2. Approval page
PRESENTER DR FADEELA LAWAL
REVIEWED BY DR ADEYEMI
CLINICAL SUPERVISOR
APPROVED BY DR MUHAMMAD M.M.S
3. LEARNING OBJECTIVES
TO UNDERSTAND WHAT IS ECTOPIC PREGNANCY
TO IDENTIFY THE DIFFERENT SITES AND HIGH RISK
GROUPS OF ECTOPIC PREGNANCY
TO DISCUSS THE OUTCOME OF TUBAL PREGNANCY
5. INTRODUCTION
Ectopic pregnancy is one of the direct causes of maternal
death and is an important causes of maternal mortality in
the first trimester, it is the 8th out 129 direct cause of
death, and account for 9% of all maternal death
9. INCIDENCE
The incidence of ectopic pregnancies in Nigeria is 1.5–
2.7/100 deliveries
In 2020 the prevalence of ectopic pregnancy in Kaduna
state was 0.89% of all deliveries and 2.74% of all the
gynaecological admissions
10. ETIOLOGY
:
Salpingitis and pelvic inflammatory disease (PID)
Contraception failure
• There is relative increase in tubal pregnancy (7 times more)
should pregnancy occur with IUD in situ
• After sterilization operation there is 15-50% chance of being
ectopic if pregnancy occurs
Tubal surgery
Artificial reproductive technology
11. Previous ectopic pregnancy: There is 10-15% chances of repeat
ectopic pregnancy.
Prior induced abortion significantly increases the risk
Developmental defects of the tube:
• Elongation
• Diverticulum
12. RISK FACTORS
Maternal age of 35 years or above
History of pelvic surgery
History of endometriosis
History of previous ectopic pregnancy
Smoking
History of STI
13. MORBID ANATOMY
CHANES IN THE TUBE:
• Implantation in the tube occurs more commonly intercolumnar fashion, i.e. in
between two mucosal folds.
• Decidua change at the site of implantation is minimal , the muscles undergo
limited hyperplasia and hypertrophy.
• The blastocyst burrows through the mucous membrane and lies between the
lumen and the peritoneal covering (intramuscular implantation)
• The tube on the implantation site is distended and the wall is thinned out.
14. MORBID ANATOMY CONT
• The stretching of the peritoneum over the site of implantation results in
episodic pain
• Finally, tubal rapture occurs when the muscles and the serosa are maximally
stretched and undergo necrosis.
• Hemoperitoneum is found in all cases of raptured tubal ectopic pregnancy.
The trophoblasts of ectopic pregnancy do not usually grow as that of a normal
pregnancy. As a result, hCG production is inadequate compared to a normal
pregnancy.
15.
16. CHANGES IN THE UTERUS
Under the influence of estrogen, progesterone form corpus luteum and
chorionic gonadotropin, there is varying amount of enlargement of the uterus
with increased vascularity.
The decidua develops all the characteristics of intrauterine pregnancy except
that it contains no evidence of chorionic villi.
When progesterone level falls due to fall in the level of hCG, endometrial
growth is no longer maintained. Endometrium sloughs out causing uterine
bleeding.
Sometimes entire decidua expelled as a single piece through the cervix. This is
known as decidua cast that may be confused with spontaneous abortion.
17. Heterotopic pregnancy
its defined as the presence of multiple gestation with one
being present in the uterine cavity and the other outside
the uterus ,commonly in the fallopian tube and
uncommonly in the cervix or ovary
Its more common following ART procedures
18. CLINCAL FEATURES OF ECTOPIC PREGNANCY
Clinically 3 distinct types are described as per the duration of manifestation:
Acute/Ruptured (obstetric) emergency
Unruptured
Chronic
19. ACUTE/RUPTURED
Less common (30%)- associated with cases of tubal rupture or tubal abortion
along with massive intraperitoneal hemorrhage.
Usually young patient (20-30 years).
Mostly Nulliparous
Alter infertility treatment.
20. CLINICAL PRESENTATION IN RUPTURED
Symptoms:
• Amenorrhea of short period 6-8 weeks or a delayed period or slight spotting.
• Abdominal pain.
• Pain is agonizing or colicky.
• Vaginal bleeding-slight, sanguineous or dark coloured.
