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).