MANAGEMENT OF ECTOPIC PREGNANCY

Dr.V.Ravimohan

Incidence 11.1/1000 pregnancies

Treatment options 1.Expectant 2.Medical 3.Surgical

Ruptured ectopic with collapse

Get help- call senior SPR/Consultant on call and anaesthetist

ABC of resuscitation give facial oxygen Site two IV lines (at least 16g), commence IV fluids (crystalloid) Send blood for FBC, Clotting screen and cross-match at least 4 units of blood.

insert indwelling catheter arrange theatre for laparotomy whilst awaiting transfer to theatre continue fluid resuscitation and ensure

intensive monitoring of haemodynamic state do not wait for BP and pulse to normalise prior to transfer-resuscitation and

surgery need to go hand in hand. Pfannensteil incision, locate tube directly and clamp salpingectomy and wash out of abdomen assess bloods consider CVP / HDU discuss with anaesthetist record operative findings including the state of the remaining tube/pelvis Anti – D immunoglobulin (250 IU)to be given to Rhesus negative women

Surgical ManagementLaparoscopy Laparotomy

Less intraoperative blood loss

Shorter operation time

Shorter hospital stay

Lower analgesic requirement

Future intrauterine pregnancy rate same

Future intrauterine pregnancy rate same

Lower repeat ectopic pregnancy rate

Preferable in the haemodynamically unstable patient

Salpingectomy Vs Salpingotomy

No randomised controlled studies available Evidence from observational studies

Case series Cohort

Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contra lateral tubal disease and the desire for future fertility.

Salpingectomy Salpingotomy

There may be a higher subsequent intrauterine pregnancy rate associatedwith salpingotomy but the magnitude of this benefit may be small

Trend towards higher subsequent ectopic pregnancy

small risk of tubal bleeding in the immediate postoperative period

potential need forfurther treatment for persistent trophoblast

Persistent trophoblast

When salpingotomy is done, protocols should be in place for the identification and treatment of women with persistent trophoblast.

Monitoring serum HCG levels would help to identify the pesistent trophoblast.

Criteria for medical therapy

Selection criteria Minimal symptoms HCG <3,000 Absence of fetal heart beat Normal FBC,U&E(urea & electrolytes),LFT(liver function tests)

Exclusion creiteria Any hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood

dyscrasia(WCC <2000 cells cm3). Difficulty or unwillingness of patient for prolonged follow-up (average follow-

up 35days). Ectopic mass >3.5mm The presence of cardiac activity in an ectopic pregnancy Women on concurrent corticosteroid therapy

Medical management Treatment

Methotrexate-Intramuscular(buttock or lateral thigh) Dose calculated from body surface area Usual dose ranges between 75-95 mg HCG checked on day 4 & day 7

If fall is less than 15 % consider second dose of methotrexate

The empty syringe or needle should be placed in a separate Sharp Safe, labelled “Cytotoxic waste forspecial incineration”

Anti-D should also be given if required Rest up to one hour after the injection. Check for any local reaction. If local reaction noted consider anti-histamine or steroid cream (very rare).

Patient undergoing medical management

14 % of medical management second dose of methotrexate

75% would experince abdominal pain-separation pain.This usually occurs between day 3-7

10% would finally require surgical management

Medical management.... Patient should be given information on(preferably written)

Need for further treatment Adverse effects

Women should be able to return easily for assessment at any time during follow-up Advice

avoid sexual intercourse during treatment to maintain ample fluid intake use reliable contraception for three months after methotrexate has been given,

because of a possible teratogenic risk.(barrier or hormonal) side effects of the drug are minimal but may include nausea, vomiting and

stomatitis. avoid alcohol or folic acid containing vitamins during treatment. Avoid exposure to sunlight.

Outcome 90% successful treatment with single dose regime. Recurrent ectopic pregnancy rate 10 – 20%. Tubal patency approximately 80%.

Medical management....

Day 1- Do FBC, LFTs, U &Es, serum hCG and give Methotrexate

Day 4 – Do serum hCG Day 7 – Do serum hCG, FBC, LFTs and U&Es On day 4 and day 7 blood results should be reviewed by

the doctor with regard to resolution, need for a second dose or surgical treatment.

Then blood tests should be repeated once or twice weekly until levels of hCG drop below 20 IU/L.

Cost benefit

Medical management is cheap in the initial period but considering the cost of follow up & the

loss of work time for patient & carers no cost saving was seen at serum hCG

levels above 1500 iu/l due to the increased need for further treatment and prolonged follow-up.

Expectant management of pregnancy of ectopic pregnancy

Criteria for selection asymptomatic women with an ultrasound

diagnosis of ectopic pregnancy. less than 100 ml fluid in the pouch of Douglas decreasing hCG levels that are less than hCG

1000 iu/l at initial presentation Adnexal mass less than 4 or 5 cm was the cut

off for the studies assessing expectant management.

Monitoring

Initial follow up twice weekly with serial hCGmeasurements weekly by transvaginal examinations

By the first week drop in HCG level more than 50% Adnexal mass size more than 50%

Otherwise reassess the options (Medical/Surgical) If the fall of HCG & reduction in size of

adnexal mass satisfatory weekly hCG and transvaginal ultrasound

examinations Till the HCG falls less than <20 IU

Expectant management of pregnancy of unknown location

Selection criteria Clinically stable patient with minimal symptoms initial upper level of serum hCG of 1000–1500 iu/l

Explain the possibility ectopic pregnancy to the patient. 44–69% of pregnancies of unknown location resolve

spontaneously with expectant management Ectopic pregnancy was subsequently diagnosed in 14–28% of

cases of pregnancy of unknown location Intervention has been shown to be required in 23–29% of cases.

Anti-D immunoglobulin

Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.

Dose 250 IU

Follow up Women must be made aware of the risk of a

further ectopic pregnancy

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Source: Royal college of Obstetericians & Gynaecologists Guideline