Ectopic Pregnancy
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Ectopic Pregnancy






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Ectopic Pregnancy Ectopic Pregnancy Document Transcript

  • ‫بسم ال الرحمن الرحيم‬ KHARTOUM NORTH TEACHING HOSPITAL ECTOPIC PREGNANCY  INTRODUCTION : Ectopic Pregnancy is one of the direct causes of maternal death, and is an important cause of maternal mortality in the 1st trimester. It is the 8th out 129 direct causes of maternal death in UK. It accounts for 9% of all maternal deaths. INCIDENCE: Previously, it was 1 per 150 mature birth in UK, but the incidence is rising all over the world. It has increased from 4.9/1000pregnancies up to 9.6/1000, but the case fatality rate has decreased. It has high incidence in races other than white. DEFINITION: It is defined as pregnancy occurring outside the endometrial lining of the uterus. SITES: 1) 95% occur in the tubes: the commonest site is the Ampulla, followed by the Isthmus. 2) The uterus: I. Intramural. II. Angular III. Cervical IV. Rudimentary Horn 3) The Ovary. 4) Broad Ligament 5) Abdominal: I. Primary: first implantation occurs in a peritoneal surface.
  • II. Secondary: original implantation occurs first in the tube-ostia, aborted subsequently then reimplanted into a peritoneal surface. 6) Multiple Ectopic: may occur: a) Involving both tubes b) Combined intra- & extra-uterine pregnancy (Heterotopic Pregnancy): accounts for 1 in 4000 to 1 in 7000 pregnancies. RISK FACTORS: 1. Infection 2. Contraception 3. previous Ectopic 4. Abdominal Surgery 5. Congenital tubal abnormalities 6. Assisted Reproductive Technology 7. Salpingitis Isthmica Nodosa 8. Endometriosis & lieomyomata 9. Diethyl Stilbesterol (DES) 10.others INFECTION:  Inflammation and infection may cause damage of the tube without tubl blockage.  Sexually Transmitted Diseases, mainly Chlamydia Trachomatis infection, are common and major cause of PID. Difficulties occur in diagnosing C. trachomatis due to its obligate intracellular life cycle which makes lab. Isolation and diagnosis difficult.  Gonococcus and Tuberculosis infection.  Also Appendicitis. CONTRACEPTION: in form of IUD Progesterone and Progesterone Only pills. Women who use IUDs are 6 to 10 times more likely to suffer Tubal pregnancy. Minipills and Subdermal implants (Norplant) protect against both intrauterine and Ectopic pegnancy when compared with no contraception, but if pregnancy occurs, the chance of it being ectopic is 10% with minipills and 30% in Norplant. ~Ectopic Pregnancy was also reported after Emergency contraception following rape.
  • TUBAL SURGERY: 1. Tubal Repair or reconstruction to correct obstruction-Lyses of adhesions. 2. Sterilisation: this depends on the method used:  Site of tubal occlusion.  Residual tube length.  Surgical technique  Associated conditions, e.g.: infection. PREVIOUS ECTOPIC. CONGENITAL ANOMLIES OF THE TUBES: Such as: o Diverticula o Accessory Ostia o Hypoplasia o Congenital anomalies of the cilia,e.g.: Young Syndrome and Kartagner Syndrome. ABDOMINAL SURGERY: Such as: o Ovarian Cystectomy o Wedge resection. This results in Peritubal scarring (adhesions interfere with passage of the ovum).
  • ASSISTED REPRODUCTION: IVF accounts for 10-15% of Ectopic pregnancy. SALPINGITIS ISTHMICA NODOSA: It is non inflammatory pathological condition of the tubes in which the tubal epithelium extends into the myosalpinx and forms a true diverticula. These diverticulae interfere with the myometrial electrical activity over the divrticula. ENDOMETRIOSIS, LIEOMYOMATA. DIETHYL STILBESTEROL: Exposure in utero causes tubal hypoplasia. OTHERS: Includes the following:  Smoking: strongly associated with : Abruptio Placentae; Placenta Previa; and Ectopic pregnancy. Smokers have 2 times higher than non-smokers. Smoking affects the cilia in the nasopharynx as well as the cilia of the genital tract.  Multiple sexual partners.  Early age of first intercourse  Vaginal douching.
