Ectopic Pregnancy

ECTOPIC PREGNANCYGroup 14, 2D-MT

Cruz, James ChristopherNuqui, RowenaTomas, Danica

Faculty of PharmacyDepartment of Medical Technology

University of Santo TomasEspaña, Manila

INTRODUCTION

Pregnancy- fertilization of egg which normally occurs in the uterus

EP- abnormal development of embryo outside the uterus

• Greek word ektopos: out of place

• Occurrence:

*Fallopian tube- 97%

55% in the ampulla,

25% in the isthmus

17% in the fimbia

*abdomen, cervix

and ovary-3%

Parts of the Fallopian Tube

• 1970: EP increased six fold occurring in

22% of all pregnancies• 11th Century: primitive methods

starvation

bleeding

injection of strychnine

administration of electricity in growing gestational sac

• 1800s: surgery- resulted to more than 80% of death

• Previous researches: save mothers life

Recent researches: saving the woman’s fertility

• Cause of morbidity in first world countries as well as in third world countries

• 40-50% of ectopic pregnancies are misdiagnosed

• Diagnosing EP: physical treatment

progesterone measurement

beta-hCG measurement

ultrasonography

• Treating EP: Medical management

Surgery

Expectant method

THE STUDIES

FAILING PREGNANCIES OF UNKWON LOCATION: A PROSPECTIVE EVALUATION OF THE HUMAN

CHORIONIC GONADOTROPHIN RATIO(a report)

Bourne et. al (2006)

PUL Ectopic pregnancy

behave like ectopic pregnancy vs failing beta- hCG

ultrasonically represent EP blob sign

bagel sign

gestational sac

PUL is different from ectopic pregnancy. For a pregnancy to be considered ectopic, it should meet the necessary requirements in terms of the elevation or demotion of chemical markers present in the human body and the unusual presence of signs.

ECTOPIC PREGNANCY COMPLICATED BY AN AVM OF THE FALLOPIAN TUBE

Henrich, Blasi, Stupin, Joachin & Dudenhausen (2008)

CAUSES OF ECTOPIC PREGNANCY

Chronic Salpingitis

STD (gonorrhea and Chlamydia)

pelvic inflammatory disease

previous abortion

bitubal ligation

IUD

assited preoperative techniques

late primiparity

previous surgery

AVM

DIAGNOSING ECTOPIC PREGNANCY

Transvaginal Sonography

2D transvaginal scanning

color Doppler imaging

3D transvaginal scanning

angiography

Chronic salpingitis is the most common finding associated with ectopic pregnancy. However, AVM is another factor to be considered; it causes abdominal pregnancy but can be diagnosed as early as possible with angiography.

DIAGNOSING AND TREATMENT OF ECTOPIC PREGNANCY

(a review)Baakdah, Bardell, Murray & Tulandi (2005)

Table1: Risk factors for ectopic pregnancy

OR (and 95% CI) Factor Ankum et al 17 Mol et al 18 Dart et al 9

Previous tubal surgery 21 (9.3-4.7) --- ---Previous ectopic pregnancy 8.3 (6.0-11.5) --- ---in utero DES exposure 5.6 (2.4-1.3) --- ---History of PID 2.5 (2.1-3.0) --- ---History of Infertility 2.5-21* --- 5.0 (1.1-28)History of chlamydial orGonococcal Cervicitis 2.8-3.7* --- ---Documented tubal abnormality 3.5-25* --- ---Tubal ligation --- 9.3 (4.9-18) 18 (3.0-139)Current IUD use --- 4.2-45* 5.0 (1.1-28)Note: OR =odds ratio, CI – confidence interval, DES =diethylstilbestrol, PID =pelvic inflammatory disease, IUD =intrauterine device.*Range; summary OR not calculated owing to significant heterogeneity between studies.

Among the known risk factors for ectopic pregnancy, previous tubal surgery was found to be the most common.

Table 2: Performance of serum levels of β human chorionic gonadotropin (β-hCG) in identifying ectopic pregnancy and abnormal intrauterine pregnancy (IUP

Predictive value ( 95% CI ), %Outcome Sensitivity Specificity Likelihood ratio (+)

Kohn et al;26 serum β-hCG level <1500 IU/LEctopic pregnancy 42 (32-52) 81 (78-82) 2.4Ectopic pregnancy orabnormal IUP 38 (33-43) 93 (91-96) 5.8Kaplan et al; 23 serum β-hCG level <1000 IU/LEctopic Pregnancy 38 (26-51) 90 (87-93) 3.8Ectopic pregnancy orabnormal IUP 25 (20-31) 97 (95-99) 9.5

