Download - Ectopic Pregnancy A
-
7/30/2019 Ectopic Pregnancy A
1/37
-
7/30/2019 Ectopic Pregnancy A
2/37
-
7/30/2019 Ectopic Pregnancy A
3/37
-
7/30/2019 Ectopic Pregnancy A
4/37
Case study 1:
s A 22-year-old woman, para 0, was admitted with mild
vaginalbleeding after 7 weeks ofamenorrhoea.She had had a positive home pregnancy test.
Ultrasound scan showed an empty uterus, with an
adnexal mass around 2 cm. quantitative -hCG was
2000 iu/ml.At laparoscopy ectopic pregnancy was confirmed in the
ampulary part of the right tube.
Linear salpengotomy was performed. The patient was
discharged home the following day in good condition.
-
7/30/2019 Ectopic Pregnancy A
5/37
Case study 2:
s A 22-year-old woman, para 0, was admitted with
vaginalbleeding after 8 weeks ofamenorrhoea.She had had a positive home pregnancy test, and
described passing some tissue per vaginum.
Ultrasound scan showed an empty uterus, although
urinary B-hCG was still positive.A presumptive diagnosis of incomplete abortion was
made, and evacuation of the uterus carries out
uneventfully. She was discharged the following day
Was readmitted that night with lower abdominal pain; aruptured ampullary ectopic was found at laparotomy.
Histology of curettage decidua with Arias-Stella type reaction, no
chorionic villi seen.
-
7/30/2019 Ectopic Pregnancy A
6/37
Case study 3:
s An 33-year old woman para 4, was broughtinto E.R. collapsed with lower abdominal
pain. On admission she was shocked withblood pr. Of 60/40, a pulse of 120 bpm and
tender rigid abdomen. Vaginal exam.
Revealed a slight red loss, bulky uterus andmarked cervical excitation with a tender
mass in the right fornix.
At laparotomy, 3000 ml of fresh blood was removed
from the peritoneal cavity and a ruptured right tubal ectopicpregnancy was found. The patient was in irreversible D.I.C.
with Hb =0 .5 gm/dl and eventually died
-
7/30/2019 Ectopic Pregnancy A
7/37
Definition: Any pregnancy occurring outside the uterus
Incidence: Increasing due to P.I.D./ infertility
1-2% of all births9% after IVF-ET
Site of implantation:
-
7/30/2019 Ectopic Pregnancy A
8/37
SITES OF ECTOPIC PREGNANCY
1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian
6)Cervical 7)Cornual-Rudimentary horn 8)Secondary
abdominal 9)Broad ligament 10)Primary abdominal
Ampulla (>85%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)
-
7/30/2019 Ectopic Pregnancy A
9/37
Risk Factors:
Any factor that leads, directly or indirectly, to a reduction intubal motility increases the risk for tubalpregnancy
History of infertility
Pelvic inflammatory disease
Pelvic operations { tubal appendix }failed tubal sterilization
Previous tubal pregnancy
Assisted conception { particularly IVF if tubes are patent and
damaged }
Failed contraceptive methods
Presence of an intra uterine device.
-
7/30/2019 Ectopic Pregnancy A
10/37
-
7/30/2019 Ectopic Pregnancy A
11/37
Pathology of Ectopic Pregnancy
s Fertilized ovum borrows through the epithelium
s Zygote reaches the muscular walls Trophoblastic cells at zygote periphery proliferate, invade, and
erode adjacent muscularis
s Maternal blood vessels disrupted leading to hemorrhage
s Outcome:tubal abortion or rupture with hemorrhage
-
7/30/2019 Ectopic Pregnancy A
12/37
Tubal Pregnancy
s Commonest site of ectopic pregnancy (99%)
s The ampulla is the most frequent location of
implantation (64%)
Symptoms:
s Onset occurs ~7 weeks after LMPs Abdominal pain
s Vaginal bleeding
Signs:s Abdominal tenderness (91%)
s 1st
trimester bleeding (79%)
Common associated findings:s Adnexal tenderness (54%) , Amenorrhea
s Early pregnancy symptoms
s Cullens sign (Periumbilical bruising)
s Nausea, vomiting, diarrhea, dizziness
-
7/30/2019 Ectopic Pregnancy A
13/37
Other Signs:
s Tachycardia, Low grade fever
s Chadwicks sign (cervix and vaginal cyanosis)
s Hegars sign (softened uterine isthmus)
s Hypoactive bowel sounds
s Cervical Motion Tenderness
s Enlarged uterus
s Tender pelvic or adnexal mass
s Cul-de-sac fullness
s Decidual cast (Passage of decidua in one piece)
Signs suggestive of ruptured ectopic pregnancy:
s Usually between 6 and 12 weeks gestation
s Severe abdominal tenderness with rebound, guarding
s Orthostatic hypotension
-
7/30/2019 Ectopic Pregnancy A
14/37
Differential Diagnosis Appendicitis
Threatened Abortion Ruptured ovarian cyst
PID
Salpingitis
Endometritis
Nephrolithiasis
Ovarian torsion
Intrauterine pregnancy
Alternative diagnoses:
Dysmenorrhea
Dysfunctional uterine bleed
UTI
Diverticulitis
Mesenteric lymphadenitis
-
7/30/2019 Ectopic Pregnancy A
15/37
Symptoms & Signs:
In a woman of child bearing age with pelvi-
abdominal pain and/ or vaginal bleeding
ALWAYS.think
-
7/30/2019 Ectopic Pregnancy A
16/37
-
7/30/2019 Ectopic Pregnancy A
17/37
DIAGNOSISs In recent years, inspite of an increase in
the incidence of ectopic pregnancy therehas been a fall in the case fatality rate.
