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Ectopic pregnancy

Ectopic pregnancy



Seminar on ectopic pregnancy prepared by 2 medical students in Sulaimani university/Iraq

Seminar on ectopic pregnancy prepared by 2 medical students in Sulaimani university/Iraq



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  • …global causes.
  • Along the way we’ve discovered…

Ectopic pregnancy Ectopic pregnancy Presentation Transcript

  • Normal pregnancy implantation
    Pregnancy is the period during which a
    woman carries a developing fetus normally
    in the uterus, starting from conception
    (fertilization of ova) until the baby born.
    After ovulation the ovum is picked up by the
    fimbria of fallopian tubes and then swept
    by ciliary action towards the ampulla where
    fertilization occurs.
    As soon as the zygote develops it begins
    dividing very rapidly, it remains in the fallopian
    tube for 3 -4 days untill reaches morula stage
    (8-32 cell stage)
  • Normal pregnancy implantation
    The embryo proceeds through the isthmus to the uterine cavity for up to 72 hours, by the sixth day it enters the uterus and begins to penetrate the decidua (endometrium) this is called implantation which takes place within the uterine cavity in normal positioned pregnancy .
    Then hCG is produced by trophoblast, which can be detected in the serum of the mother in the first week after implantation, its level doubles every 36-48 hours in normal healthy pregnancy starting from 5 to 50 ,100, till reaching 1000 IU/L
    Delay or obstruction of the passage of fertilized egg down the fallopian tube to the uterus may result in implantation in the fallopian tube or ovary or peritoneal cavity, this known as ectopic pregnancywhich eventually most fails to develop , and the hCG fails to raise dramatically as happens in the normal intra uterine pregnancy.
  • Normal pregnancy implantation
  • Ectopic pregnancy ?
  • Ectopic pregnancy
    An ectopic pregnancy, or eccysis , is a complication of pregnancy Occurs when the site of implantation is outside of the womb (uterine cavity) either in the tubes,ovaries or abdominal cavity, With rare exceptions, ectopic pregnancies are not viable, Pregnancy can even occur in both the womb and the tube at the same time (heterotopic pregnancy).
    1- tubal pregnancy:
    The vast majority of ectopic pregnancies 95-98 % implant in the Fallopian tube, among these:
    80% in the ampulla
    10% in isthmus
    5 % in fimbria
    2% interstitial
    2% in a rudimentary horn of a bicornuate uterus
  • classification
    2-Nontubal ectopic pregnancy
    Rare sites (2-5%) are;
    The ovaries,
    broad ligaments,
    Abdominal cavity and peritoneum
    3-Heterotopic pregnancy
    in rare cases of ectopic pregnancy 1/1000, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy.
    Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies.
  • classification
    Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound
    Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF.
  • Common sites for ectopic pregnancy
  • epidemiology
    22/1000 live births
    16/1000 pregnancies
    In USA from 1970 – 1992 , the risk 5x increased from 4 to 19 / 1000 pregnancies
    fatality rate :
    fatality rate from ectopic pregnancies dropped almost 90% (from 35.5 per 1000 ectopics to 3.8 per 1000 ectopics).
    Despite the sharp improvement in the fatality rate by the end of this period of time, ectopics were still the second leading cause of maternal mortality in the USA (accounting for 12% of all maternal deaths in 1987).
  • Why?
    The reason for the increase in ectopic pregnancy during this time period is not entirely clear, but it was thought that the increase of risk factors were responsible for a significant portion of the increased number of cases of ectopic pregnancy.
  • Risk factors
    Any mechanism that interferes with the normal function of fallopian tube increases the risk of ectopic pregnancy
    The mechanism canbe:
    Anatomical; scarring that blocks transport of the egg
    Functional; impaired tubal mobility
  • Risk factors
    1-History of pelvic infection
    PID is the most common risk factor for ectopic pregnancy
    8 folds increases the risk, due to destruction of the fallopian tubes. Chlamydia (a common sexually transmitted disease) and Gonorrhea are both able to grow within the fallopian tubes and cause;
    1-tremendous damage to the endosalpinx (lining of the inner tubal lumen),
    2-agglutination (sticking together) of the mucosal folds in the tube
    3-peritubal adhesions (scar tissue).
