Ectopic Pregnancy

ECTOPIC PREGNANCY Group 14, 2D-MT Cruz, James Christopher Nuqui, Rowena Tomas, Danica Faculty of Pharmacy Department of Medical Technology University of Santo Tomas España, Manila

INTRODUCTION

Pregnancy- fertilization of egg which normally occurs in the uterus

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EP- abnormal development of embryo outside the uterus

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• 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 ultrasonically represent EP

vs

failing beta- hCG 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.

Table1 :

DIAGNOSING AND TREATMENT OF ECTOPIC PREGNANCY Risk factors for ectopic pregnancy (a review) Baakdah, Bardell, Murray & Tulandi (2005) OR

95% CI) Factor Mol et al 18 Dart et al Previous tubal surgery --Previous ectopic pregnancy

9

Ankum et al

(and

17

21 (9.3-4.7) --8.3 (6.0-11.5) --5.6 (2.4-1.3)

in uteroDES exposure ----History of PID 2. 5 ( 2. 1- 3. 0) ----History of Infertility 2.5-21* --5.0 (1.1-28) History of chlamydial or Gonococcal 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 --Among the risk factors for previous tubal surgery 4.2-known 45* 5.0ectopic (1.1-28pregnancy, )

Note : ORfound =oddstoratio , CImost – confidence was be the common.interval, DES =diethylstilbestrol, PID =pelvic inflammatory disease, IUD =intrauterine device. *Range; summary OR not calculated owing to significant heterogeneity between studies .

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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 (+) 26 Kohn et al ; serum β - hCG level < 1500 IU / L Ectopic pregnancy 42 (32-52) 2. 4 Ectopic pregnancy or abnormal IUP 38 (33-43) 96) 5.8 23 Kaplan et al ; serum β - hCG level < 1000 IU / L Ectopic Pregnancy 38 (26-51) 3. 8 Ectopic pregnancy or abnormal IUP 25 (20-31) 99) 9.5

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

81 (78-82) 93 (9190 (87-93) 97 (95-

Table 3 : Performance of progesterone levels in identifying ectopic pregnancy and abnormal IUP Predictive value ( 95% CI ), % Outcome Sensitivity Specificity Likelihood ratio (+) 31 Dart et al ; serum progesterone level ≤ 5 ng / mL * Ectopic pregnancy 88 (69-97) 40 (3249) 1.47 Ectopic pregnancy or abnormal IUP 84 (77-89) 97 (87-99) 28 Buckley et al ; 29 serum progesterone level ≤ 22ng / mL * Ectopic Pregnancy 100 (94-100) 27 (2330) 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.

( LS ) for the treatment of ectopic pregnancy [ abridged *] Treatment success rate, % Difference Study (no. of patients) MTX LS in rate Other outcomes Comments Hajenius et al, 199756 82 72 NS No difference in rates All patients (100) underwent laparoscopy

for diagnosis or treatment.

Fernandez et al, 199857 (100) centres using

88

group (96% v. 62p <

a scoring

0.05 but not of

of tubal preservation

96

NS

Four doses of MTX Higher rate of future One of a few pregnancy in MTX

system and

recurrent ectopic

local MTX

pregnancy) injection for ectopic pregnancy) Sarah et al, 199858 95 91 NS No difference in rates (75) of tubal patency or was underfuture pregnancy Sowter et al, 200159 (62) represents

powered 65

93

95% CI

Less time till β-hCG This study 10-47 clearance in LS group: 15 (5-49)

general clinical

management

The study

v. 28 (14-71) d of ectopic pregnancy

Note: NS = not significant , CI =and confidence interval were the known methods of treating Laparoscopy methotrexate *An abridged version of this table is available at www.cmaj.ca/cgi/content/full/173/8/905/DC1.

ectopic pregnancy. However, choosing the more effective method of treatment is still uncertain.

the

MANAGEMENT OF ECTOPIC PREGNANCY: A TWOYEAR STUDY (experimental method) Mabooh & Mazhar (ND)

Fig 1 . Occurrence of ectopic 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

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

Fig 3. The success rate of conservative management

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

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*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