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Ectopic pregnancy rs

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Ectopic pregnancy rs

  1. 1. ECTOPIC PREGNANCY Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & Hospital Mahatma Gandhi Medical College, Jaipur.
  2. 2. INTRODUCTION• CASE DESCRIBED IN EGYPTIAN HEIRLOGRAPHICS• DEFINITIVE SURGERY FIRST SUCCESSFULLY DONE BY LAWSON TAIT IN 1883 AD - SALPINGECTOMY• ANY FACTOR INTERFERING WITH NORMAL FERTILISATION & NIDATION CAN CAUSE ECTOPIC• INCIDENCE 1: 150-300 PREGNANCIES• HIGHEST INCIDENCE REPORTED 1:28 WEST INDIES (STD)• ICMR 1990 INCIDENCE 3.2per1000 PREGNANCIES
  3. 3. Ectopic PregnancyThe Rising Incidence1per300 PREG-19701per70/200 PREG-1990 Trend of Ectopic Pregnancy Incidence in the US 100 slide 80 Ectopics 60 40 20 0 1970 1975 1980 1985 1990
  4. 4. Ectopic PregnancyPotentially Lethal• Leading cause of maternal death• Accounted for 15% of all maternal deaths in the US in 1988 (1)• Risk of deaths five times higher in teenagers (2)(1) National Centre for Health Statistics. 1990; 38(13): 23(2) Goldner T E et al. MMWR Morb Mortal. 1993; 42(SS-6): 73
  5. 5. DEFINITION• Ectopic pregnancy is defined as implantation and development of zygote at a site other than normal implantation site
  6. 6. Then what is the normal implantation site?• Uterine cavity but does not include the angles of the cavity and cervical canal.
  7. 7. SITES & INCIDENCE UTERINE (3%)  TUBAL (96%) CERVICAL (0.2 %) AMPULLARY (80%) ANGULAR ISTHMUS (12%) FIMBRIAL (5%) CORNUAL INTERSTITIAL (2%) DIVERTICULA  OVARIAN (0.2%) RUDIMENTARY  ABDOMINAL (1.4%) HORN  INTRALIGAMENTARY  POST-HYSTERECTOMY PROLAPSED TUBE CERVICAL STUMP VESICO-VAGINAL/RECTAL SPACE Bilateral tubal HETEROTROPIC 1:10000
  8. 8. AETIOLOGICAL FACTORS• TUBAL• ANATOMICAL FACTORS ABNORMAL TUBAL DEVELOPMENT / ATRESIA / ACESSORY OSTIA / DIVERTICULA / ABNORMAL LENGTH / KINKING• PHYSIOLOGICAL FACTORS TUBAL SPASM / IMPAIRED PERISTALSIS / IMPAIRED CILIARY MOTION CILIARY DESTRUCTION / BLOCKAGE MUCUS PLUG SYNECHIAE FORMATION  POCKETS & PARTIAL OBSTRUCTION• INFECTIONS  ENDOSALPINGITIS (tubercular, non tubercular) / EXOSALPINGITIS• ENDOMETRIOSIS• PRIOR SURGERY  TUBECTOMY,TUBOPLASTY,PELVIC SURGERY• BROAD LIGAMENT FIBROID , peritubal adhesions, large ovarian/paraovarian tumours causing stretching of tube• DES EXPOSURE
  9. 9. AETIOLOGICAL FACTORSOVARIAN FACTORSFERTILISATION OF UNRUPTURED OVATRANSMIGRATION OF OVALATE OVULATIONOVUM ENLARGEMENT DRUGS
  10. 10. AETIOLOGICAL FACTORSZYGOTE ABNORMALITIESABNORMAL SPERM MOTILITYABNORMAL SPERMATOZOA MORPHOLOGY BODY / TAILCHROMOSOMAL ABNORMALITIES
  11. 11. AETIOLOGICAL FACTORSEXOGENOUSINTRAUTERINE CONTRACEPTIVE DEVICE 6-8 FOLD INCREASE AS IT PREVENTS INTRAUTERINE IMPLANTATION EFFECTIVELY Cu-T : 3-4 times ; PROGESTASERT : 9-10 timesPROGESTERONE ONLY PILL / INJ DEPOT-PROVERA REDUCED TUBAL PERISTALSIS, TUBAL DECIDUALISATIONEMERGENCY CONTRACEPTION FAILURE, TUBAL DECIDUALISATION
  12. 12. AETIOLOGICAL FACTORSMISCELLANEOUSASSISTED REPRODUCTIVE TECHNIQUES  9.5% INCIDENCE OF ECTOPICS• SIFT• ZIFT• GIFT• IVF-ETELONGATED CERVIX
  13. 13. PATHOLOGY• INVASIVENESS OF TROPHOBLAST INTO THIN ANATOMICAL STRUCTURE (MUSCULAR LAYER) LACK OF RESISTANCE LEADS TO RUPTURE & HAEMORRHAGERECURRENT BLEEDING LAMINATIONS TUBAL MOLETUBAL ABORTION  PELVIC HAEMATOCELE,EXPULSION OF RPOCABSORPTIONTUBAL EROSION/PENETRATION/ PERFORATION  PERITUBAL HAEMATOMA  BROAD LIGAMENT/SECONDARY ABDOMINAL PREGNANCYTUBAL RUPTURE  BROAD LIGAMENT HAEMATOMA/PELVIC HAEMATOCELECONTINUATION OF PREGNANCY
  14. 14. OVARIAN PREGNANCY• EXTRAOVULAR / INTRAOVULAR• SPEIGELBERG’S CRITERIA TUBES SHOULD BE INTACT ABSOLUTELY. SAC MUST BE CONNECTED BY OVARIAN & MESO-OVARIAN LIGAMENT. OVARIAN TISSUE MUST BE COVER SAC. SAC MUST BE IN POSITION OCCUPIED BY OVARY.
