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Management of non tubal ectopic pregnancy

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  • Mx is Difficult
  • f
  • ultrasonic criteria were developed by (Raskin, 1978; Hofmann et al., 1987)
  • The differential diagnosis initially must include cervical cancer, presence of a cervical fibroid, trophoblastic tumor, and
    abnormalities of placental location such as a placenta previa or low-lying placenta
  • Hysterectomy , cerclage
  • Transcript

    • 1. Management of Non tubal Ectopic pregnancy Berhanu Mohammed Ovarian
    • 2. Contents 1. Introduction 2. Interstitial Pregnancy 3. Abdominal Pregnancy 4. Ovarian EP 5. Cervical EP 6. Heterotopic pregnancy 7. cesarean scar ectopic pregnancy (CSP) 8. PUL 9. References
    • 3. Introduction • Derived from the Greek word ektopos, meaning out of place • Ectopic pregnancies were initially described in the 10th century (Albucasis in 936-1013 A.D.) • In 1693 Boucier noted the presence of ectopic pregnancy at postmortem examination of an executed prisoner • A more complete report was made in 1731 • for a long time were universally fatal events for the mother
    • 4. ….cnt’d • Nontubal ectopic pregnancies accounts for only 5 % of all EPS, yet they account for 20 % of the fatalities • Traditionally diagnosed late and have been associated with significant morbidity and mortality • Over recent years increase in the early diagnosis of non-tubal ectopic pregnancies • Management has now progressed from open surgical management to the use of minimal access techniques and the exploration of medical and conservative treatments either alone or as adjuvant therapies
    • 5. Sites of implantation of 1800 ectopic pregnancies from a 10-year population- based study. (Data from Callen, 2000; Bouyer and colleagues, 2003.)
    • 6. Aetiology • Unclear • Many theories
    • 7. Presentation • Acute • Silent • Subacute
    • 8. Diagnosis • Short period of Ammenorrhea , pain and vaginal bleeding(slight, brownish, continouse , clots rarely) • Pain in epigastrium and shoulder(acute bleeding) • History of PID, Use of IUD • History of sterility • Palpable mass , tenderness in the pelvis, enlarged ux • Cervical motion tenderness
    • 9. …cnt’d Signs • Adler’s sign-fixed abdominal tenderness • Bath room sign-pain on defaecation or perineal discomfort manifest as inability to sit square on hard seat • Cullen’s sign-periumblical ecchymosis from intraperitoneal bleeding • Davis’s sign- subdiaphragmatic space – shoulder tip pain • Murphy’s sign- blood along the urachus to umbilicus bruise
    • 10. …cnt’d Lab findings • Hgb /Hct is falling • HCG test -75% positive • Leucocytes <20,000, mostly only slight increased but ESR rises Currettage X-ray
    • 11. …cnt’d ULTRASONOGRAPHY • At defined hCG titers, ultrasonography is excellent for identifying an IUP. • Transabdominal ultrasound : detects GS by 5 – 6 wks Detects fetal heart activity at 7 wks of gestation. Detects IUP at β-hCG of 6000 to 6500 mIU/ml • Transvaginal ultrasound : detects IUP 1 wk earlier than transabdominal U/S. It diagnosis IUP in the range of 1500 to 2000 mIU/ml hCG.