    . the risk of an ectopic pregnancy is greater when the woman with the infection is younger
    Other pelvic or lower abdominal infections can also result in pelvic adhesions and an increase in the ectopic pregnancy rate (such as appendicitis).
    The chances of another ectopic in the same fallopian tube also in the other tube are increased 5x
  • Risk factors
    2-History of surgery on the fallopian tubes or within the pelvis:
    Tubal ligation in the past 2 years,When a bilateral tubal ligation (tubes tied) is followed by either an unexpected pregnancy (failed tubal ligation) or is "reversed" with a tubal reanastomosis (tubal reconstruction) there is an increased risk of a tubal ectopic pregnancy.
    When a woman has a history of pelvic surgery that is associated with significant adhesion formation (such as myomectomy) there is also an increased risk of an ectopic pregnancy.
  • Risk factors
    3- Prior history of ectopic pregnancy. 
    When an ectopic pregnancy in the fallopian tube is treated conservatively (by preserving the tube), there is a roughly 10 fold increase the risk of recurrence in the same tube
    4-History of IUD use. The use of an IUD is a classic "risk factor" for ectopic pregnancy. Actually, all but the progesterone containing IUDs are relatively protective against ectopic pregnancy while the IUD is in place. That is, the number of ectopic pregnancies in women using an IUD for contraception is about one half that of women using no contraception. However, of IUD pregnancies there is a greater chance of an ectopic location (3-4%) since the number of intrauterine pregnancies with an IUD in place is markedly reduced.
  • Risk factors
    Additionally, IUDs can be associated with infections of the uterine cavity and fallopian tubes (especially just after insertion) which can independently increase the chance for an ectopic pregnancy..
    The reason for this increase in the nomber of EPs with progesterone IUD is not clear. A theory is that somehow the progesterone enhances tubal implantation.
  • Risk factors
    5-History of Diethylstilbestrol (DES )exposure in utero. 
    This drug is a  is a synthetic nonsteroidal estrogen that was used for certain conditions, including breast and prostate cancers  ,From about 1940 to 1970, DES was given to pregnant women under the mistaken belief it would reduce the risk of pregnancy complications and losses
    Later researches has shown that this drug has many bad medical effects and female babies of women who used it were at risk of developmental abnormalities of the genital system
    Their tubes are more likely to be abnormal and predispose to ectopic pregnancy, these females were known as DES daughters
  • Risk factors
    6-History of destruction of the uterine cavity or lining. 
    Such as history of uterine synechiae (scar tissue) from previous surgery (like endometrial ablation for dysfunctional bleeding ) or presence of multiple submucosal fibroid tumors this cause a larger percentage of the pregnancies to implant in a space other than the uterine cavity.
    Similar to the situation with IUDs, the total ectopic pregnancy rate may not be increased but when a pregnancy does occur the reduced likelihood of an intrauterine pregnancy increases the relative percentage of ectopic pregnancies.
  • Risk factors
    7-History of non-infectious pelvic inflammation (endometriosis, foreign body).
     Inflammation of the delicate tubal structures can result in adhesion formation (scar tissue), which will then increase the risk of an ectopic pregnancy. This inflammation may be due to endometriosis or the presence of a foreign body, either of which are strongly associated with scar tissue formation.
  • Risk factors
    8-Use of assisted reproductive technology (such as IVF (in vetro fertilization) and GIFT (gamete intrafallopiantransfere). 
