incidence The incidence in the United Kingdom has changed little in the last decade with 9.6 ectopics per 1000 pregnancies in 1991–1993 and 11.0 per 1000 pregnancies in 2000–2002This may be due, at least in part, to a higher incidenceof salpingitis, an increase in ovularion inductionand assisted reproductive technology, and moretubal sterilization
Increasing Ectopic PregnancyRatesA number of reasons at least partially explain the increased rate of ectopic pregnancies in the United States and many European countries. Some of these include:1. Increasing prevalence of sexually transmitted infections, especially those caused by Chlamydia trachomatis2. Identification through earlier diagnosis of some ectopicpregnancies otherwise destined to resorb spontaneously
3. Popularity of contraception that predisposes pregnancy failures to be ectopic4. Tubal sterilization techniques that with contraceptive failure increase the likelihood of ectopic pregnancy5. Assisted reproductive technology6. Tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility.
Mortality According to the World Health Organization (2007), ectopic pregnancy is responsible for almost 5 percent of maternal deaths in developed countries.
Risk factors for ectopicpregnancy History of previous ectopic pregnancy (IUCD) or sterilization failure Pelvic inflammatory disease Chlamydia infection Early age of intercourse and multiple partners History of infertility Previous pelvic surgery Increased maternal age Cigarette smoking Strenuous physical exercise In utero DES exposure
TUBAL PREGNANCY The fertilized ovum may lodge in any portion of the oviduct, giving rise to ampullary, isthmic, and interstitial tubal pregnanciesIn rare instances, the fertilized ovum may implant in the fimbriated extremity. The ampulla is the most frequent site, followed by the isthmus. Interstitial pregnancy accounts for only about 2 percent. From these primary types, secondary forms of tubo-abdominal, tubo-ovarian, and broadligament pregnancies occasionally develop.
Clinical presentation1-subacute clinical picture ofA. abdominal pain &vaginal bleeding in early pregnancy. Vaginal bleeding is usually dark red, indicative old bloodB- abdominal/ pelvic pain may be localized to the iliac fossa.C- sholder tip pain indicative of free blood in the abdominal cavityD- dizzeness (anaemia)Bimanual examination can reveal tenderness in the fornices and there may be cervical excitation2- Acute clinical presentation due to rupture ectopic pregnancy with massive intraperitoneal bleeding. They can present with signs of hypovolaemic shock & acute abdomen
Investigation The following are useful investigation for the diagnosis of ectopic pregnancy 1- observations :Bp, pulse ,temperatuer 2- laboratory investigations: Haemoglobin. blood group(prepare blood forr cross match) & B-HCG A B-HCG level of less than 5mIU/ml, is considered negative for pregnancy& any thing above 25 mIU/ml is considered positive for pregnancy In 85% of pregnancy the B-HCG levels almost double every 48 hours in normally developing intrautrine pregnancy
In ectopic pregnancy the rise in B-HCG is suboptimal,. However multiple readings are required for comparison purposes.Transvaginal ultrasound scan (TVS)An intrauterine gestational sac should be visualized at 4.5 weeksGestation.the corresponding B-HCG at that gestation is around 1500 mIU/ml.By the time a gestational sac with fetal heart pulsation is detcted (at around 5 weeks gestation)B-HCGlevel should be around 3000 mIU/mlThus , if there were discrepancy betwween B-HCG cocentration and that seen on ultrasound scan(e.g.a highB-HCG with no intruterine pregnancy on ultrasound scan), the differential diagnosis of an ectopic pregnancy must be made.
Identification of an intruterine pregnancy(gestational sac, yolk sac, and fetal pole) on TVS effectively excludes the possibility of ectopic pregnancy in most patients except in those patients with rare hterotopic pregnancy. The presence of free fluid during TVSis suggestive of a ruptured cetopic pregnancy Lparoscopy:this can be used to diagnose and treat ectopic pregnancy
CuldocentesisThis simple technique was used commonly in the past to identify hemoperitoneum. The cervix is pulled toward the symphysis with a tenaculum, and a long 16- or 18-gauge needle is inserted through the posterior vaginal fornix into the cul-de-sac. If present, fluid can be aspirated, however, failure to do so is interpreted only as unsatisfactory entry into the cul-de-sac and does not exclude an ectopic pregnancy, either ruptured or unruptured. Fluid containing fragments of old clots, or bloody fluid that does not clot, is compatible with the diagnosis of hemoperitoneum resulting from an ectopic pregnancy. If the blood subsequently clots, it may have been obtained from an adjacent blood vessel rather than from a bleeding ectopic pregnancy.