s This is due to the widespread introduction
of diagnostic tests and an increasedawareness of the serious nature of this
disease.
s This has resulted in early diagnosis andeffective treatment.
s Now the rate of tubal rupture is as low as
20%.
-
7/30/2019 Ectopic Pregnancy A
18/37
METHODS OF EARLY
DIAGNOSIS
s Immunoassay utilising monoclonalantibodies to beta HCG
s Ultrasound scanning Abdominal &
Vaginal including Colour Doppler
s Laparoscopy
s Serum progesterone estimation not
helpful A combination of thesemethods may have to be
employed.
-
7/30/2019 Ectopic Pregnancy A
19/37
Diagnostic modalities
1. Pregnancy test.a) Urinary B-hCG sensitive, detects 25-50 ml I.U/ml.. Positive
before missing the next period
b) Serum B-hCG Mainly used for quantitative rather than
qualitative purposes
2. Pelvic ultrasound scan
a) Abdominal. Sac at 5 wks F.H. at 7 wks.. Needs full bladder
b) Transvaginal. A wk earlier than abdo empty bladder
In 85% normal pregnancy B-hCG doubles every 2-3 days
In 85% ectopic pregnancy B-hCG 65% Increase every 2-3 days
METHODS OF EARLY
-
7/30/2019 Ectopic Pregnancy A
20/37
METHODS OF EARLY
DIAGNOSIS
s TVS can visualise a gestational sac as early as4-5 weeks from LMP.
s During this time the lowest serum beta HCG is
2000 IU/Lt.s When beta HCG level is greater than this and
there is an empty uterine cavity on TVS, ectopicpregnancy can be suspected.
s In such a situation, when the value of beta HCGdoes not double in 48 hours ectopic pregnancywill be confirmed.
At 4-5 weeks-
-
7/30/2019 Ectopic Pregnancy A
21/37
-
7/30/2019 Ectopic Pregnancy A
22/37
-
7/30/2019 Ectopic Pregnancy A
23/37
METHODS OF EARLY DIAGNOSIS
2. Poorly defined tubal ring possibly containing
echogenic structure and POD typically
containing fluid or blood.
3. Ruptured ectopic with fluid in the POD and an
empty uterus.
4. In Colour Doppler, the vascular colour in a
characteristic placental shape, the so-calledfire pattern, can be seen outside the uterine
cavity while the uterine cavity is cold in respect
to blood flow
The USG features of ectopic pregnancy after 5
weeks can be any of the following-
-
7/30/2019 Ectopic Pregnancy A
24/37
Diagnostic modalities
Early Pregnancy Assessment Clinic {EPAC}:
If early pregnancy problems. Urine B-hCG + AScan
Intra-uterine pregnancy .GOOD
No Intra-uterine gestation Seen serum B-hCG + TVS.
with serum B-hCG of 1500-2000 ml I.U/ml Intra uterine gestation should beseen using TVS otherwise suspect Ectopic pregnancy
3. Diagnostic Laparoscopy.
-
7/30/2019 Ectopic Pregnancy A
25/37
Diagnostic modalities
Early Pregnancy Assessment Clinic {EPAC}:
.
With Advance in diagnosis and improvement in patient awareness
ectopic pregnancy is more and more being diagnosed in its early
stages. So, to reduce the incidence of maternal mortality and serious
morbidity this dedicated clinic is a must in regional hospitals.
Patients with early pregnancy problems to report to
Facilities to perform urine and serum P.T. onsite
Facilities and expertise in performing TVS
Access to operating theatre and blood bank
-
7/30/2019 Ectopic Pregnancy A
26/37
MANAGEMENT
Depending on the presentation:Acute with ruptured ectopic and intra-abdominal bleeding.
ABC,,, + surgical approach.