Serum beta-hCG is sensitive in detecting Ectopic pregnancy but not specific in differentiating ectopic pregnancy from abnormal intrauterine pregnancy

Table 3: Performance of progesterone levels in identifying ectopic pregnancy and abnormal IUP

Predictive value ( 95% CI ), %Outcome Sensitivity Specificity Likelihood ratio (+)Dart et al;31 serum progesterone level ≤ 5 ng/mL*Ectopic pregnancy 88 (69-97) 40 (32-49) 1.47Ectopic pregnancy orabnormal IUP 84 (77-89) 97 (87-99) 28Buckley et al;29 serum progesterone level ≤ 22ng/mL*Ectopic Pregnancy 100 (94-100) 27 (23-30) 1.36

*All patients had β-hCG concentration < 3000 IU/L and indeterminate ultrasound findings.

Progesterone level measurement is sensitive in detecting ectopic pregnancy but not specific.

Table 4: Randomized studies comparing methotrexate (MTX) with laparoscopic salpingostomy (LS) for the treatment of ectopic pregnancy [abridged*]

Treatment success rate, % Difference

Study (no. of patients) MTX LS in rate Other outcomes CommentsHajenius et al, 199756 82 72 NS No difference in rates All patients (100) of tubal preservation underwent laparoscopy for diagnosis or treatment.

Four doses of MTXFernandez et al, 199857 88 96 NS Higher rate of future One of a few(100) pregnancy in MTX centres using group (96% v. 62p < a scoring 0.05 but not of system and recurrent ectopic local MTX pregnancy) injection for ectopic pregnancy)Sarah et al, 199858 95 91 NS No difference in rates The study (75)

of tubal patency or was under- future pregnancy poweredSowter et al, 200159 65 93 95% CI Less time till β-hCG This study(62) 10-47 clearance in LS represents

group: 15 (5-49) the general v. 28 (14-71) d clinical management

of ectopic pregnancy Note: NS = not significant, CI = confidence interval*An abridged version of this table is available at www.cmaj.ca/cgi/content/full/173/8/905/DC1.

Laparoscopy and methotrexate were the known methods of treating ectopic pregnancy. However, choosing the more effective method of treatment is still uncertain.

MANAGEMENT OF ECTOPIC PREGNANCY: A TWO-YEAR STUDY

(experimental method)Mabooh & Mazhar (ND)

Fig 1. Occurrence of ectopic pregnancy

Ectopic pregnancy

Normal Pregnancy

It was found out that ectopic pregnancy accounts for 1% of the entire pregnancy in Islamabad.

Fig 2. Treatment administered to patients with ectopic pregnancy

conservative treatment (14%)

medical treatment (28%)Laparotomy (58%)

Laparotomy was found to be the best method in treating an ectopic pregnancy

successful67%

unsuccessful33

Fig 3. The success rate of conservative management

successful80%

unsuccessful20%

Fig 4. The success rate of methotrexate management

Other findings

Ectopic pregnancy (Islamabad) 1%

Women mostly affected 28 yrs old

Abdominal pain as the most common symptom 100%

Young women are mostly affected by this condition.

Abdominal pain is the most common symptom experienced by the patients with ectopic pregnancy.

(experimental method)Archibog, Eskandar, Sadek & Sabonde (2002)

There is an increasing occurrence of ectopic pregnancy

Seasonal variation affects the occurrence of ectopic pregnancy.

CONCLUSION

• Causes, treatment and diagnosis of ectopic pregnancy are still being develop by experts

• The causes of ectopic pregnancy:*AVM

*Chronic salpingitis caused by sexually transmitted diseases (gonorrhea and Chlamydia), pelvic inflammatory diseases, previous abortions, bitubal ligations , IUD, assisted preoperative techniques, late primarity and previous surgery, previous ectopic pregnancy and infertility

*seasonal variation and geographical location

• Mahbooh & Mazhar found out that ectopic pregnancy frequently occurs at age 28 while Sepillian & Wood stated that the highest rate of ectopic pregnancy occurs at age 35- 44.

• The diagnosis of ectopic pregnancy can be done through the use of chemical marker termed as ß-hCG and by monitoring the level of progesterone; Ultrasound imaging is mostly favored by patients with ectopic pregnancy regardless of its higher cost compared to any other method.

•Among the three identified methods of treating an ectopic pregnancy, the surgical management is preferred over medical and expectant management because of its minimal drawbacks; however, there were recorded cases of recurrences of ectopic pregnancy among patients who undergone this method.

•Despite of the rampant occurrence of ectopic pregnancy among first world countires, third world countries, like the Philippines, are not gravely affected