    When multiple embryos or gametes are placed into the uterus or the fallopian tubes, the risk for multiple pregnancy rises significantly. The risk of twins and heterotopic pregnancy is generally thought to be about 1 / 30,000 pregnancies .
    with ARTs the rates of ectopics and dizygotic twins have increased to 1/10,000 .
    the incidence of heterotopic pregnancy may increase to as frequently as 1 /100 pregnancies.
  • Tubal pregnancy
  • Pathophysiology
    The trophoblast develops in the fertilized ovum and invades deeply into the tubal wall.
    Following implantation, the trophoblast produces hCG which maintains the corpus luteum.
    The corpus luteumproduces oestrogen and progesterone which change the secretoryendometrium into decidua. The uterus enlarges up to 8 weeks and becomes soft.
    The tubal pregnancy does not usually proceed beyond 8-10weeks 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.
  • Pathophysiology
    Separation of the gestational sac from the tubal wall leads to its degeneration, and fall of hCG level, regression of the corpus luteum and subsequent drop in the oestrogen and progesterone level.
    This leads to separation of the uterine decidua with uterine bleeding.
    Fate of tubal pregnancy
    Tubal mole
    Tubal abortion
    Tubal rupture
  • Fate of tubal pregnancy
    1- Tubal mole:
    The gestational sac is surrounded by a blood clot and retained in the tube.
    This may remain for long period in the tube and forms so called (chronic ectopic pregnancy),or they may be gradually absorbed (involution)
    2-Tubal abortion:
    This occurs more if ovum had been implanted in the ampullary portion of the tube.
    Separation of the gestational sac is followed by its expulsion into the peritoneal cavity through the tubal ostium.
    Rarely, reimplantation of the conceptus occurs in another abdominal structure leads to secondary abdominal pregnancy.
  • Fate of tubal pregnancy
    If expulsion was complete the bleeding usually ceases but it may continue due to incomplete separation or bleeding from the implantation site.
  • Fate of tubal pregnancy
    3-Tubal rupture:
    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.
    Usually profuse bleeding occurs ->
    If rupture occurs in the mesenteric border
    of the tube, broad ligament haematoma
    will occur.
  • presentation
    Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks
    The most common presenting symptoms that are suggestive for EP are:
  • Clinical traid (3As)
    Abdominal pain Abnormal vaginal
  • symptoms
    Pain and discomfort
    In the Lower back , abdomin, or pelvis.
    Usually unilateral
    Pain may be confused with a strong stomach pain, it may also feel like a strong cramp
    Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign.
    Pain while urinating
    Pain while having a bowel movement
  • symptoms
    Vaginal (external)bleeding usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. 
    Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube.
    Dizziness, headache, weakness, fainting all may happen due to bleeding
  • signs
    General examination:
    signs of early pregnancy (Breast tenderness, nausea and vomitig, change of apettite …)
    Weakness, pallor, hypotension and tachycardia, tachypnoea due to bleeding
    Abdominal examination:
    Lower abdominal tenderness and rigidity especially on one side may be present.
  • signs
    Vaginal examination:
    Vaginal spotting
    Bluish vagina and bluish soft cervix.
    Uterus is slightly enlarged and soft.
    Marked pain in one iliac fossa on moving the cervix from side to side.
    Ill defined tender mass may be detected in one adnexa in which arterial pulsation may be felt.
    Speculum or bimanual examination should not be performed unless facilities for resuscitation are available, as this may induce rupture of the tube
  • diagnosis
    The diagnosis can be difficult
    Your doctor may perform some tests to help confirm suspected ectopic pregnancy including;
    Detailed history of (cycle, pregnancy, PID,infertility, gynaecological surgery, contraception…)
    Proper general, abdominal, vaginal examination and vital signs
    Investigations: including
  • Diagnosis
    1.hormonal assay
    Serum β-hCG
    Urine pregnancy tests are positive in only 50-60% of ectopic. Detection of β-hCG in the serum by ELISA or radioimmunoassay are more sensitive and can detect very early pregnancy about 10 days after fertilization i.e. before the missed period.