Early stages, with intact ectopic:
1. Expectant decreasing B-hCG . Tubal abortion
2. Medical Depending on size of ectopic and level of B-hCG..
Use methotrexate.. Not common approach
3. Surgical
-
7/30/2019 Ectopic Pregnancy A
27/37
Surgical Management
Conservative,Open vs laparoscopic.. Linear salpengotomy vs
milking of the tube
Radical,
laparoscopic vs open . salpengectomy
Fertility post ectopic surgery
-
7/30/2019 Ectopic Pregnancy A
28/37
SURGICAL TREATMENT OF
ECTOPIC PREGNANCY
LAPAROTOMY?
VS.LAPAROSCOPY?
SALPINGECTOMY?VS
SALPINGOSTOMY / SALPINGOTOMY?
The debate goes on
-
7/30/2019 Ectopic Pregnancy A
29/37
COMPARING LAPAROTOMY Vs LAPAROSCOPY
Ltomy Lscopy
Hospital cost More? Less?
Post operative adhesions More LessRisk of future ectopic Same Same
Future fertility Same Same
Experience of Surgeon Trained SpecialInstruments General Special
-
7/30/2019 Ectopic Pregnancy A
30/37
SALPINGECTOMYVS
SALPINGOSTOMY / SALPINGOTOMY
All tubal pregnancies can be treated by partialor total Salpingectomy
Salpingostomy / Salpingotomy is onlyindicated when:1. The patient desires to conserve her fertility
2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible4. Unruptured and < 5Cm. In size
5. Contralateral tube is absent or damaged
-
7/30/2019 Ectopic Pregnancy A
31/37
The choice of surgical treatment does notinfluence the post treatment fertility, but priorhistory of infertility is associated with a marked
reduction in fertility after treatmentMaking the choiceChapron et al (1993) have
described a scoring system, based on the
patients previous gynaecological history andthe appearance of the pelvic organs, to decidebetween salpingostomy / salpingotomy andsalpingectomy.
SALPINGECTOMYVS
SALPINGOSTOMY / SALPINGOTOMY
-
7/30/2019 Ectopic Pregnancy A
32/37
Fertility reducing factor Score
Antecedent one Ectopic pregnancy 2
Antecedent each further
Ectopic pregnancy 1 Antecedent Adhesiolysis 1
Antecedent Tubal micro surgery 2
Antecedent Salpingitis 1
Solitary tube 2
Homolateral Adhesions 1
Contralateral Adhesions 1
SALPINGECTOMYVS
SALPINGOSTOMY / SALPINGOTOMY
-
7/30/2019 Ectopic Pregnancy A
33/37
The rationale behind the scoring system
is to decide the risk of recurrent ectopic
pregnancy.
Conservative surgery is indicated with a
score of 1-4 only, while radical treatmentis to be performed if the score is 5 or
more.
SALPINGECTOMYVS
SALPINGOSTOMY / SALPINGOTOMY
Fertility post ectopic surgery
-
7/30/2019 Ectopic Pregnancy A
34/37
Fertility post ectopic surgery
The overall subsequent conception rate in women with ectopicpregnancies is about 60%
less than half of these pregnancies result in another ectopicor spontaneous abortion, so only about one third of women withectopic pregnancies have subsequent live births. The subsequent fertility rate is significantly higher in parouswomen younger than 30 years. If the ectopic pregnancy is a
women's first pregnancy, her subsequent conception rate isonly about 35%. On the other hand, women with high parity(more than three pregnancies) who develop an ectopicpregnancy have a relatively high rate of conception (80%). Thesubsequent conception rate is lower in women who have ahistory of salpingitis and in those who have gross evidence ofdamage to the opposite oviduct as a result of previoussalpingitis. Future fertility is significantly higher in women whohave unruptured tubalpregnancies than in those who haveruptured ectopic pregnancies; hence, early diagnosis withserial hCG and ultrasound is desirable.
Repeat Ectopic Pregnancy
-
7/30/2019 Ectopic Pregnancy A
35/37
Repeat Ectopic Pregnancy
The rate of repeat ectopic pregnancy
after a single ectopic pregnancy rangesfrom 8% to 20%, with a mean of 15%.Only about one of three nulliparouswomen who have an ectopic pregnancy
ever conceives again (35%), and aboutone third have another ectopicpregnancy (13%). After two ectopic
pregnancies, infertility rates as high as90% have been reported
-
7/30/2019 Ectopic Pregnancy A
36/37
Ectopic pregnancy is a life threatening condition & on the
increase
Not all cases present with a classical picture
ALWAYS suspect ectopic pregnancy in a woman of a child-
bearing age c/o pain and/or p.v. bleeding
Early diagnosis and management is feasible {EPAC}, which
should be available in referral centers
Tailor your management on the patient presentation.+/_ F.up
-
7/30/2019 Ectopic Pregnancy A
37/37