  15. 15. CERVICAL PREGNANCY• MORE COMMON AFTER MTP• PROFUSE BLEEDING MAY OCCUR IN ASSOCIATION WITH PAINLESS ABORTION• D.D.  CA CX / ENDOCervical CA /DEGENERATING FIBROID POLYP / INCOMPLETE ABORTION• RX.  D&C WITH LIGATION DESCENDING CERVICAL ARTERY OR SHIRODKAR’S CERVICAL SUTURE ; TAMPONADE USING FOLEY’S CATHETER OR SENGSTAKEN BLACKMORE TUBE ; HYSTERECTOMY .
  16. 16. STUDDIFORD CRITERIAPRIMARY ABDOMINAL PREGNANCY• TUBES SHOULD BE NORMAL• OVARY SHOULD BE NORMAL• NO PRESENCE OF UTERO-TUBAL FISTULA
  17. 17. SECONDARY ABDOMINALPREGNANCY• History suggestive of Threatened Abortion/Ectopic pain , bleeding , fainting .• Minor ailments of pregnancy severely exaggerated .• Fetus felt very easily , also fetal movements .• Abnormal position in abdomen .• No Braxton Hick’s contractions .• Uterus separate from fetus .• X-ray abdomen AP & Lateral : Gas shadows & intestinal shadows overlie fetus shadows Fetal skeleton overlies maternal spine
  18. 18. SECONDARY ABDOMINAL PREGNANCY• INV : sounding uterus, HSG , USG , Doppler , Placentography• Terminate pregnancy when diagnosis confirmed, as it is associated with 50%foetal malformation rate.• Keep 4-5 Units blood available at laparotomy.• Wait only if issueless , elderly primigravida , BOH , POG =32 weeks . NO CONGENITAL ANAMOLIES DETECTED .• Placenta should not be removed from adherent invaded tissues . Only separated parts of placenta or part attached to omentum, may be removed along with omentum , leave drain , give METHOTREXATE .• Patients usually have failure to lactate due to placental hormones
  19. 19. CLINICAL SYMPTOMATOLOGY &SIGNS• ABDOMINAL PAIN ILIAC FOSSAE 95% CASES (Precedes Bleeding PV) ill fitting pain/lancinating/pulsatile/colicky/ tenesmus suprapubic–epigastric /shoulder tip• AMENORRHOEA followed by BLEEDING PV 75% CASES (Irregular around menses in 4-5%) Blood Brownish-Violet with disintegrated granular endometrial tissue• PREGNANCY SYMPTOMS i.e. NAUSEA/EMESIS• PYREXIA MILD < 100.4*F• 5 P’s : PALLOR,PAIN,PROSTRATION,PULSE(TACHYCARDIA), PRE SSURE(HYPOTENSION)• LETHARGY / LISTLESS
  20. 20. Ectopic PregnancyThe Masquerader & The Chameleon• Varied presentations• Features may change character even in the same patient over time• The ‘classic’ triad of pain, amenorrhea and vaginal bleeding seen in less than half• In a classic history, only 14% had ectopic pregnancy(1) Schwartz et al. Obstet Gynecol. 1980;56:197
  21. 21. CLINICAL SYMPTOMATOLOGY &SIGNS• ACUTE PRESENTATION (1%)  PAIN ABDOMEN AMENORRHOEA followed by BLEEDING PV SHOCK FEATURES• CHRONIC PRESENTATION  AMENORRHOEA BLEEDING PV PAIN ABDOMEN DYSURIA / TENESMUS / DIARRHOEA (increase frequencyof motion) PALLOR ICTERUS ABDOMINAL TENDERNESS REBOUND/FIXED POINT PV : ADNEXAL MASS
  22. 22. CLINICAL SYMPTOMATOLOGY &SIGNS• Abdomen :Inspection – Reduced movements, Peri umbilical discolouration (Cullen’s Sign)Palpation – Guarding, tenderness, Reboundtenderness, Fixed point tenderness(Adler’s Sign)• Per Vaginal :Cervical Rocking test + 20% Cases ? fallacious tendernessPulsatile Fornix , Boginess in fornixUterus enlargement < 6 weeksTENDER ADNEXAL MASS
  23. 23. CLINICAL SYMPTOMATOLOGY &SIGNS SYMPTOM ACUTE CHRONICPain Abdomen +++ Silent / Less severeBleeding PV +++ +Syncope ++ -/+Shoulder tip Pain ++ -SIGNSCVS Collapse +++ -Abd Tender ++ -/+PV Tender + +Fornix Mass -/+ ++
