Ectopic pregnancy for undergraduate
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Ectopic pregnancy for undergraduate

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  • First, dose anybody know the meaning of this word, ectopic. Well, most of you look a little bit confused. Actually, this term is derived from Greek word ”ektopos”. It means out of place or misplaced. Knowing this, I think you can figure out the definition.板书 :定义 which means a pregnancy out of place, in other words, a pregnancy in which the embryo is implanted and develops outside the endometrial lining of the uterus . <br />
  • In the previous slide, the pregancy is implanted in the fallopian tube. As a matter of fact, ectopic pregnancy can also occur at other locations.板书 According to the site of implantation , the ectopic prenancy can be classified as tubal pregnancy, ovarian pregnancy, abdominal pregnancy and cervical pregnancy. 97% of ectopic pregnancies occur in the Fallopian tube. What I would like to point out although interstitial tubal pregnancies , together with ovary, cervix, or abdomen are very rare, they represent nearly 20% of deaths due to ectopic pregnancies. The high morbidity at these locations are due to massive bleeding when they rupture. <br />
  • The primary risk factor for ectopic pregnancy is a prior history of pelvic inflammatory disease, eg. previous chlamydia or gonorrhoea. It is one of the main causes of the increase seen in ectopic pregnancies in recent years. Risk of an ectopic increases about 7-fold after a woman suffers acute pelvic infection. Infection may lead to : <br /> -destruction of the tubal epithelium with reduction or loss of ciliary current <br /> -intratubal adhesions resulting in partial tubal obstruction <br /> -peritubal adhesions resulting in restricted tubal motility: these figures show the peritubal adhesions that distort the tubal. <br /> All these situations, acting alone or in combination, can slow the passage of the egg which gives it time to implant itself in the tube. <br />
  • In this short animation, we can see that the sperm enters the follopian tube and meet with the ovum. However, due to some reasons, the fertilized egg is trapped here before it reached the uterus and develops into a misplaced embryo. This misplaced embryo is somewhat like a time bomb because tissues at these abnormal locations for implantation are vulnerable and thin, they cannot support and accommodate the growing embryo. After several weeks , it may rupture and cause massive intraperitoneal bleeding, resulting in a potentially serious situation. <br />
  • The tubal pregnancy dose not usually proceed beyond 8-10 weeks due to : Lack of decidual reaction in the tube, the thin wall of the tube , the inadequacy of tubal lumen, bleeding in the site of implantation as trophoblast invades <br /> Eventually, tubal pregancy will end up in either one of the following four outcomes. <br /> 1. Tubal abortion <br /> -This occurs more if ovum had been implanted in the ampullary portion of the tube <br /> -as shown in this figure, gestational sac is seperated is expelled into the peritoneal cavity through the tubal ostium --if explulsion was complete the bleeding usually ceases but it may continue due to incomplete separation or bleeding from the implantation site. <br />
  • Tubal rupture <br /> Rupture of tubal pregancy can cause profuse internal bleeding and even death. More common if implantation occurs in the narrower portion of the tube which is the isthmus. Rupture may occur in the anti-mesenteric border of the tube and cause intraperitoneal hemorrhage. Or rupture into the mesenteric border of the tube and develops broad ligament hemotoma . <br />
  • Secondary abdominal pregnancy <br /> Most abdomianl pregancies occur after the embryo first implants in the follopian tube, after it is aborted from the fimbrial opening of the tube and it is implanted in the abdomen structure and form a secondary abdominal pregnancy. In most cases , the baby will die to but occasionally they may survive. <br />

Ectopic pregnancy for undergraduate Ectopic pregnancy for undergraduate Presentation Transcript