    • 12. …cnt’d Culdocentesis • Positive tap - aspiration of at least 0.5ml non clotting blood that has a Hct of 15% – obtained in 70-90% of patients with EP. • Negative tap - aspiration of at least 0.5ml of serous fluid. • Nondiagnostic - Failure to aspirate any fluid -the needle is not in the cul-de- sac
    • 13. …cnt’d Laparascopy • Is the gold standard for diagnosis • Used when diagnosis is uncertain • Direct visualization of pelvic organs offer a reliable diagnosis. • Compared with laparotomy, laparoscopy is more cost - effective
    • 14. Interstitial Pregnancy • The proximal portion that lies within the muscular wall of the uterus. It is 0.7 mm wide and approximately 1–2 cm long • Rare condition, • Accounts for no more than 2% to 4% of all tubal pregnancies, a mortality rate in the range of 2.0–2.5%. • Occurs once every 2,500 to 5,000 live births • Gestational sac is better protected in the interstitial than in other portions of the tube • symptoms of interstitial ectopic pregnancies may manifest later (>12 gestational weeks)----myometrial distensibility
    • 15. …cnt’d • Pelvic pain and vaginal spotting are common early symptoms • Most of the same risk factors for interstitial pregnancy are similar to those for ectopic pregnancy in general • PID, previous pelvic surgery and the use of ART • Ipsilateral salpingectomy is unique risk factor, occurring in 37.5% of patients
    • 16. Diagnosis • critical evaluation of all the criteria used for other types of tubal pregnancy • includes acute abdominal pain, intraperitoneal bleeding, a low hematocrit, and a positive serum or urine pregnancy test • sensitive β-hCG immunoassay and vaginal ultrasonography • Asymmetry of the uterus
    • 17. Timor-Tritsch and colleagues established TVU criteria • An empty uterine cavity, • A chorionic sac seen separately and >1 cm from the most lateral edge of the uterine cavity, and • A thick myometrial layer surrounding the chorionic sac. • "Interstitial line sign“ echogenic line extending from endometrial cavity into the cornual region & abutting the gestational sac Specificity (88% to 93%), sensitivity (only about 40%) for the diagnosis of interstitial pregnancy
    • 18. Treatment • Traditionally, the treatment of cornual pregnancy has been hysterectomy or cornual resection at laparotomy • Depends on the extent of trauma that has occurred in the uterine wall and on the interest of the patient in preserving her fertility
    • 19. …cnt’d Surgical Laparotomy • Hysterectomy • Cornual resection • Uterine artery ligation and repair of ruptured uterine cornu Laparoscopic procedures • Cornual resection • Salpingostomy- • Cornual resection and salpingectomy
    • 20. …cnt’d Hysteroscopic procedures • Hysteroscopic endometrial resection under laparoscopic control • Hysteroscopic cornual evacuation aided by polyp forceps under ultrasound (USS) or laparoscopic guidance Medical • Systemic methotrexate • USS guided methotrexate • Laparoscopic guided methotrexate/potassium chloride • Systemic methotrexate followed by selective uterine artery embolisation
    • 21. Key points for medical treatment • Haemodynamic stability is an essential prerequisite for medical management. • There should be no signs of rupture. • The woman should be well motivated to attend for regular (perhaps prolonged) follow- up. • There should be no medical contraindications to methotrexate.
    • 22. Future pregnancy • Uterine rupture • C/S • Rate of recurrence • In conservatively treated cases
    • 23. Abdominal pregnancies • Very Rare,0.9- 1% all EP • Ranging from 1 in 3,371 deliveries to greater than 1 in 10,200 deliveries • Maternal mortality risk 7.7 times tubal EP, 90x greater than IUP – 5.1 per 1000 cases • Classified as primary or secondary • Most are secondary, the result of early tubal abortion, rupture or ovarian abortion with secondary implantation of the pregnancy into the peritoneal cavity
    • 24. Primary Abdominal pregnancy • rare event, first true primary peritoneal pregnancy described by Gallabin, 1903 Must meet the three criteria defined by Studdiford in 1942: 1. Both tubes and ovaries must be in normal condition with no evidence of recent or remote injury. 2. No evidence of uteroperitoneal fistula should be found. 3. The pregnancy must be related exclusively to the peritoneal surface and 4. early enough to eliminate the possibility that it is a secondary implantation following a primary implantation in the tube. • ???? Helpful diagnosis or management.