  24. 24. Ectopic PregnancyA Diagnostic Dilemma Net result of these vagaries of presentation of ectopic pregnancy is that accuracy of the initial clinical evaluation is less than 50% Tuomivaara L et al. Arch Gynecol. 1986; 237: 135
  25. 25. Ectopic PregnancyHow is the woman deceived?• Does not suspect pregnancy at all• She thinks she is normally pregnant• She thinks she is aborting a uterine pregnancy
  26. 26. Ectopic PregnancyNothing Characteristic About It• Pain extremely variable in intensity, location and character• Amenorrhea may be absent in a fourth of women• Adnexal mass in only upto 50% women• Cervical motion tenderness may not be present
  27. 27. DIFFERENTIAL DIAGNOSISALL ACUTE ABDOMEN EMERGENCIESAPPENDICITISDIVERTICULITISCHOLECYSTITISPERFORATED DUODENAL ULCERPANCREATITISPYELO-NEPHRITISMESENTRIC CYSTCOLITISTHROMBOSIS MESENTRIC ARTERYSPLENIC RUPTUREHEPATIC RUPTUREANAEMIAS & VIRAL HEPATITIS IN CHRONIC ECTOPICS
  28. 28. DIFFERENTIAL DIAGNOSIS• DYSMENORRHOEA WITH IRREGULAR PERIODS• RETROVERTED GRAVID UTERUS• ABORTION WITH SALPINGITIS• THREATENED ABORTION• RUPTURED / BLEEDING CORPUS LUTEUM CYST• TORSION OF OVARIAN CYST / ADNEXAL MASS• BLEEDING INTO ENDOMETRIOTIC CYST• PREGNANCY WITH OVARIAN CYST / PEDUNCULATED FIBROID• RED DEGENERATION OF FIBROID
  29. 29. Ectopic PregnancyHow to Diagnose It Then?‘Be Ectopic Minded’‘Keep a high index of suspicion’‘Be paranoid about ectopic’ – after all, paranoia is but a heightened sense of awareness!Have no regrets that it wasn’t ectopic – even if you find that after a laparoscopy or laparotomy!
  30. 30. INVESTIGATIONS• BASIC 1. Hb, TLC, DLC, BT, CT, PCV 2. Blood Group ABO/Rh 3. Urine RE/ME 4. LFT• DISEASE 1. Urine Pregnancy Test 2. Beta hCG Assay 3. Ultrasonography Abdominal / TVS Plain 53% 70% Doppler 73% 93% Gestational Sac absent in uterus Thickened Endometrium Adnexal Mass POD Collection Ring of Fire 4. Diagnostic Laproscopy 5. Culdocentesis / Paracentesis 6. D & C
  31. 31. MANAGEMENTFACTORS DETERMINING MODALITIESPATIENT ‘s CLINICAL STATUSAGEPARITYFERTILITY FUNCTIONPRIOR SURGERY
  32. 32. MANAGEMENT• WATCHFUL EXPECTANTINDN : Asymptomatic, Reliable, Stable Patient.USG Diagnosed Unruptured sac <2cm /Missed Abortion (NoFHM in Ectopic Gestation).Low Beta hCG <5000IU/ml.PROCEDURE : Monitor patientSerum Beta hCG document falling titre.TVS demise of Ectopic & reduction in size.Shift to Medical Management if Criteria not fullfill.
  33. 33. MANAGEMENT• MEDICALINDN : Stable Patient . USG Gestation Sac < 3cms. No FHM.Serum Beta hCG titre low preferably below 5000IU/ml.PROCEDURE :(a) Inject 20% KCl 0.5-1.0 ml near Fetal Cardiac Region.(b) Inject Methotrexate 25 mg into Gestation Sac.(c) Inject Methotrexate 50 mg/Sqm or 1mg/Kg IM.Dose apprx 50 mg per ampule.30% Failure Rate, Require repeat doses.
  34. 34. MANAGEMENT• ADVANCED OPERATIVE LAPROSCOPIC SURGINDN : Stable Patient. Tubal Ectopic .Gestation Sac <5cms. Preferably Unruptured.PROCEDURE :(a) Injection of Mrthotrexate into Gestational Sac via laproscope.(b) Linear Salpingotomy(c) Linear Salpingostomy(d) Partial / Complete Salpingectomy(e) Segmental Resection & Anastomosis
  35. 35. MANAGEMENT• EXPLORATORY LAPROTOMYINDN : Unstable Patient. Adnexal MassUSG Gestation Sac > 5cms . Massive Haemoperitoneum.Cornual / Angular Ectopic pregnancy . Abdominal Pregnancy .PROCEDURE :RESUSCITATE the Patient aggressively . Replace Blood .Autotransfusion . Cell Saver . MAST Suit .Partial / Complete Salpingectomy with or withoutOophorectomy.

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