Ultrasound With the advent of diagnostic ultrasound and the increasing use of conservative treatment, the diagnosis of ectopic pregnancy is increasingly made without the help of surgery. Gestational sac with a live embryo and a yolk sac Uterus
In women with ectopic pregnancies bleeding within theuterine cavity may resemble an early intrauterine pregnancy (‘pseudosac’). The presence of free fluid in the pouch of Douglas is afrequent finding in women with normal intrauterine pregnancies and it should not be used to diagnose an ectopic. However, the presence of blood clots is important and is a common finding in ruptured ectopics
In women with intrauterine pregnancy on the scan apossibility of heterotopic pregnancy should be excluded.This is particularly the case in women who conceived after stimulation of ovulation orIVF (in vitro fertilization).
Serum Progesterone. A single progesterone measurementcan be used to establish with high reliability that there is a normally developing pregnancy. A value exceeding 25 ng/mL excludes ectopic pregnancy with 92.5-percent sensitivity . Conversely, values below 5 ng/mL are found in only 0.3 percent of normal pregnancies . Thus, values 5 ng/mL suggest either an intrauterine pregnancy with a dead fetus or an ectopic pregnancy. Because in most ectopic pregnancies, progesterone levels range between 10 and 25 ng/mL, the clinical utility is limited
Novel Serum Markers. A number ofpreliminary studies have been done to evaluate novel markers to detect ectopic pregnancy. These include vascular endothelial growth factor (VEGF), cancer antigen 125 (CA125), creatine kinase, fetal fibronectin, and mass spectrometry-based proteomics None of these are in current clinical use.
Differential diagnosisThe diagnosis is from any other acute abdominalcatastrophe such as rupture of a viscus or acuteperitonitis. The clinical picture is so typical that inmost cases diagnosis presents no difficulty. Otherdiagnoses which may confuse are:• inevitable miscarriage;• bleeding with an ovarian cyst;• pelvic appendicitis;• acute salpingitis.
Expectant management Expectant management has important advantages over medical treatment as it follows the natural history of the disease and is free from serious side effects of methotrexate. Expectant management requires prolonged follow-up and it may cause anxiety to both women and their carers.However, the main limiting factor in the use of expectantmanagement is the relatively high failure rate andthe inability to identify with accuracy the cases that arelikely to fail expectant management. To minimize therisk of failure many authors have used very strict selectioncriteria for expectant management such as the initialhCG <250 IU
SurgerySurgery has been traditionally used both for the diagnosis and treatment of ectopic pregnancy.With recent advances in operative laparoscopy, the minimally invasive approach has also become accepted as the method of choice to treat most tubal ectopic pregnancies.There are important advantages of laparoscopic over open surgery which include less post-operative pain, shorter hospital stay and faster resumption of social activity
LaporatomyIn a case of severe haemorrhage in ruptured ectopic pregnancy , the patient must be taken immediately to the operating theatre. Little time should be wasted in attempting resuscitation which can prove useless and may only increase bleeding. An intravenous drip should be set up and a blood transfusion given as soon as possible.
Surgical ManagementLaparoscopy is the preferred surgical treatment for ectopic pregnancy unless the woman is hemodynamically unstable Tubal surgery is considered*conservative when there is tubal salvage. Examples include salpingostomy, salpingotomy, and fimbrial expression of the ectopic pregnancy. *Radical surgery is defined by salpingectomy.
Laparoscopy techniques exist to:• kill the embryo with a direct injection ofmethotrexate or mifepristone allowing absorptionso requiring no surgery on the tube;• incise the swollen tube over the ectopic pregnancy,aspirate the embryo, and achievehaemostasis (salpingostomy).
Salpingostomy. This procedure is used to remove a small pregnancy that is usually less than 2 cm in length and located in the distal third of the fallopian tube . A 10- to 15- mm linear incision is made with unipolar needle cautery on the antimesenteric border over the pregnancy. The products usually will extrude from the incision and can be carefully removed or flushed out using high- pressure irrigation that more thoroughlyremoves the trophoblastic tissue
Salpingotomy. Seldom performed today, salpingotomy is essentially the same procedure as salpingostomy except that the incision is closed with delayed-absorbable suture..
Salpingectomy. Tubal resection may be used for both ruptured and unruptured ectopic pregnancies. When removing the oviduct, it is advisable to excise a wedge of the outer third (or less) of the interstitial portion of the tube. This so-called cornual resection is done in an effort to minimize the rare recurrence of pregnancy in the tubal stump. Even with cornual resection, however, a subsequent interstitial pregnancy is not always prevented .
