bleeding in early pregnancy ectopic pregnancy
TRANSCRIPT
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