    • 25. Dx Made usually intraoperatively (hx, P/E and Ix) • Recurrent abdominal discomfort, • Fetal movement beneath the abdominal wall, and • Presence of fetal movements high in the upper abdomen • Cessation of fetal movement, • Vomiting late in pregnancy, • Fetal malposition, • Closed and uneffaced cervix, or the • Failure of oxytocin to stimulate the gestational mass
    • 26. Dx …cnt’d • Fetal small parts in the lateral position overlying the maternal spine was first noted by Weinberg and Sherwin in 1956 • A plain abdominal X-ray may reveal the fetus to be separate from the uterus and the finding of bowel shadows amid the fetus is said to be pathonomonic • Ultrasound can usually identify an abdominal gestation as separate from the nonpregnant uterus • MRI, if U/S is unequivocal • serum a-fetoprotein
    • 27. characteristics of abdominal pregnancy on ultrasound • Presence of a fetus outside the uterus • Absence of the uterine wall between the bladder and the fetus • Extrauterine location of the placenta • poor visualization of the placenta • pseudo-placenta previa appearance • Oligohydramnios • Fetal parts adjacent to the mother’s abdominal contents • Abnormal fetal presentation, and • The absence of amniotic fluid between the fetus and placenta
    • 28. …cnt’d
    • 29. …cnt’d • MRI is becoming the investigation of choice in suspected abdominal pregnancy • Hysterosalpingography is reserved for cases where fetal death has been confirmed
    • 30. Complications • Massive bleeding, Anemia • Pelvic abscess • Peritonitis • Sepsis • DIC • Pulmonary embolism • Massive rectal bleeding or rectal passage of fetal bones • MM 4% to 29% • Fetal mortality is notoriously high, ranging from 75% to 95% of all cases
    • 31. When to operate • Immediate laparotomy before viability • Between the 28th and 34th weeks controversial with alive fetuse • For dead fetus waiting for 8weeks if there is no evidence of infection • In cases with a live foetus near to obstetric viability, to delay the operation in the hope of obtaining a live baby • The patient must be hospitalized as soon as the diagnosis is suspected
    • 32. Prerequisites for conservative approach • absence of fetal malformation; • absence of maternal or fetal decompensation; • continued surveillance of fetal well-being; • placental implantation low in the abdomen, far away from the liver or spleen; • adequate amniotic fluid; • continuous hospitalization in an appropriate facility; and • informed consent from the patient
    • 33. Management • Preoperative preparation include • an adequate supply of compatible blood and blood products • appropriate intravenous infusion lines that can deliver large amounts of fluid quickly • surgical team should be standing by (bowel, vascular, or genitourinary) • Anti-shock trousers and autotransfusion apparatus should also be available • bowel preparation and prophylactic antibiotic administration in preparation for surgery
    • 34. Placenta management • Still controversial • Most clinicians believe the best treatment is • to clamp the cord • to leave the placenta in situ, and • to close the abdomen, but to allow retroperitoneal drainage if possible • Can be removed after complete cessation of function is demonstrated by quantitative β-hCG titers • Removed during laparotomy only if it is accessible and if its removal can be accomplished without excessive blood loss • MTX
    • 35. Factors that favour primary removal • Early gestation and therefore a smaller and less vascular placenta; • placental invasion that is confined to removable organs such as tube, ovary and uterus; • foetal death with probable thrombosis of most of the placental vessels; • attachment of the placenta to the broad ligament; and • severity of any haemorrhage present and the effectiveness of haemostatic measures already applied
    • 36. Ovarian Ectopic Pregnancy • 1 in 10 000 pregnancies; they account for 0·5– 3 per cent of all ectopic pregnancies • may be primary or secondary and diagnosis is seldom made prior to surgery • associated with neither PID nor infertility • DDX (1) haemorrhagic ovarian cyst, and (2) ruptured corpus luteum cyst
    • 37. …cnt’d The etiology and pathogenesis of OP two seem to be the most responsible causes: • primary OP with intra-follicle fertilization • retrograde flow in the fallopian tube of the fertilized ovum released on to the ovary Clinical picture • same as that of a tubal ectopic, but • degree of haemorrhage and haemoperitoneum more sever
    • 38. Diagnosis Based on Spiegelberg’s criteria formulated in 1878. The criterion states that: (1) The tube on the affected side must be intact. (2) The fetal sac must occupy the position of the ovary. (3) The ovary must be connected to the uterus by the ovarian ligament. (4) Definite ovarian tissue must be found in the sac wall.
    • 39. …cnt’d • Most difficult • does not always present by the triad of period of amenorrhoea, per vaginal bleeding and pelvic pain/tenderness/ cervical excitation • persistent pelvic pain alone, a symptom not always easily related to its cause, is the most frequent clinical manifestation of an ovarian gestation • Haemothorax (4 case reports RT side haemothorax ) • ovarian pregnancy does not recur
    • 40. Management Conservative Mx: Important because these patients are usually young, healthy, fertile & desire future childbearing. Medical Management Systemic methotrexate • unruptured ovarian pregnancy • no significant hemoperitoneum • hemodynamically stable patient Localized surgical resection • ovarian wedge resection or • cystectomy
    • 41. …cnt’d Laparoscopy : used to resect or perform laser ablation of ovarian pregnancies Definitive Mx : Oopherectomy indications : 1. Technical difficulties due to increased vascularity & fragility 2. Rarely profuse/uncontrolled hemorrhage
    • 42. Cervical Ectopic Pregnancy • Rare, less than 1% of all ectopic gestations • Have an estimated incidence of one in 2500 to one in 18,000 pregnancies. • Passage of a blastocyst through the uterine cavity and its subsequent implantation and growth within the mucosa that lines the endocervical canal • Dx frequently delayed and is often made intraoperatively in the presence of extensive hemorrhage, necessitating an emergency hysterectomy in about 50% of cases
    • 43. The Aetiology is unknown, • likely to result from a combination of factors including local cervical pathology. • Predisposing factors include • previous instrumentation • anatomic anomalies (myomas, synechiae), • Intrauterine device (IUD) use, • in vitro fertilisation (IVF 3.7%), and • diethylstilbestrol exposure, although these are not strong associations.