• Nausea, vomiting, fainting attacks, syncope (10%)
21. CLINICAL PRESENTATION IN RUPTURED CONT
On examination:
• Tachycardia
• Hypotension
• Pallor
On per abdomen examination:
• Tenderness and muscle guard on lower abdomen on affected side.
• An irregular and tender mass in the lower abdomen
• Cullen’s sign: dark discoloration surrounding umbilicus suggesting
intraperitoneal hemorrhage
22. CLINICAL PRESENTATION IN RUPTURED CONT
On Bimanual examination:
• Vaginal mucosa pale
• Uterus normal or bulky
• Cervical movement tenderness
• Tender fornices with or without palpable mass
• An ill defined boggy and tender mass felt through the posterolateral fornix
extending to the POD
23. UNRUPTURED
Clinical symptoms:
• Delayed period or spotting
• Uneasiness on one side of the flank
Signs:
• Uterus slightly smaller than the period of amenorrhea- evidence of early
pregnancy.
• A small pulsatile, tender, well circumscribed mass felt in one fornix separated
from the uterus
24. CHRONIC ECTOPIC
Clinical symptoms:
• Amenorrhea for 6-8 weeks
• Lower abdominal pain-starts as acute and gradually becomes dull and colicky
• Vaginal bleeding
• symptoms- bladder irritation, dysuria frequency, retention of urine, rectal
tenesmus following infected hematocele.
On examination:
• Patient looks ill with varying degree of pallor not proportionate to vaginal
bleeding
• Persistent high pulse rate even during rest
• Features of shock are absent
25. DIAGNOSIS
INVESTIGATIONS:
• Blood examination
ABO and Rh grouping
Culdocentesis:
• A 18-guage lumbar puncture needle fitted with a syringe, the posterior fornix is
punctured to gain access to the pouch of Douglas
• Aspiration of non-clothing blood with hematocrit greater than 15% signifies
ruptured ectopic pregnancy
26. DIAGNOSIS CONT
Examination of beta hCG:
A single estimation of beta hCG level either in the scrum or in the urine confirms
pregnancy but cannot determine its location.
The suspicious findings are:
Lower concentration compared of normal intrauterine pregnancy
Doubling time in plasma fails to occur in 2days (less than 66% rise in 48 hours)
27. Sonography
Transvaginal sonography (TVS):
The diagnostic features are:
• Absence of intrauterine pregnancy with a positive
pregnancy test.
• Fluid in the pouch of Douglas.
• Adnexal mass clearly separated from the ovary
• Rarely cardiac motion may be seen in an unruptured
tubal ectopic pregnancy
Colour Doppler Sonography (TV-CDS).
28. DIAGNOSIS CONT
Combination of quantitative b-hCG values and sonography:
The lowest level of serum b-hCG at which a gestational sac is consistently visible
using TVS (discriminatory zone) is 1,500 IU/L. The corresponding value of serum
b-hCG for TAS is 6000 IU/L
• When the b-HCG value is greater than 1500IU/L and there is an empty uterine
cavity, ectopic pregnancy is more likely.
• Failure to double the value of b-hCG by 48 hours along with an empty uterus is
very much suggestive.
29. Laparoscopy
Dilatation and curettage:
• Identification of decidua without villi structure is very much suggestive
Serum progesterone:
• Level greater than 25 ng/mL is suggestive of viable intrauterine pregnancy where
as level less than 5 ng/mL suggests an ectopic or abnormal intrauterine
pregnancy.
30. Laparotomy:
• The old axiom ‘’open and see’’ holds good especially when the patient is
hemodynamically unstable.
31. MANAGEMENT OF ECTOPIC PREGNANCY
ACUTE:
Antishock treatment: Antishock measures are to be taken energetically with
simultaneous preparation for urgent laparotomy.
Ringers solution (crystalloid) is started , if necessary with venesection
Arrangement is made for blood transfusion.
After drawing the blood samples for grouping and cross matching, volume
replacement with colloids s to be done.
