Ectopic pregnancy CS pregnancy national library of medicine Type EP Cause – best management ? Main...
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Transcript of Ectopic pregnancy CS pregnancy national library of medicine Type EP Cause – best management ? Main...
Ectopic pregnancy
CS pregnancy national library of medicine
Type EP
Cause – best management ?
Main objective . Prevention massive blood loss
• Conservation of uterus
Cause CSP ?
Embryo implanation through a small dehicence or tract into uterine wall .
First CSP 1978
1978 and 2001 18 case
Next 3 years 66 case
Expectant management
• woman desire to continue preg and us evidence, sac growing towards uterine cavity .
• termination recommended once diagnosis
• Ellective cs around 28-30 wk
Conservative medical treatment
• Pain free
• Hemodynamically stable
• Less then 8 wk
• Myometrial thickness loss 2 mm CS bladder
Systemic methotrexate
pregnancy < 9 wk
• Short half life MTX
• Fibrous tissue surrouding scar
• Can limit systemic absorption MTX
• Delaying disappearance G-sac
• Local MTX have greater success
MTX injected locally to G-sac
TV ultrasound control
20-22 gauge needle in case of concurrent embryo aspiration
different embryocides kcl, hypertonic glucose
Failed requiring MTX and uterine curretageVAE .
Combined treatment
Hysterocopy :
Identification G.sac , vessels coagulation
Local injection techniques
Rapid return to fertility
Requires anesthesia , operative skills
Laparoscopy
Laparotomy
Uterine curretage An sac aspiration
failure rate 70% inefective
Uterine artery embolization :
• UAE + cystemic MTX
• Well tolerated effective 64 blood loss 25 ml
• UAE + local MTX
212 ( 22-25 )
• Uterine arteery embolizatoin + intraarterial MTX 24-48 h suction curretage
• Cystemic MTX 50mg if BHCG < 50% 50mg MTX
abdominal guidance
5-6 months 2 wk BHCG
Uterine curettage and Sac aspiration
blind uterine curettage + should be discouraged under US control
G week < 7 wk
Myometrial thickness > 3.5mm
more reports documenting U-curettage ineffective
68 cases of CSP ( 40-28)
• TV Ultrasound guided embryo aspiration + MTX local 50 mg
• after on week 50 mg MTX IM
• Systemic MTX + curettage with hysteroscopy a week later 50 mg MTX IM 50% decreased BHCG , us indicate lower blood flow at the scare , curettage .
Figure 1. Ultrasound follow‐up at 5, 6 and 7 weeks gestation. At 5 and 6 weeks gestation (A and B), a midline sagittal transvaginal image demonstrating a
gestational sac implanted at the isthmic region between the cervix and the empty uterine cavity (small arrows), i.e. anatomical location of a previous Caesarean
section scar (large arrow). At 7 weeks gestation (C), a midline longitudinal transabdominal scan demonstrating an empty uterine cavity. The tip of the sac is
bulging towards the bladder (large arrow).
Diagnosis
Criteria interstitial EP
• Empty U-cavity
• G sac at least 1 cm lateral most borders U-cavity
• Myometrial bed thinning sac
• color Doppler us periphoblastic arterial flow
Interstitial pregnancy
• G-sac in uterin horn
• Hemodynamically stable
• conservative management
• sytemic methatrenate
• Laparoscopic wedge resection
• Laparoscopy
• Laparoscopic salpingocentesis + MTX
• C-EP and I-EP systemic MTX+miferiston preserve fertility
• eliminate anesthesia
Cervical pregnancy
1/9000 pregnancy
major predisposing factor D&C
PCS
IVF
Asherman’s synd
Prior EP
Infertility
Instrumentation on therapeutic – ab
Painless V-bleeding
1/3 lower ab – cramping
Soft disproportionately large cervix an hour – glass shaped uterus
US 81.8% correct diagnosis
Ushakou criteria ( C-preg )
• G-sac in endocervix
• Intact portion C-canal between sac – endometrial
• Local invasion c-tissue
• Embryomic or fetal structures in sac
• Empty uterine cavity
• Hourglass uterus
On speculum examination Ex-os may be open fetal membranous , tissue pregnancy cystic lesion on cervical Lip .
Medical therapy :
Hemodynamic stable
Multidose MTX in very early
cardiac activity , multidose MTX and intra Af and or intrafetal KCL
Take a few months
needle 22 1-5cc KCL 20% .
Surgical therapy
main complication severe bleeding
• Transvaginal ligation cervical branches UA 3-9 o’clock
• Shirodkar cerclage , angiographic UA emb
• Intracervical vasopressin 20-30cc gauge needle 21 cervical stroma
• UAE
• If implantation site bleeding
• Foley catheter (26) 30 ml balloon .
After 24-48 balloon deflated gradually
hours to days and removed if bleeding picks up or recurs reinflated
• Angiographic embolization b-internal iliac artery ligation , U-A ligation , surgical evacuation several hours to 24 h .
• Hystrectomy
An ultrasonographic sagittal view shows the viable fetus within an
ectopic
gestational sac in the posterior cervical stroma.
A visible defect (black arrow) with prolapsing fetal membranes (black arrow)was seen in the posterior
cervix.
This ultrasonographic image, obtained 1 week after direct instillation of
methotrexate into the cervical ectopic gestational sac, shows the resolving
ectopic pregnancy (white arrow).