    If the test is negative (generally less than 5 IU/L), normal and abnormal pregnancy including ectopic are excluded.
    If the test is positive , and doubles every 36-48 hour till reaching 1500 IU/L which is The threshold of discrimination for intrauterine pregnancy, this indicates a normal intrauterine pregnancy,
    An abnormal rise in blood β-hCG levels may indicate an ectopic pregnancy and ultrasonography is indicated.
  • Diagnosis
    The second most common hormone after hCG in pregnancy is progesterone.
    Generally, a progesterone concentration of greater than 25 ng/mLis highly correlated with a normal intrauterine pregnancy while a concentration of less than 5 ng/mLis highly correlated with an abnormal and nonviable pregnancy
  • Diagnosis
    In general, a positive β-hCG test with empty uterus by sonar ± adnexial mass indicates ectopic pregnancy.
    Discriminatory hCG zones:
    Diagnosis of ectopic pregnancy is made if there is:
    An empty uterine cavity by abdominal sonography with b -hCG value above 6000 mIU/ml.
    An empty uterine cavity by vaginal sonography with b -hCG value above 2000 mIU/ml.
  • Ultrasound
  • Diagnosis
    in this test, a needle is inserted into the space at the top of the vagina, behind the uterus and in front of the rectum to aspirate fluid and
    Determines if there is blood in the space behind the uterus
    If non-clotting blood is aspirated from the Douglas pouch , intraperitonealhaemorrhage is diagnosed. But if not, ectopic pregnancy cannot be excluded.
  • Diagnosis
    4-laparoscopy or laparotomycan also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred.
    Laparoscopy: an endoscope is inserted through a small incision in the woman’s abdomen
    This allows you to see the fallopian tubes and other organs
    This takes place in an operating room with anaesthesia
  • Uncommon Sites of Ectopic Pregnancy
    1-Cornual angular pregnancy
    2-Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.
    3-Cervical pregnancy
    4-Ovarian pregnancy
    5-Abdominal (peritoneal) pregnancy
  • Cornual angular pregnancy
    It is implantation in the interstitial portion of the tube.
    It is uncommon but dangerous because when rupture occurs bleeding is severe and disruption is extensive that needs hysterectomy.
    In some cases, the pregnancy is expelled into the uterus and rupture does not occur.
  • Pregnancy in a rudimentary horn
    Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.
    As such a horn is capable of some hypertrophy and distension, rupture usually does not occur before 16-20 weeks.
  • Cervical pregnancy
    Implantation in the substance of the cervix below the level of uterine vessels.
    May cause severe
    vaginal bleeding.
    Can be diagnosed by
    trans vaginal ultrasound
  • Ovarian pregnancy
    * Pelvic adhesions.
    * Favourable ovarian surface for implantation as in ovarian endometriosis.
    * Fertilization of the ovum inside the ovary or,
    * implantation of the fertilized ovum in the ovary.
  • Ovarian pregnancy
    Spiegelberg criteria for diagnosis of ovarian pregnancy:
    * The gestational sac is located in the region of the ovary,
    * the ectopic pregnancy is attached to the uterus by the ovarian ligament,
    * ovarian tissue in the wall of the gestational sac is proved histologically,
    * the tube on the
    involved side is intact.
  • Abdominal (peritoneal) pregnancy
    Primary: implantation occurs in the peritoneal cavity from the
    Secondary: usually after tubal rupture or abbortion.
    Intraligamentous pregnancy: is a type of abdominal but extraperitoneal pregnancy. It develops between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the myometrium) pregnancy.
  • Abdominal (peritoneal) pregnancy
    History: of amenorrhoea followed by an attack of lower abdominal pain and slight vaginal bleeding which subsided spontaneously.
    Abdominal examination:
    Unusual transverse or oblique lie.
    Foetal parts are felt very superficial with no uterine muscle wall around.