    • 44. Presentation • Presenting symptoms generally include • Vaginal bleeding which is usually painless but may be coupled with • Abdominal pain and urinary problems, particularly in more advanced pregnancies • Examination findings at admission vary, • Enlarged, Globular or • Distended cervix, which is often associated with dilatation of the external os.
    • 45. Rubin's criteria Dx cv preg • close attachment of the placenta to the cervix, cervical glands present opposite the implantation site, • placental location below uterine vessel insertion or below anterior and posterior reflections of the visceral peritoneum of the uterus, and • No fetal elements in the uterine corpus
    • 46. Clinical criteria • Uterine bleeding without cramping pain following a period of amenorrhea • A soft, enlarged cervix equal to or larger than the fundus • The presence of a closed internal os, • No chorionic tissue found on curettage of the endometrial cavity, and • Dilation of the external os
    • 47. DDX • A cervical ectopic pregnancy and • Intrauterine pregnancies with a low implantation site (isthmico-cervical pregnancy) or in the process of spontaneous expulsion • Incomplete Abortion
    • 48. …DDX • cardiac activity is often seen in a cervical pregnancy with a visible embryo, but not in an incomplete abortion • the gestational sac of a cervical pregnancy has regular contours, while an incomplete abortion sac often has irregular contours that may change shape during the scan • the cervical os is typically closed in a cervical pregnancy, but is open in an incomplete abortion
    • 49. MX • In the past hysterectomy often performed • A range of conservative (uterus preserving) treatment options have been suggested and may be broadly categorised as: • Cerclage • Curettage and tamponade, • Reduction of blood supply, Arterial Embolization • Excision of trophoblastic tissue, • intra amniotic fetocide and systemic chemotherapy (Medical Management)
    • 50. …cnt’d • Dilatation and curettage, with uterine artery ligation or embolisation, or cervical balloon tamponade to prevent blood loss – had a high failure rate (hysterectomy required in 22% of patients) – their role is now limited mainly to patients with life-threatening bleeding
    • 51. …cnt’d • Local injection of the ectopic pregnancy with potassium chloride or methotrexate became the favoured technique in the late 1990s. • The success rates were high (close to 100%) • Systemic side-effects and complication rates low
    • 52. Heterotopic Pregnancy • Coexistence of an IUP & ectopic pregnancy. • The incidence is estimated to be 1: 30,000 of spontaneous pregnancy. • With the use of ovulation induction & ART, the incidence is higher. • Potentially a fatal condition, because • diagnosis is often missed • 50 % of cases present late with rupture • associated with profuse hemorrhage
    • 53. …cnt’d Diagnosis : Criteria that aid diagnosis • Uterine size compatible or more with date • With persistent or rising β-hCG after D & C or spontaneous abortion • Presence of two corpus luteum • Absence of vaginal bleeding with sign & symptoms of an ectopic pregnancy • After ART • Ultrasonographic evidence of IUP & extra uterine pregnancy
    • 54. …cnt’d Management. • Systemic MTX is contraindicated in the presence of IUP. • LAPAROSCOPY: 60 % of patients with viable IUP at the time of surgery had favorable outcome. • LAPAROTOMY: Indicated in patients with • hermodynamically unstable • an interstitial- IUP is present • Local injection of KCl into the extra uterine gestation
    • 55. cesarean scar ectopic pregnancy (CSP) • Pregnancy implanted in a cesarean section scar • Rarest forms of ectopic pregnancy, 6 percent of ectopic pregnancies among women with a prior cesarean delivery • Increased report • Increase in c/s rate • Better diagnostic accuracy of this condition
    • 56. Strict imaging criteria to establish the diagnosis: • Empty uterus, • Empty cervical canal, • Development of the sac in the anterior part of isthmic portion, and • A diminished myometrial layer between the bladder and the sac