32. MANAGEMENT OF ECTOPIC PREGNANCY CONT
Laparotomy:
indications of Laparotomy are:
• Patient Hemodynamically unstable
• laparoscopy contraindicated
• evidence of rupture
The principle in laparotomy is "quick in quick out
33. CHRONIC ECTOPIC
All cases of chronic or suspected ectopic are to be admitted as an emergency.
the patient is kept under observation, investigations are done and the patient is
put up for laparotomy at the earliest convenient time.
Usually a pelvic hematocele is found, blood clots are removed. the affected tube
is identified and salpingectomy is commonly done.
Resumption of Ovulation and contraception:
About 15% of women ovulate by 19 days and about 25% ovulate by the 30th
postoperative day.
35. EXPECTANT MANAGEMENT
Indications are:
• Initial serum hCG level less than 1,000 IU/L and the subsequent levels are falling.
• Gestation sac size level less than 4cm
• No fetal heart beat on TVS
• No evidence of bleeding or rupture on TVS.
36. CONSERVATIVE MANAGEMENT
may be either medical or surgical.
Otherwise salpingectomy is done.
The advantages of conservative management are:
• Significant reduction in operative morbidity, hospital stay as well as cost.
• Improved chance of subsequent intrauterine pregnancy.
• Less risk of recurrence.
37. MEDICAL MANAGEMENT
Number of chemotherapeutic agents have been used
either systemic or direct local( under sonographic or
laparoscopic guidance) as medical management of ectopic
pregnancy.
The drugs commonly used for salpingocentesis are :
methotrexate, potassium chloride, prostaglandin (PGF2a)
38. CRITERIA FOR MEDICAL MANAGEMENT:
the patient must be....
hemodynamically stable.
serum hCG level should be less than 3,000 IU/L
tubal diameter should be less than 4cm without any fetal
cardiac activity.
there should be no intra abdominal haemorrhage.
for systemic therapy, a single dose of methotrexate (MTX)
50MG/m2 is given intramuscularly.
39. MEDICAL MANAGEMENT CONT
MONITORING:
• Done by measuring serum b-hCG on D4 and D7 is greater than or equal to15%,
patient is followed up weekly with a serum hCG until hCG less than 10mIU/L.
• If the decline is less than 15%, a second dose of MTX 50mg/M2 is given on D7.
• Variable dose methotrexate (MTX) includes ; MTX- 1mg/kg IM on D1,3,5,7 and
leucovorin 0.1mg/kg on D2,4,6,8.
• Serum b-HCG is monitored weekly until less than 5.0mIU/L
40. CONSERVATIVE SURGERY
The procedure can be done either laparoscopically or by microsurgical
laparotomy.
Indications:
a) Cases not fulfilling the criteria of medical therapy.
b) Cases where b-HCG levels are not decreasing despite medical therapy.
c) Persistent fetal cardiac activity
1. Linear salpingostomy:
• A longitudinal incision is made on the antimesenteric border directly over the
site of ectopic pregnancy.
• After removing the products the incision line is kept open to be healed later on
by secondary intention.
41.
42. CONSERVATIVE SURGERY CONT
2. Linear salpingotomy:
The procedure are the same as those of salpingostomy. But the incision line is
closed in two layers with interrupted vicryl sutures. This is not commonly done.
3. Fimbria Expression:
This is ideal in cases of distal ampulla (fimbria) pregnancy and is done digitally.
43. PERSISTENT ECTOPIC PREGNANCY
Due to incomplete removal of trophoblast.
Prophylactic single dose MTX (1 mg/kg) IM is effective to resolve the problem.
44. Following conservative surgery or medical treatment,
estimation of b-hCG should be done weekly till the value
becomes less than 5.0mlU/mL. additional monitoring by
TVS is preferred.
Following laparoscopic salpingostomy, persistent ectopic
pregnancy ranges between 4% and 20%.
45. SALPINGECTOMY
Done when
i) Whole of the affected tube is damaged,
ii) Contralateral tube is normal or
iii) Future fertility is not desired.
46. CONCLUSION
Ectopic pregnancy is still the leading cause of death in the
first trimester pregnancy
A high index of suspicion is required for an early diagnosis
because sign and symptoms are not specific
With the use of transvaginal ultrasound and serial ß-hCG
levels, and in some cases uterine curretage, most ectopic
pregnancies can be diagnosed and treated at an early stage
Medical and surgical treatment of ectopic pregnancy have
similar success rates.