    Vaginal examination:
    The uterus is soft, about 8 weeks and separate from the foetus.
    No presenting part in the pelvis.
  • Abdominal (peritoneal) pregnancy
    Special investigations:
    Plain X-ray: shows abnormal lie. In lateral view, the foetus overshadows the maternal spines .
    Ultrasound: shows no uterine wall around the foetus
    Magnetic resonance imaging (MRI): has a particular importance in preoperative detection of placental anatomic relationships.
  • (2) Gynecologic disorders
  • Treatment options
  • Criteria for selection
    asymptomatic women no evidence of rupture or hemodynamic instability
    less than 100 ml fluid in the pouch of Douglas
    hCG less than 1000 iu/l at initial presentation
    Adnexalmass less than 3cm
    they should objective evidence of resolution, such as decliningbhCG levels.
    They must be fully compliant and must be willing to accept the potential risks of tubal rupture.
    Initial follow up
    twice weekly with serial hCGmeasurements
    weekly by transvaginal examinations
    By the first week
    drop in HCG level
    Adnexal mass size
    Otherwise reassess the options (Medical/Surgical)
    If the fall of HCG & reduction in size of adnexal mass satisfatory
    weekly hCG and transvaginal ultrasound examinations
    Till the HCG falls less than <20 IU
  • 45–70% of pregnancies of unknown location resolve spontaneously with expectant management
    Ectopic pregnancy was subsequently diagnosed in 14–28% of cases of pregnancy of unknown location
    Intervention has been shown to be required in 23–29% of cases.
    Selection criteria
    Minimal symptoms & The patient must be hemodynamicallystable
    no signs or symptoms of active bleeding or haemoperitoneum.
    Absence of foetal heart beat
    Normal FBC,U&E(urea & electrolytes),LFT(liver function tests)
    Exclusion criteria
    Any hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood dyscrasia(WCC <2000 cells cm3).
    Difficulty or unwillingness of patient for prolonged follow-up (average follow-up 35days).
    Ectopic mass >3.5cm
    The presence of cardiac activity in an ectopic pregnancy
    Methotrexate – a drug that destroys actively growing tissues such as the placental tissues ,is used as an injection in selected cases to avoid surgery (in non ruptured ectopic)
    Side effects include abdominal pain for 3 – 7 days in 50% of cases and mild symptoms of nausea, mouth dryness and soreness and diarrhoea,
    Methotrexate-Intramuscular(buttock or lateral thigh)
    Dose calculated from body surface area
    Usual dose ranges between 75-95 mg
    HCG checked on day 4 & day 7
    If fall is less than 15 % consider second dose of methotrexate
    • Anti-D should also be given if required
    • Rest up to one hour after the injection.
    • Check for any local reaction.
    Patient should be given information on(preferably written)
    Need for further treatment
    Adverse effects
    Women should be able to return easily for assessment at any time during follow-up
    avoid sexual intercourse during treatment
    to maintain fluid intake
    use reliable contraception for three months after methotrexate has been given, barrier or hormonal)
    Avoid exposure to sunlight.
    “- Avoid alcohol and vitamin preparations containing folic acid until the hormone level is back to zero.
    - Avoid aspirin or drugs such as Ibuprofen for one week after treatment.
    90% successful treatment with single dose regime.
    Recurrent ectopic pregnancy rate 10 – 20%.
    Tubal patency approximately 80%.
    14 % of medical management second dose of methotrexate
    75% would experience abdominal pain-separation pain. This usually occurs between day 3-7
    10% would finally require surgical management
    • cheap in the initial period
    • but considering the cost of follow up & the loss of work time for patient & carers
    • no cost saving was seen at serum hCG levels above 1500 IU/l due to the increased need for further treatment and prolonged follow-up.
  • 3
  • Indications for surgical treatment
    The patient is not a suitable candidate for medical therapy.
    Medical therapy has failed.
    The patient has a heterotopic pregnancy with a viable intrauterine pregnancy.
