ectopic pregnancy a

7/30/2019 Ectopic Pregnancy A

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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.


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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.


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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


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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:


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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%)


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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.


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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


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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


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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


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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


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Symptoms & Signs:

In a woman of child bearing age with pelvi-

abdominal pain and/ or vaginal bleeding

ALWAYS.think


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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%.


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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.


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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


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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-


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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-


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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.


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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


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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


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Surgical Management

Conservative,Open vs laparoscopic.. Linear salpengotomy vs

milking of the tube

Radical,

laparoscopic vs open . salpengectomy

Fertility post ectopic surgery


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SURGICAL TREATMENT OF

ECTOPIC PREGNANCY

LAPAROTOMY?

VS.LAPAROSCOPY?

SALPINGECTOMY?VS

SALPINGOSTOMY / SALPINGOTOMY?

The debate goes on


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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


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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


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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



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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



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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




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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


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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


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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


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ectopic pregnancy a

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