Ectopic Pregnancy—Medical management an overview

28 Mar

Introduction

The blastocyst normally implants in the endometrial lining of the uterine cavity. 1Implantation anywhere else is considered an ectopic pregnancy World Health Organization (2007) ,ectopic pregnancy is responsible for almost 5 percent of maternal deaths in developed countries .

Sites – Fallopian tube commonest

Dr Pratiksha Gupta, Ectopic Pregnancy, Female Reproductive Cross Section

 

 

 

 

 

 

Risk Factors

 

Factors Increasing  the Ectopic Pregnancy Rates

  • Increasing prevalence of sexually transmitted infections, especially those caused by Chlamydia trachomatis)
  • Identification through earlier diagnosis of some ectopic pregnancies otherwise destined to resorb spontaneously
  • Popularity of contraception that predisposes pregnancy failures to be ectopic
  • Tubal sterilization techniques that with contraceptive failure increase the likelihood of ectopic pregnancy
  • Assisted reproductive technology
  • Tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility.

Fate of tubal ectopic pregnancy

Tubal Rupture

Tubal Abortion Abdominal Pregnancy

Broad Ligament Pregnancy

Interstitial and Cornual Pregnancy

Multifetal Ectopic Pregnancy

Symptoms and Signs

 Pain. Pelvic and abdominal pain  – 95 %

Abnormal bleeding. Amenorrhea with some degree of vaginal spotting bleeding -60% to 80 %

Abdominal and pelvic tenderness

Uterine changes

Vital signs ,Fall in Blood Pressure, Tachycardia.

gastrointestinal symptoms (80 percent)

dizziness or light-headedness (58 percent

Diagnosis of Ectopic Pregnancy

BETA-HCG

Serum Progesterone levels-25 ng/mL

Sonography

Culdocentesis

Management

Medical Management–with Methotrexate

This folic acid antagonist is highly effective against rapidly proliferating trophoblast

contraindication

Active intra-abdominal hemorrhage ,intrauterine pregnancy.breast feeding;

immunodeficiency,alcoholism; chronic hepatic, renal, or pulmonary disease;

blood dyscrasias; and peptic ulcer disease.

Patient Selection

The best candidate for medical therapy is the woman who is asymptomatic, motivated, and compliant, with.

Success rate depends on

  • Initial serum  Beta hCG level,

Success rate is 1.5 percent if the initial serum hCG concentration was <1000 mIU/mL;5.6 percent with 1000-2000 mIU/mL; 3.8 percent with 2000-5000 mIU/mL;

and 14.3 percent when levels were between 5000 and 10,000 mIU/mL

  • Ectopic pregnancy size

93-percent success rate with single-dose methotrexate when the ectopic mass was <3.5 cm, compared with success rates between 87 and 90 percent when the mass was >3.5 cm.

Fetal cardiac activity -relative contraindication to medical therapy

 Rupture of Persistent Ectopic Pregnancy

This is the worst form of primary therapy failure with a 5 to 10-percent occurrence in women treated medically.

Expectant Management

Tubal ectopic pregnancies only

Decreasing serial  – BHCG levels

Diameter of the ectopic mass not >3.5 cm

No evidence of intra-abdominal bleeding or rupture by transvaginal sonography

Resolution without treatment was more likely if the initial serum  -hCG level was <1000 mIU/mL.

Surgical Management

Laparoscopy

Laparotomy

References

1. F. Gary Cunningham, Kenneth J. Leveno,et al, Williams Obstetrics, 22edition, Section III, chapter10.

About the Author:

Author

Dr Pratiksha Gupta

Associate Professor

Department of Gynecology and Obstetrics

PGIMSR,ESIC,

Basaidarapur

New Delhi

Corresponding author

Dr Pratiksha Gupta

House number 11284 Laj building

No 1, doriwalan new rohtak road

Karol baghNew delhi110005

Mobile no. 09871128703

Email-  drpratiksha@gmail.com

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