Management Ectopic Pregnancy SLCOG
Management Ectopic Pregnancy SLCOG
Management Ectopic Pregnancy SLCOG
2.Management of Ectopic
Pregnancy
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2.2 Aetiology
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2.3 Epidemiology
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2.4 Diagnosis
2.4.1 History
2.4.2 Examination
2.4.3 Investigations
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2.5 Management
2.5.1 Levels of management
2.5.2 Management strategies
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2. Special circumstances
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2. .1 Ruptured ectopic pregnancy-management 40
2. .2 Anti-D immunoglobulin
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2.7 Summary
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2.8 References
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Contributed by
Dr. A.G.S.K. Ranaraja
Dr. Saradah Hemapriya
Dr. Harsha Attapattu
Dr. R.M.A.K. Rathnayaka
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Introduction
The aim of this guideline is to provide recommendations to
aid General Practitioners and Gynaecologists in the
management of Ectopic Pregnancy. This treatment could
be initiated in a primary care setting or in centres with
advanced facilities. The objective of management in
ectopic pregnancy is to make an early diagnosis, treat,
prevent complications, and consequently to improve
quality of life
2.1
2.2 Aetiology
2.1.1 Definition
an
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2.3 Epidemiology
2.4 Diagnosis
2.4.1 History
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2.4.2 Examination
2.4.2.1 Signs
The most common finding is tenderness in the
abdomen and pelvis. Often, a mass is felt on the side of the
uterus (adnexial mass). In about one third of women, an
enlarged uterus is found which is smaller than would be
found in a normal pregnancy, except when an interstitial
pregnancy is present. Tachycardia and hypotension can be
found if there has been profuse blood loss. However, in
most early ectopic pregnancies no abnormal findings
can be found.
2.5 Management
2.5.1 Levels of management.
Level 1.
2.4.3 Investigations
-HCG Blood levels,
Transvaginal ultrasonography.
(Grade X)
Level 2.
Base Hospital with Obstetrician and Gynaecologist.
Ultrasonography (USS) facility,
Laparotomy facility with or with out Laparoscopy facility.
Level 3.
General Hospital/Teaching Hospital with Obstetrician and
Gynaecologist with all level 2 facilities.
Human
Chorionic
Gonadotrophin
(hCG)
level
measurements available (24 hours)
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(Grade Y)
Ideal at level 3
Medical therapy should be offered to suitable
women, and units should have treatment and follow-up
protocols for the use of methotrexate in the treatment of
ectopic pregnancy. In stable patients a variety of medical
treatment options are as effective as surgery.17
If medical therapy is offered, women should be
given clear information (preferably written) about the
possible need for further treatment and adverse effects
following treatment. Women should be able to return easily
for assessment at any time during follow-up.
Medical therapy option may be considered for
women with an hCG level below 3000 iu/l.20, 21
The presence of cardiac activity in an ectopic
pregnancy is associated with a reduced chance of success
following medical therapy and should be considered a
contraindication to medical therapy.11, 12
The drug of choice is methotrexate. It can be given
intravenous / intramuscular /oral or local injection at the
site of the ectopic either laparoscopically, ultra sound
guided hysteroscopically. Intramuscular methotrexate given
as a single dose calculated from patients body surface area
(50 mg/m2). For most women this will be between 75 mg.
and 90 mg. Serum hCG levels are checked on days four
and seven and a further dose is given if hCG levels have
failed to fall by more than 15% between day four and day
seven.12, 18,19
However, the success rate is 75%. According to a
small randomised controlled trial (RCT) there is no
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(Grade Y)
Type of surgery
i. Salphingectomy.
According to meta analysis, this method gives rise
less recurrent ectopic pregnancy rate (10%) and with no
failure of removal of all ectopic tissue. However, there is
no diferrence between laparatomy and laparoscopy except
the advandages of laparoscopy.
In the presence of a healthy contralateral tube there
is no clear evidence that salpingotomy should be used in
preference to salphingectomy.0 -12
ii. Salphingotomy.
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ii. Laparoscopy.
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Recommendations.
(Grade X)
1.Laparascopic method is superior to laparatomy method with
regard to less cost, shorter hospital stay, less analgesic
requirements, higher subsequent intrauterine pregnancy
(IUP) and less recurrent ectopic rates. Therefore,
laparascopic method needs to be considered as a first
option in unruptured ectopic.
2.Laparatomy is best in the case of life saving as well as with
inadequate facilities.
3.Medical management should be conducted only by wellexperienced consultants with emergency facilities at hand.
4.Expectant management should be carried out only with
reliable and compliable patients.
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2.7 Summary
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2.6 References
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