    The patient is hemodynamically unstable and needs immediate treatment.
  • Get help- call senior /Consultant on call
    ABC of resuscitation
    give facial oxygen
    Site two IV lines , commence IV fluids (crystalloid)
    Send blood for FBC, Clotting screen and cross-match at least 4 units of blood.
    insert indwelling catheter
    arrange theatre for laparotomy
    whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive monitoring of haemodynamic state
    do not wait for BP and pulse to normalise prior to transfer-resuscitation and surgery need to go hand in hand.
    salpingectomy and wash out of abdomen
    assess bloods /consider CVP
    record operative findings including the state of the remaining tube/pelvis
    Anti – D immunoglobulin (250 IU)to be given to Rhesus negative women
  • LaparascopyORlaparatomy??
    Laparoscopy has become the recommended approach in most cases.
    Laparotomy is usually reserved for patients:
    • who are hemodynamically unstable
    • patients with cornual ectopic pregnancies.
    • for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is difficult
  • SalpingectomyORSalpingotomy ??
    Salpingectomy (tubal removal) is the principle treatment especially where there is tubal rupture
    Conservative surgical management may be employed when the ectopic has not ruptured and where the tube appears normal
    Total salpingectomy is the procedure of choice:
    • In a patient who has completed childbearing and no longer desires fertility
    • in a patient with a history of an ectopic pregnancy in the same tube.
    • in a patient with severely damaged tubes,
  • Persistent trophoblast
    When salpingotomy is done, protocols should be in place for the identification and treatment of women with persistent trophoblast.
    Monitoring serum HCG levels would help to identify the persistent trophoblast.
    Most Easily Treated With MTX
  • Other Types
  • Cervical pregnancy
  • Ovarian pregnancy
    Laparotomy and inoculation of the ectopic pregnancy and reconstruction of the ovary if possible. Otherwise, removal of the affected ovary is indicated.
    Ovarian cystectomy is the preferred treatment
    Treatment with MTX and prostaglandin injection has also been reported
  • Abdominal (peritoneal) pregnancy
    The condition should be terminated surgically through Laparotomy once diagnosed
    MTX treatment appears to be contraindicated because of the high rate of complications due to rapid tissue necrosis
  • Heterotropic pregnancy
    Depends upon
    the state of the
    and the skill of
    the doctor.
  • Laparoscopy is the ideal surgical method to remove an ectopic pregnancy before it ruptures without interrupting the viable pregnancy. Although the intrauterine pregnancy can still survive if the ectopic pregnancy ruptures, there is an increased danger of miscarriage. The surgery must be done with great skill and it is important that bleeding be addressed quickly. Medical therapies include injecting the ectopic pregnancy in order to terminate the gestation.
  • Anti D
    Non sensitized women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.
    In accordance with RCOG Guideline it is recommended that anti-D immunoglobulin at a dose of 250 IU (50 micrograms) be given to all non sensitized women who are rhesus negative and who have an ectopic pregnancy.
    Not using IUCD
    Not using progesterone only pills
    Treatment for any PID
    Follow up by HCG that should disappear after 1 month
    Do HSG after 40 day to see patency of the tube
    Use barrier method of contraception
    Timing of pregnancy, visit specialist in any missed period
  • Recurrence of ectopic
    Shock & death
    Tubal rupture & organ damage
    Surgical Rx
    Medical Rx
  • Prognosis
    Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior of infertility. The treatment choice history , whether surgical or nonsurgical, also plays a role. For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment. Rate of fertility may be better following salpingostomy than salpingectomy.
  • Reference
    1.Gynecology & obstetrci by Ten teachers 19th edition
    2.RCOG guidelines (Royal college of obstetric & gynecology)
    3.ACOG(American college of obstetric & gynecology)
    4.ASRM(American society of reproductive medicine)
    5.Wikipedia .com
    7.Dr.Abraham ( laparascopy Video)