Persistent Trophoblast. Incomplete removal of trophoblastmay result in persistent ectopic pregnancy. Because of this, administered a “prophylactic” 1 mg/m2 dose of methotrexate postoperatively. Persistent trophoblast complicates 5 to 20 percent of salpingostomies and can be identified by persistent or rising hCG levels. Usually -hCG levels fall quickly and are at about 10 percent of preoperative values by day 12 . Also, if the postoperative day 1 serum - hCG value is less than 50 percent of the preoperative value, then persistent trophoblast rarely is a problem
Medical Management with MethotrexateThis folic acid antagonist is highly effective against rapidly proliferating trophoblast, and it has been used for more than 40 years to treat gestational trophoblastic disease
Selection criteria for conservative management of ectopic pregnancy1. Minimal clinical symptoms2. Certain ultrasound diagnosis of ectopic3. No evidence of embryonic cardiac activity4. Size <5 cm5. No evidence of haematoperitoneum on ultrasound scan6. Low serum hCG (methotrexate <3000 IU/l; expectant7. <1500 IU/l)
The followin are resonable indications for methotrexate use 1-cornual pregnancy 2-Prsistant trophoblastic disorders 3- patient with one fallopian tubeand fertility desired . 4-patient who refuse surgery or whome surgery is risky 5-treatment of ectopic pregnancy where trophoblast is adherent to bowel or blood vessel
Contrindications of medicaltreatment 1- chronic liver, renal or haematological disordes 2- active infection 3-immunodeficency 4- breast feedingSide effect of methotrexatenausea.vomiting ,stomatitis, cojuctivitis, GI upset, photosensitive skin reaction Abdominal painAdvise the women to take contraception for three months after methotreate. It is also important to avoid alcohol & exposure to sunlight during treatment
Non-tubal ectopicsInterstitial ectopicsThe implantation of the conceptus in the proximal portionof the Fallopian tube, which is within the muscularwallof the uterus, is called an interstitial pregnancy. The incidence of interstitial ectopic is 1 in 2500–5000 live births and it accounts for2–6% of all ectopic pregnancies
Ruptured interstitial pregnancy usually presents dramatically with severe intra-abdominal bleeding, whichrequires urgent surgery. Haemostasis can usually beachieved by removing the pregnancy tissue and suturingthe rupture site. However, in cases of extreme bleeding acornual resection or in rare cases a hysterectomy may benecessary to arrest the bleeding.
The sac is completely surrounded by a myometrial mantle, which is typical of interstitial pregnancy.
Pregnancies located below the internal os –cervicaland Caesarean scar ectopicsCervical pregnancy is defined as the implantation of the conceptus within the cervix, below the level of the internal os. Caesarean scar pregnancy is a novel entity, which refers to a pregnancy implanted into a deficient uterine scar following previous lower segment Caesarean section
An attempt to remove cervical or Caesarean sectionpregnancy is likely to cause severe vaginal bleeding andhysterectomy rates of 40% have been described whena D&C was attempted without pre-operative diagnosisof cervical pregnancy
Ovarian pregnancyOvarian pregnancy is defined as the implantation of theconceptus on the surface of the ovary or inside the ovary,away from the fallopian tubes. The diagnosis of ovarian pregnancy is rarely achievedpre-operatively; hence most women are treated surgically as the diagnosis is reached only at operation
Abdominal pregnancyAbdominal pregnancy is a rarity that only a fewgynaecologists will encounter during their professionalcareer. Most abdominal pregnancies are the result of reimplantation of ruptured undiagnosed tubal ectopic pregnancies.With the increasing accuracy of first-trimestertransvaginal scanning it is likely the prevalence ofadvanced abdominal pregnancy will decrease even furtherin the future.
The clinical and ultrasound featuresof an early abdominal pregnancy are very similar totubal ectopic pregnancies. However, viable abdominalpregnancies, which progress beyond the first trimester,are typically missed on routine transabdominal scanning.Abdominal pregnancy should be suspected in womenwith persistent abdominal pain later in pregnancy andin those who complain of painful fetal movements.
Treatment of abdominal pregnancy is surgical. In advanced abdominal pregnancies accompanied by normal fetal development diagnosed in the late second trimester termination of pregnancy may be delayed for a few weeks until the fetus reaches viability.At surgery the gestational sac should be opened carefullyavoiding disruption of the placenta. The fetus should beremoved, the cord cut short and the placenta should be left in situ .
Any attempt to remove the placenta may resultin massive uncontrollable haemorrhage. Adjuvant treatment with methotrexate is not necessary and the residual placental tissue will absorb slowly over a period of many months, sometimes a few years. The placental tissue left in situ may become infected leading to the formation of a pelvic abscess, which may require drainage.