Marie Ellström Engh

Overlege Professor

Kvinneklinikken Akershus

Universitetssykehus

Bleeding in early pregnancy

Ectopic pregnancy

The gynecological appendicitis

Definition

Implantation of a fertilized egg in a location

outside of the uterine cavity

By Donna M. Peretin, RN. (A

80%

12%

5 %

2% 1.4 %

0,2%

0,2%

,

Incidence

2 % of all pregnancies,

90 % in the fallopian tube

6-16% of women seeking help

Mortality rate USA 2007 50/100.000 live births

Creanga Obstet Gynecol 2011

Incidence of ectopic pregnancy per 10 000 women-years by age. Diamonds represent women aged 15–24

years, squares represent women aged 25–34 years and triangles represent women aged 35–44 years.

Skjeldestad Hum Reprod. 2006;21(12):3132-3136.

Cornual or isthmical

Risk factors Visiting your office with abdominal pain and

a positive pregnancy test

History

Previous ectopic pregnancy

Pelvic inflammatory disease (PID)

Salpingitis

Abdominal surgery or tubal ligation

Smoking,

Contraception; progesteron only

Infertility

Multiple sexual partners

Age

Etiology

Anything that hampers or delays the migration of the

fertilized ovum (blastocyst) to the endometrial cavity

Tubal damage

Altered tubal motility

Tubal damage

Infections Pelvic inflammatory

disease (PID)

Multiple sexual partners

Abdominal surgery or tubal ligation

Previous ectopic pregnancy 50-80% chance of IUP

10-25% tubal EP

2 or more years of infertility

Altered tubal motility

Smoking

Minipills progesterone-only

Intrauterine device 1:2 Mirena

1:16 Copper

1:50 Non-users

Backman Am J Obstet Gyn 2004

Age

Most patients presenting with an

ectopic pregnancy have no

identifiable risk factor

Bouyer J et al Am J Epidemiol. Feb 1 2003

Diagnosis Classical triad

Abdominal pain

Amenorrhea

Vaginal bleeding

>50% do not have

ANY symptoms before rupture.

Other symptoms

Dizziness or weakness

Fever

Flulike symptoms

Vomiting

Syncope

Cardiac arrest

Visiting your office with abdominal pain and

a positive pregnancy test

Examination

Visiting your office with abdominal pain and

a positive pregnancy test

Examination

Vital signs (20% of sever bleeding no

change )

Visiting your office with abdominal pain and

a positive pregnancy test

Vagina inspection

Uterine contents in the vagina ?

Cervix closed

Visiting your office with abdominal pain and

a positive pregnancy test

Gynecological examination

Uterus slightly enlarged soft

Motion tenderness

Adnexal mass

No statistically significant differences

in the presenting symptoms of

patients with unruptured ectopic

pregnancies versus those with

intrauterine pregnancies.

Stovall T et al Ann Emerg Med. Oct 1990;

Likelihood ratio

A likelihood ratio of higher than 1 indicates the

test result is associated with the disease.

How to diagnose an ectopic pregnancy ?

Absence of intrauterine pregnancy LR of 111

Presence of adnexal mass on TVU

Absence of intrauterine pregnancy LR- 0.12

Absence of adnexal mass on TVU

Clinical history any component LR <1.5

Physical examination

Cervical motion tenderness LR 4.9

Adnexal mass 2.8

Adnexal tenderness 1.9

Barclay L. JAMA. 2013;309:1722-1729

Diagnosis using transvaginal ultrasound

Granberg S

Diagnosis: Abnormal development on ultrasound Ectopic pregnancy Pseudogestational sack

Granberg S

Diagnosis: Normal development on ultrasound Gestational sack 4-5 weeks

Granberg S

Diagnosis: Abnormal development on ultrasound Ectopic pregnancy Tubal mass

Granberg S

Intrauterine

Ectopic

Diagnostic tests

"Transvaginal sonography is the single

best diagnostic modality”

Visualization of an intrauterine sac, with

or without fetal cardiac activity, is often

adequate to exclude ectopic pregnancy

Diagnostic tests

In a normal pregnancy, the level doubles

every 48-72 hours until it reaches 10,000-

20,000 mIU/mL

In ectopic pregnancies, S-hCG levels

usually increase less. (But 30% have a

normal rise)

Diagnostic tests S-hCG

Absence of an intrauterine pregnancy on a

scan

>2000 mIU/mL with transvaginal

ultrasonography represents an ectopic

pregnancy Barnhart Obstet Gynecol 1999

or a recent abortion

Diagnostic tests Combined ultrasound and S-HCG

Management

Expectant

Medical

Surgery

Expectant management

Asymptomatic

TVUS no gestational sac/extrauterine

Declining S-hCG levels up to 1500 mIU/mL

Close follow-up, tubal rupture may occur despite

low and declining serum levels of S-hCG.

Medical : Methotrexate

•Acts by inhibiting the metabolism of folic acid and

thereby the DNA synthesis

•Hemodynamic stable

•TVUS ectopic mass <3-4 cm and no fetal cardiac

activity

•S-hCG levels < 5000 mIU/mL Menon et al Fertil Steril 2007

• No peritoneal fluid (?)

•Close follow-up. Tubal rupture may occur despite

low and declining serum levels of S-hCG.

Methotrexate

•35% of ectopic pregnancies eligible for treatment Van den Eeden

Obstet Gynecol 2005

•Risk of recurrence the same as for surgery Gervaise Fertil Steril 2004

Seems to be the most cost-effective treatment for tubal EP.

Systemic MTX is a good alternative in selected patients with

low S- hCG concentrations. Mol et al . Hum Reprod update 2008

Surgery

Salpingectomy Salpingotomy

Fertility prognosis

The status of the contralateral tube,

adhesions, other risk factors, such as endometriosis,

more important for future fertility than does the choice of surgical

procedure. Rulin et al Obste Gynecol 1995

Same fertility rates laparotomy/ laparoscopy

Salpingectomy/salpingostomy if the contralateral tube is patent

Salpingostomy if the contralateral tube is affected

Management Rhesus prophylaxis to non sensitized Rh- Always