant controls.

or a presentation of a lifestyle associated with an increased risk of tubal infection. . alterations in tube mortility.Cigarette smoking  Patients who smoke cigarettes are a slightly increased risk for ectopic pregnancy.  Theories include impaired immunity in smokers predisposing them to pelvic infections.

Pathology  Tubal abortion  Rupture of tubal pregnancy  Secondary abdominal pregnancy  Persistent ectopic pregnancy .

Pathology  Tubal change characteristics: 输卵管蜕膜 反应,胚胎发育不良,发生流产;胚胎 滋养叶细胞穿破输卵管小动脉,引起破 裂。 .

Pathology Uterus change: 增大、变软,但不随停经 月份增加  子宫内膜:蜕膜反应,但不见绒毛。病 理蜕膜变,也可有增生期和分泌期反应  .

Ectopic pregnancy and ART  Location: fallopian tube is the most common site for ectopic pregnancy following IVF.  Tubal pathology  Ovulation induction  Embryo transfer  Heterotopic pregnancy .

Rare types of ectopic pregnancy  Abdominal pregnancy  Ovarian pregnancy  Cornual pregnancy  Cervical pregnancy  Heterotopic pregnancy .

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Clinical Feature  Amenorrhea  Abdominal pain  Vaginal bleeding  Shock  Pelvic mass .

Examination finding  Abdominal guarding  Cervical excitation  Tender adnexal mass  Cul-de-sal fullness  Orthostatic hypotension .

.Transvaginal ultrasound  Identify an intrauterine pregnancy with nearly 100% accuracy for gestational greater than 51/2 weeks.

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Diagnosis  Clinical feature  Assay of hCG  Ultrasound  Others .

Diagnostic algorithm for ectopic pregnancy .

临床决策        ß-HCG≥1500 IU/L: 1 超声诊断异位妊娠 2 超声无法诊断,二日后复查 ß-HCG≤1500 IU/L: 1 无法诊断,三日复查 2 HCG无倍增或下降,可按输卵管妊娠处理 3 HCG 倍增,等待超声结果 .

Treatment  Surgical treatment Laparotomy Laparoscopy  Non-surgical treatment Expectant management Chemotherapy .

 . rise at least 66% and up to twofold every two days.  Recent data shown that that the minimum rise for a potentially viable pregnancy that presents with pain and vaginal bleeding may be as low as 53% in 2 days.Serial β-HCG chorionic gonadotropin The β-HCG in normal pregnancy.

 No established cutoff to use to discriminate between to entities.Progesterone  Progesterone levels are higher in intrauterine than in ectopic pregnancy. .  Low pregnancy level of less than 5 ng/mL can rule out a normal pregnancy with almost 100% accuracy.

The advantages of laparoscopical surgery  Quicker recovery  Reduced hospital stay  Reduced blood loss  Fewer adhesions .

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Indication for laparotomy  Ruptured ectopic pregnancy  Ectopic mass > 5cm in diameter  Extensive adhesion  Operator inexperience with laparoscopic surgery .

000mIU/ml  Positive fetal heartbeat : proceeding with caution  Willingness of patient to comply with subsequent treatment monitoring .Indication for systemic MTX for uncomplicated ectopic pregnancy  No rupture  UTZ size « 4cm  Β-HCG « 10.

Medical management  Multiple-dose methotrexate  Single-dose methotrexate  Two-dose methotrexate .

Multiple-dose MTX  Multiple-dose MTX therapy is tailored to the patient’s weight and ectopic pregnancy responsiveness. .

Single-dose MTX

50mg/m2

Two-dose MTX

50mg/m2, day0 and day4

Dealing with methotrexate failure

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Operate when high suspicion of rupture Pain is severe and persistent, regardless of βHCG levels Falling hematocrit Orthostatic hypotension Consider operating when signs of treatment failure Levels of β-HCG do not decline by at least 15% between days 4 and 7 of treatment Levels of β-HCG increase or plateau after first week or treatment

Persistent ectopic pregnancy  Persistent ectopic pregnancy is diagnosed by a plateauing or rising β-HCG concentration following conservative surgical therapy. .

 Falling β-HCG level under 1.Expectant pregnancy  Ectopic pregnancy may resolve spontaneously.000mIU/ml have been followed with conservative expectant management .

Future fertility after EP  IUP (linear salpingostomy): 60%  Recurrent EP: 15%  IUP (tube removed): 38%  Recurrent EP: 10%  IUP (single-dose MTX): 38%  Recurrent EP: 15% .

. ultrasound. ectopic pregnancy can be diagnosed before symptoms develops and treated definitively with few complications. and curettage allow early diagnosis of ectopic pregnancy and use of medical therapy as the initial therapy operation.  Quantitative β-HCG testing.Summary point  In most circumstances.

Summary point  Conservative surgical therapy and medical therapy for ectopic pregnancy are comparable in terms of success rates and subsequent fertility. . medical failures. Medical therapy is the preferred choice because of the freedom from surgical complications and lower cost.  Surgery is the treatment of choice for hemorrhage. and when medical therapy is contraindicated. neglected cases.

neglected cases. medical failure. and complex cases when medical therapy is contraindicated. .  Prophylactic postopertaive systemic methotrexate( a single dose) can prevent virtually all cases of persistent ectopic pregnancy following salpingostomy.Summary point  Laparoscopic salpingotomy or salpingectomy is favored for cases of intra-abdominal hemorrhage.

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Implantation sites for ectopic pregnancy .

用药后随访 2周内每3天复查超声和HCG  HCG下降,包快缩小为有效  用药第7日,HCG下降≤25%,超声无变 化可考虑再次给药  如有内出血考虑手术  .

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