TUBAL ECTOPIC PREGNANCY: TREATMENT

 

CONTENT

-INTRODUCTION

-NON SURGICAL TREATMENT

--EXPECTANT MANAGEMENT

--MEDICAL MANAGEMENT

-SURGICAL TREATMENT

 

INTRODUCTION

After confirmation, the treatment of ectopic pregnancy is grossly dependent on whether the ectopic pregnancy has ruptured or not. This can be divided into non surgical and surgical method of treatment.

 

NON SURGICAL TREATMENT

This method of treatment is meant for patients who are clinically stable without any features of intra-abdominal bleeding and an ultrasound finding of a non ruptured ectopic pregnancy with or without a history of vaginal bleeding. This method of treatment can be divided into expectant management and medical management.

 

EXPECTANT MANAGEMENT

Following the advent of high resolution trans-vaginal scan, many women with unruptured ectopic pregnancies have been observed to have somehow became well with their ectopic pregnancies resolving naturally without any incident. In other words nature seems to take care of itself in certain cases of ectopic pregnancy. This is not surprising as ectopic pregnancies are abnormal pregnancies often associated with non-viable fetuses. On this basis ectopic pregnancies, may be managed conservatively and expectantly if they fulfill some very strict criteria. These criteria include

1. The patient must be stable without any signs and symptoms of shock.

2. There must be no history of abdominal pain.

3. The ultrasound report must confirm that the fetus is not viable.

4. The gestational sac must be less than 4cm in all its dimensions.

5. The serum β HCG assay must be less than 1000i.u/ml.

Subsequently, the patients must be monitored by serial measurement of their serum β HCG assay and trans-vaginal scans along with close monitoring of their clinical status over the following weeks for any changes that may warrant that the method of treatment be changed. This is because there is still a small but significant risk of rupture of the ectopic pregnancy despite meeting the above criteria. The method is said to be successful when the serum β HCG assay becomes undetectable over the following weeks or months. A more active approach to treatment should be taken immediately the patient experience a sudden sharp abdominal pain, a feeling of dizziness and or a fainting attack or if the serum β HCG assay keeps rising instead of falling.

 

MEDICAL MANAGEMENT

Various regimens for the medical treatment of ectopic pregnancy are available for patients who meet some certain criteria similar to the above, following which you will be offered some chemotherapeutic or cytotoxic medications that are expected to destroy the fetus and its placenta usually in one or two doses. Before you are given these medications, your blood will be collected to assess your kidney and liver function along with your blood cells count. Not all people are ideal for these medications even after meeting the criteria. This may be because of known reactions to the agents used, or a possible detrimental effect of the cytotoxic medication on their organs and or the presence of medical conditions that may prevent the usage of such drugs. It is also important for you to know that you will be monitored for complications that may arise following the use of the medications. An example of such medication is Methothrexate. Criteria for selecting patient for medical management are exactly as that for expectant management except that:

The Serum β HCG assay must be less than 3000i.u/ml. Subtle differences may exist in the criteria used by different centers.

All patients on expectant and medical management of ectopic pregnancy must bear it in mind that despite these strict selection criteria and the use of these powerful medications, they is still a risk of an unexpected rupture of their ectopic pregnancy and as such they must present to their specialist immediately they notice a sharp abdominal pain or any form of distress and not refuse adequate follow up protocols laid down by their specialist.

For patient with a  non-ruptured ectopic pregnancy and or those with a serum β HCG assay greater 3000i.u, who ordinarily do not strictly speaking, qualify for expectant or medical management of ectopic pregnancy, some specialists may still opt for medical management despite a significant increased risk of a sudden rupture of the ectopic pregnancy. It is important however that such patients be monitored closely to prevent a sudden rupture going unnoticed.

 

SURGICAL TREATMENT

The preferred method of management of ruptured ectopic pregnancy and slow leaking ectopic pregnancy is by a surgical procedure called salpingectomy in which the whole or part of the affected fallopian tube is ligated and removed to stop the bleeding associated with the ectopic pregnancy. This may be done by laparotomy, in which the abdominal cavity is accessed by making a large incision on to the abdomen or by laparoscopy, in which the abdominal cavity is accessed using a thin hole into which an apparatus called a laparoscope, is inserted into the abdominal cavity. The choice of selection usually depends on the surgeons’ expertise, availability of equipments, volume of blood loss and the clinical status of the patient. Overall, laparotomy is usually reserved for clinically unstable patients with massive amount of bleeding into the abdominal cavity and in cases where the expertise for and or equipment for laparoscopy is unavailable.

 

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REFFERENCES

1. American Pregnancy Society: americanpregnancy.org/pregnancy-complications/ectopic pregnancy.