  • ECTOPIC PREGNANCY Dr Manal Behery Professor OB&GYNE Zagazig university 2014
  • Ectopic : (Ektopos) out of place Definition Ectopic pregnancy: fertilized embryo implanted outside the uterine cavity
  • Classification of ectopic pregnancy >95%
  • Mechanical factors       Congenital: long narrow tube, diverticulae and accessory ostia. Traumatic: operation on the tube as salpingoplasty and tubal reversal following ligation. Inflammatory: Chronic salpingitis Neoplastic: Narrowing of the tube by a fibroid or a broad ligament tumor. Functional: As tubal spasm or antiperistaltic contractions. endometriosis in the tube. encourages embedding of the fertilized ovum.
  • RISK FACTORS  Hz of tubal surgery Hx of STD’s (such as chlamydia)  Hx of ART  Hx of ectopic (esp if conservatively managed without surgery)  Smoking  IUD in place at time of conception 
  • Prior history of PID (pelvic inflammatory disease)
  • TUBAL SURGERY
  • Animation of intrauterine implantation
  • P athology of E ctopic P regnancy
  • Outcomes 1. Tubal abortion
  • 2. Rupture of tubal pregnancy
  • Ruptured ectopic pregnancy
  • •Extraperitoneal rupture (rupture through floor of the tube) •may lead to broad ligament hematoma with death of the ovum, or intraligamentary pregnancy. 17 WWW.SMSO.NET
  • 3. Secondary abdominal pregnancy
  • 19 WWW.SMSO.NET
  • Symptoms & Signs: In a woman of child bearing age with pelvi-abdominal pain and/ or vaginal bleeding …… ALWAYS….think
  •  Clinical Finding: Undistrubed ectopic   Amenorrhoea A dull aching pain is usually present in one iliac fossa. It is due to distension of the tube and stretching of its peritoneal coat.  Classic signs –  adnexal or cervical motion tenderness. 
  • Signs:     Abdominal examination: Tenderness in one iliac fossa. Vaginal examination: (cervical motion tenderness or jumping sign) The cervix is soft and severe pain occurs when it is moved from side to side A mass may be felt to one side of the uterus. It is very tender, soft and may be pulsating.
  • Subacute type:Symptoms:  Short period of amenorrhea in (25%) no history of amenorrhea due to occurrence of post conceptional bleeding that mistaken as a true menstrual period  Pain: It is felt in one iliac fossa. It may be dull aching or sharp stabbing or colicky Fainting attacks or even shock Vaginal bleeding occurs after pain  
  • With ruptured ectopic pregnancy     abdominal guarding and rigidity, shoulder pain fainting attacks and shock.
  • When a woman presents with an early pregnancy…  Ask yourself two questions… Where is this pregnancy? Is it viable?
  • Where is this pregnancy? In a woman with an early pregnancy you must determine if the pregnancy is intrauterine or an ectopic, because her life could depend on it!
  • How to you determine location of the pregnancy?     First determine dating by LMP Then perform ultrasound If you can see location of the pregnancy, you are done! If you cannot…it becomes more complicated…
  • β-hCG discriminatory value (or zone)  It is the lower limit of hCG at which an examiner can reliably visualize pregnancy on ultrasound. It is 1000-2000 IU/L with vaginal ultrasound and 5000-6000 IU/L with abdominal ultrasound.
  • If β-hCG levels above the discriminatory value  The absence of uterine pregnancy signifies an abnormal pregnancy; ectopic, incomplete abortion  If β-hCG levels are still below the discriminatory value, serial β-hCG and ultrasound should be done.
  • Doubling sign:  In normal pregnancy a 66% or greater increase in serum β-hCG levels should be observed every 48 hours (nearly doubles).  Inappropriately rising serum β-hCG levels suggest (but do not diagnose) an abnormal pregnancy including ectopic, however, they do not identify its location.
  • Tran abdominal US
  • Transvaginal ultrasound ( TVS):
  • Early pregnancy with unknown location    Check a serum BHCG If it is above the discriminatory zone (DZ)an intrauterine pregnancy should be seen Then do an ultrasound to see if you see the pregnancy
  • LAPROSCOPY
  • Treatment of tubal pregnancy      If the patient is shocked: antishock measures. If the patient is Rh negative and not sensitized anti-D serum is given. Medical therapy: methotrexate (a folic acid antagonist). IM methotrexate given as a single dose.
  •  The best candidate is the woman who is asymptomatic, compliant with follow-up, with an initial serum value <5000 IU/L.  Contraindications: Breastfeeding  Immunodeficiency / active infection  Chronic liver disease  Active pulmonary disease  Active peptic ulcer or colitis  Blood disorder  Hepatic, Renal or Haematological dysfunction 
  • Signs and Treatment failure and tubal rupture:  Significantly worsening abdominal pain,  Haemodynamic instability  Level of HCG do not decline by at least 15% between Day 4 & 7 post treatment   or plateauing HCG level after first week of treatment
  •  Follow-Up:  If the β-hCG level does not decline (plateau or increase), the patient may require either a second dose of methotrexate or surgery. Surgical management:  Laparoscopy approach – salpingostomy  Laprotomy – salpingostomy salpingectomy
  •  Salpingostomy / Salpingotomy is only indicated when: 1. The patient desires to conserve her fertility 2. Patient is haemodinmically stable 3. Tubal pregnancy is accessible 4. Unruptured and < 4Cm. In size 5. Contralateral tube is absent or damaged
  • •Segmental resection: removal of a portion of the affected tube.
  • laparatomy (if the mass is greater than 3.5 cm in diametar, internal bleeding, cardiovascular colapse)
  • Treatment: -metotrexate (if the mass is less then 3.5 cm in diametar) -laparascopy,or Laprotomy SALPINGOSTOMY SALPINGECTOMY intrapertoneal blood then peritoneal toilet. Removal of any pelvic hematomas or
  • Algorithm for the diagnosis of unruptured ectopic pregnancy without laparoscopy.
  • Management of ectopic pregnancy 11- Positive pregnancy test Lowe abdominal pain + Minimal Vaginal bleeding Asymptomatic with factors for ectopic pregnancy 2. History + clinical examination
  • If sure of date of LMP and /or Regular cycle, i.e. >6 wks. gestation, Arrange TV ultrasound If unsure of date of LMP and /or irregular cycle, Measure serum hCG If hCG <1000 (?early Intrauterine/ ? Ectopic pregnancy If Hcg >1000, use protocol for suspected Ectopic pregnancy 3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000 Meet criteria for Methorexate treatment Use methotrexate protocol Does not meet criteria for methotrexate treatment Laproscopic /salpingotomy/ Salpingectomy ?Proceed to laparotomy OR Laparotomy if haemodynamically unstable
  • Thank you 47 WWW.SMSO.NET