  • PATHOPHYSIOLOGY: Most likely reason for Ectopic pregnancy is delay in passage of the fertilized ovum down the tube due to damaged ciliated epithelium and peristaltic activity of myosalpinx. Implantation occurs in the muscle and connective tissues next to the tubal serosa. There a decidual reaction (Areas Stella Phenomenon). Hematoma is frequently seen surrounding the distal end of the tube. Hemoperitoneum nearly always occur. CLINICAL PRESENTATION: ♣ About 75% of patients present with subacute symptoms, while 25% or less present with acute abdomen. ♣ Symptoms: the TRIAD of: 1. abdominal pain 2. irregular menses 3. followed by vaginal bleeding or brown discharge ± syncope. ♣ The vaginal bleeding is due to shedding of the decidua or decidual cast when pregnancy fails. ♣ The diagnosis of Ectopic pregnancy is overshadowed by a wide spectrum of clinical presentations ranging from acute abdomen to hemodynamic shock. Therefore, it requires a high degree of suspicion specially in areas where the prevalence of Ectopic pregnancy is high, like in Sudan. ♣ This depends on history and examination. ♣ The presentation may be : Acute; Subacute; or Chronic (asymptomatic). ⇒ ACUTE PRESENTATION:
  •  In women with tubal rupture.  There will be acute abdominal pain and cardiovascular collapse.  Pain is typically referred to shoulder tip or interscapular region due to irritation of the diaphragm by blood (this may be provoked by raising the foot of the bed-Kehr sign).  Signs: o Shock: tachycardia+hypotension o Peritoneal irritation o PV.: cervix soft, uterus enlarged, Excitation Test +ive. ⇒ SUBACUTE PESENTATION:  Lady C/O: 1. abdominal pain localized to one of the iliac fossae. 2. delayed menstruation 3. episodes of vaginal bleeding  signs of peritoneal irritation are less marked than in the acute presentation. ⇒ CHRONIC PRESENTATION:  There is usually history of PID→infertility.  Irregular vaginal bleeding  On-and-Off abdominal pain.  Patient is Hemodynamically Stable.  INVESTIGATIONS:  URINE FOR PREGNANCY TEST:
  • This is the standard test, it is 99% specific and 99% sensitive. It is mainly a qualitative rather than a quantitative.  SERUM HCG DOUBLING TIME: Usually in chronic cases. HCG Doubling time can differentiate an Ectopic pregnancy from an intrauterine one. Normal pregnancy causes HCG level to rise by 66% in 48hr. If the serum HCG level is rising but the douling time is increased then the likelihood of an extrauterine pregnancy is high. Most omen with an HCG half life more than 7 days have an Ectopic pregnancy.  SERIAL PROGESTERONE ESTIMATIONS: The mean serum level of progesterone in patients with Ectopic pregnancy is lower than in those with normal pregnancy. In normal viable intrauterine pregnancy the level is 25ng/ml, wile in Ectopic pregnancy it is less than 5ng/ml.  OTHER ENDOCRINE & PROTEN MONITORS: 1) MATERNAL SERUM CREATININE KINASE LEVEL: significantly higher in all patients with tubal pregnancy when compared to missed abortion and normal pregnancy. 2) PREGNANCY ASSOCIATED PLASMA PROTEIN C (PAPPC)- SCHWANGER CHAFT’S PROTEIN: this is a β- glycoproteinproduced by syncytiotrophoblasts, its level is low in Ectopic pregnancy. 3) RELAXIN: is a hormonal protein produced by the corpus luteum of pregnancy. It is signicantly lower in Ectopic pregnancy and spontaneous abortion. A single reading of 33pg/ml excludes Ectopic pregnancy. 4) MATERNL SERUM α-FETO-PROTEIN: elevated in Ectopic pregnancy.