    • 57. Management • wedge resection of the ectopic pregnancy via laparotomy or laparoscopy • Hysteroscopic excision • remove the pregnancy and repair the defect • Local injection of 5 mEq KCl into the sac, and • Local or systemic MTX administration • risk of rupture and hemorrhage; hysterectomy may be necessary • Expectant management is not a good option because of the risk of rupture and maternal death • Recurrence, uterine rupture, placenta accreta, severe hemorrhage in subsequent pregnancy
    • 58. Pregnancies of unknown location(PUL) • when a woman has a positive pregnancy test, but no pregnancy can be visualised on transvaginal ultrasound (TVS). • low PUL rates of 7–10%, some report 30% • modern units should try to maintain a PUL rate of less than 15%
    • 59. …cnt’d Pregnancy outcomes Four possible outcomes: • Intra-uterine pregnancy • Failing PUL -50–70% • Ectopic pregnancy- 7–20% and • Persisting PUL
    • 60. MX • Expectant management has been shown to be safe for the majority of women. • Serum progesterone levels have been used to predict the outcome of PULs, but appear better at predicting pregnancy viability than pregnancy location. • The change in serum hCG over 48 hours expressed as the hCG ratio (hCG 48 hours/hCG 0 hours) is helpful in predicting the outcome of PULs. • Diagnostic laparoscopy or uterine curettage should not be undertaken routinely
    • 61. References • JohnA.Rock, Howard W.jones, Ectopic Pregnancy TeLinde’s operative Gynecology 10th edition • Cunningham,Leveno, Bloom, Hauth, Rouse, Spong, Ectopic Pregnancy , Williams Obstetrics 23rd Edition • Prof. Lukman Yusuf , lecture note on Ectopic pregnancy • MARTIN G. SHELTON, THE TREATMENT OF ABDOMINAL PREGNANCIES, S.A. MEDICAL JOURNA L, 1 June 1963 • Dahab et al. Journal of Medical Case Reports 2011, Full-term extrauterine abdominal pregnancy: a case report, http://www.jmedicalcasereports.com/content/5/1/531 • Geneviève et al. , Imaging in the Management of Abdominal Pregnancy: A Case Report and Review of the Literature, JANUARY JOGC JANVIER 2009 • Nuru Abseno, workineh Getaneh,Cases of Advanced Abdominal pregnancies one of which was with viable fetus, Ethiop Med J, 42 2004
    • 62. …cnt’d • Thomas A Molinaro Kurt T Barnhart, Abdominal pregnancy, cesarean scar pregnancy, and heterotopic pregnancy, UpToDate 19.1 • E. Kirk et al. Pregnancies of unknown location, Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 493–499 • P. M. Lam et al. Unsuccessful medical treatment of cesarean scar ectopic pregnancy with systemic methotrexate: a report of two cases, Acta Obstet Gynecol Scand 2004: 83: 108--116 • A. Nassar et al. Cervical pregnancy after in vitro fertilization and embryo transfer successfully treated with methotrexate and intracervical injection of vasopressin, Acta Obstet Gynecol Scand 2004; 83: 112–114 • F. USIFO, S. THAMBAN, I. O. OPEMUYI, & S. SAHOO, Ovarian ectopic pregnancy, Gynaecology case reports, J Obstet Gynaecol , www.informahealthcare.com, accessed 06/16/12 • SAMUEL LURIE,DAVID RABINERSOAN AND, ZEEVS HOHAM, The veracious etiology of ectopic pregnancy, Acta Obstet Gynecol Scand 1998; 77: 120- 121, www.informahealthcare.com
    • 63. …cnt’d • J. O. AMAGADA and S. J. VINE, Spontaneous heterotopic pregnancy remains a diagnostic enigma, Obstetric case reports, J Obstet Gynaecol www.informahealthcare.com • N. Acheson et al, Advanced abdominal pregnancy: difficulties in diagnosis, Journal of Obstetrics and Gynaecology (1996) Vol. 16, 235-238, www.informahealthcare.com • Radwan Faraj / Martin Steel, Review Management of cornual (interstitial) pregnancy, Royal College of Obstetricians and Gynaecologists 2007; 9:249–255, www.rcog.org.uk/togonline, • Getahun kifle, An abdominal pregnancy with infected gestational sac , 1987.ethiop. Med. J. 25,41 • Novak
    • 64. Thank you

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