Ectopic Pregnancy

It is called for pregnancies which are implanted outside the womb. According to localization, it is called as tubal -most frequent-, cervical, ovarian, abdominal ectopic pregnancy. It is seen at a frequency of 2%. It is quite dangerous because it can cause serious internal bleeding; diagnosed patients should be followed up closely.

CAUSES

Mostly the reason is not known so much. The most leading causes are: previous pelvic surgery, unsuccessful tube ligation, pregnancy with IUD (spiral), diffuse intraabdominal adhesions, pregnancy over the age of 40 years, smoking, previous operation (salpingectomy (totally excision of tube)) for ectopic pregnancy, those who become pregnant through helper methods to fertilize.

DIAGNOSIS

Classical triad (bleeding after menstrual delay, pain, adnexal tenderness) can be seen only in the half of patients. Signs are very various. The amount of vaginal bleeding can be stained, brown, muddy, or intensive. In general, sometimes pain is like acute abdominal pain in the lower abdominal region. When the person is examined, tenderness and pain are found in abdominal region. Particularly, if ectopic pregnancy is ruptured (sac is ruptured, causes bleeding), there is tenderness in cervical movements. In 40% of the cases, a mass can be palpated in the adnexal area or Douglas (behind the womb). Shoulder pain and mild fever are rarely seen.

*In the differential diagnosis of the patients applying with the picture of acute abdomen, abortion hazard, appendicitis, ovarian torsion, salpingitis, normal pregnancy, bloody corpus luteum cyst, endometriosis, urinary tract infections, and gastroenteritis should be considered.

DIAGNOSTIC METHODS

Blood group and blood analyses (hemogram, hematocrit, β-hCG, serum progesterone) are immediately requested. Vital findings of the person are checked. Gynecological examination and transvaginal ultrasound are done. In normalcy, β-hCG value increases by doubling in every 48 hours. To check serial β-hCG and hemogram values may be necessary. If serum progesterone level is under 5 ng/mL, there is no chance of pregnancy to live. In normal pregnancy, ,t has to be 25 ng/mL and over. If between 5 and 25, it is not clearly decided. Pregnancy sac can be seen in values of which β-hCG level is 1500 and over by transvaginal USG. If there is vaginal bleeding in the person, if the sac is not seen by USG, if no acute abdomen findings are present, values should be checked with β-hCG measures.

**DILATATION AND CURETTAGE: If vaginal bleeding, inguinal pain are present in the person, if β-hCG levels are between 1500 and 2000, if no diagnosis is clearly established by USG, then DC is suggested. Pathological sample is sent. In normalcy, if the person aborts after curettage procedure or it is an impaired normal pregnancy, β-hCG values should begin to decrease. No CORION VILLUS during pathological diagnosis make think EG. If β-hCG values do not decrease, the person should be monitored in terms of EG. These that we told may not completely carry out every time.

When checked by ultrasound, sometimes the sac that has cardiac beat inside it can be seen around tuba. In cases with rupture, free blood can be observed in Douglas’ space. When sometimes CULDOCENTESIS is performed by entering into this space by syringe, no draw anti-coagulated blood into the injector is also used among diagnostic methods. But fluid not to come does not rule out the diagnosis in this method.

TREATMENT

The person is primarily evaluated in terms of acute abdomen picture. Blood group, hemogram, hematocrit, complete biochemistry, PT, and PTT are requested. If acute abdomen picture is present, it is urgently operated. According to localization of ectopic pregnancy, want to have a baby, clinical picture, appropriate operation is performed by open or close (laparoscopic) method. These are: SALPHINGOSTOMY (EG material is taken by incision performed on tube. Bleeding tissues are cauterized. Incision site is left open. It is the most frequent applied method); SALPINGOTOMY (additionally to other technique, incision site is closed with suture); SALPINGECTOMY (Tube that is EG is incised and excised); SEGMENTAL RESECTION AND ANASTOMOSIS ( segment that is EG is removed and anastomosis is applied to remained segments by microsurgical methods).

In stable patients in whom no operation is considered, METHOTREXATE TREATMENT is applied. Conditions using MTX: *No fetal cardiac motion *Sac dimension under 3-3.5 cm *If no findings of rupture is present * β-hCG value under 6500 *If fertility is demanded *Selected cervical or corneal pregnancy. Unfavorable conditions to use MTX: to be disorder in blood tests; to be hepatic, renal, blood diseases; active lung diseases; chronic use of alcohol; to be peptic ulcer; if fetal cardiac beat is present.

**In MTX treatment, single dose or multi-dose protocol is used. By necessary blood tests and β-hCG follow-up, the person is followed up. 14-21 days after treatment, β-hCG values get lost in blood. Because rupture will be in 5% of patients during follow-up, β-hCG levels are weekly followed up until to be 5mIU/ml. If her state is stable and she will regularly come for controls, the person is not needed to be hospitalized.

**If there is blood incompatibility, anti-D (rhogam) should be applied.

** **OCs is suggested to be not pregnant during follow-up. Next pregnancies should frequently be followed up. She may be pregnant by 60% after EG.