  • 5) C-REACTIVE PROTEIN: is low in Ectopic pregnancy, but high in infections like PID (enables differentiation).  U/S SCANNING: includes the following:  Trans-Vaginal Scan: shows the following: ♦ Empty uterine cavity. ♦ In live Ectopic:intact tubal ring with a heart action (in 20% of cases). ♦ In tubal abortion: pooly defined tubal ring ±fluid in the pouch of Douglas. ♦ In ruptured Ectopic: fluid in the pouh of Douglas.  Trans-Abdominal Scan: may show: ♦ Life embryo in the adenexae (in 10% of cases). ♦ Pseudo-gestational sac in the uterus. ♦ Empty uterus ± adenexal sac ± fluid in the pouch of Douglas.  CUL DOCENTESIS: ♦ The purpose is to find non-clotted blood ♦ METHOD: apply bivalve speculum, grip the posterior cervical lip with a volsellum, then the pouch of Douglas (Cul De Sac) is entered via the posterior vaginal fornix by a needle through which the intraperitoneal content is aspirated.  LAPARASCOPY: ♦ This is the gold standard for diagnosis and treatment of Ectopic pregnancy.
  • ♦ The tubes are easily visualized and evaluated: Ectopic pregnancy distorts the normal tube architecture. ♦ Small ectopics may be missed. MANAGEMENT: DEPENDS ON THE PRESENTATION:  ACUTE PRESENTATION - RESUSCITATION: 2 wide bore cannulae Immediate IV fluids and blood as necessary. As soon as possible: Video-Laparascopy or Lparatomy should be done followed by Simple Salpingectomy with conservation of the ovaries.  SUBACUTE & ASYMPTOMAIC PRESENTATION: I. If the Δ is made BEFORE TUBAL RUPTURE: it may be treated medically with methotrexate or by local injection of drugs by laparscopy via tranvaginal or transcervical tubal canulation. II. Laparoscopic Surgery in both Ruptured & Intact Ectopic: # Major contraindications to this are: 1. Massive intra-abdominal adhesions 2. Massive bleeding. # Advantages include: a) Reduced operating time b) Reduced hospital stay c) Reduced cost d) Early return to activity e) Cosmetically acceptable
  • III.Linear Salpingotomy: when the tube’s is intact. The tube is left open after incision to heal by secondary intension. IV.Fimbrial Evacuation: ONLY if pregnancy already is aborting through the tube. V. Radical Surgery (Salpingectomy without corneal resection ± Oopherectomy): in case of irreparably damaged tube with heavy bleeding. After this procedure the rate of intrauterine pregnancy is 45% and of repeated Ectopic is 9%.  ABDOMIAL ECTOPIC PREGNANCY:  It is a rare condition with high maternal mortality.  It is always secondary to implantation of a primary tubal pregnancy.  If the fetus died & and retained: it may become infected or calcified(Lithopedion) or it may form a fatty mass (Adipocer)  In most cases the fetus should be delivered in which case the placenta should left to avoid hemorrhage.  OVARIAN ECTOPIC PRGNANCY:  Is the commonest Extra-Tubal Ectopic.  Early on, it may confused with the corpus luteum.  Treatment: a. Wedge resection of that part of the ovary containing the sac. b. Laser therapy c. Oopherectomy d. Use of Methotrexate.
  •  CERVICAL ECTOPIC:  Very rare, 0.1%of all cases.  U/S shows an empty uterus with Hour-Glass appearance of the cervix.  Treatment: Suction Curettage after vascular ligation by cervical cerclage.  CORNUAL PREGNANCY:  Very rare.  Implantation occurs in an Atretic horn of a Bicornate Uterus.  Treatment is:Salpingectomy.  INTRAMURAL ECTOPIC:  Implantation occurs in the myometrium.  Occurs in cases of; 1. Women who had uterine perforation 2. After IVF. HETEROTOPIC PREGNANCY:  Combination of intra- & extra-uterine pregnancy.  More common now after IVF-ET.  Up to 75% of intrauterine ones reach term.  Treatment of the Ectopic one is: injection of Potassium Chloride or Methotrexate.