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ectopic pregnancy

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ectopic pregnancy

  1. 1. Ectopic Pregnancy Semyatov S. Associate professor Dep. Obtetrics&Gynaecology of PFUR
  2. 2. Definition <ul><li>Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity. </li></ul>
  3. 3. Incidence <ul><li>1 in 100 ( from 1:25 to 1:250) normal pregnancies </li></ul><ul><li>1:28 in West Indies </li></ul><ul><li>4,5-16,8:1000 in Russia </li></ul><ul><li>Mortality - 0,4% in Russia </li></ul><ul><li>The Secondary Infertility - 40% after operation </li></ul>
  4. 4. Incidence <ul><li>Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries. </li></ul><ul><ul><li>USA-5 fold </li></ul></ul><ul><ul><li>UK-2 fold </li></ul></ul><ul><ul><li>France 15/1000 pregnancies </li></ul></ul><ul><ul><li>India-1in100 deliveries </li></ul></ul><ul><li>Recurrence rate - 15% after 1 st , 25% after 2 ectopics </li></ul>
  5. 5. Overview <ul><li>Incidence Increasing (Ќ 1:66 Pregnancies) </li></ul><ul><li>Mortality Decreasing With Better Detection </li></ul><ul><li>Surgical and Medical Treatment Available </li></ul><ul><li>Recurrence Rate ~ 15% </li></ul>
  6. 6. History <ul><li>Ectopic pregnancy was first described in 963 Ad by Albucasis. </li></ul><ul><li>1884 -- Robert Lawson Tait of Birmingham prformed the first successful Salpingectomy operation </li></ul><ul><li>1953 -- Stromme – Conservative surgery of Salpingostomy </li></ul><ul><li>1973 -- Shapiro & Adller – Laparoscopic Salpingectomy </li></ul><ul><li>1991 -- Young et al – Laparoscopic Salpingotomy </li></ul>
  7. 7. Aetiology <ul><li>Any factor that causes delayed transport of the fertilised ovum through the. </li></ul><ul><li>Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. </li></ul><ul><li>These factors may be Congenital or Acquired. </li></ul>
  8. 8. Aetiology <ul><li>CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis </li></ul>
  9. 9. Aetiology <ul><li>Previous Ectopic Pregnancy </li></ul><ul><li>PID </li></ul><ul><li>Congenital Defects in Fallopian Tubes (Assesory ostia, Partial stenosis, Hypoplasia, Infantilism) </li></ul><ul><li>Migration of the Ova Externa </li></ul><ul><li>Pelvic Abnormalities (Fundul Fibroma, adenomiosis of Fallopian Tubes) </li></ul><ul><li>Tubal Reconstrustive Surgery </li></ul>
  10. 10. Aetiology <ul><li>Tubectomy Operation </li></ul><ul><li>Infertility </li></ul><ul><li>IUD (~4% pregnancies with IUD in Situ are Ectopic, Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy) </li></ul><ul><li>IVF </li></ul><ul><li>Induction Ovulation with Gonadotropins </li></ul><ul><li>Extraneous Factors (Appendicitis, Endometriosis) </li></ul><ul><li>Kartegener’s Syndrome (zebra) </li></ul>
  11. 11. Sites <ul><li>Ampulla (78-95%) </li></ul><ul><li>Isthmus (8-12%) </li></ul><ul><li>Interstitial portion (2%) - very rare form </li></ul><ul><li>Cornua (< 2%) or in accessory horn </li></ul><ul><li>Ovary (0,5-3%, 20-30% in IUD users) </li></ul><ul><li>Abdomen (< 2%): Primary - very rare. Secondary. </li></ul><ul><li>Cervix (< 2%) </li></ul><ul><li>Combined Uterine Pregnancy and Ectopic Gestation - 1-3% in IVF, 1:4 000 - 1: 30 000 </li></ul>
  12. 12. Sites 1 - Fimbrial 2 - Ampullary 3 - Isthemic 4 - Interstitial 5) Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament 10) Primary abdominal Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Abdomen (< 2%) Cervix (< 2%)
  13. 13. Symptoms <ul><li>Amenorrhea ~ in 75% cases </li></ul><ul><li>Abdominal Pain - in 95% cases. Shoulder and Epigasrtric Pain </li></ul><ul><li>Vaginal Bleeding </li></ul><ul><li>Syncope </li></ul><ul><li>Pelvic Mass </li></ul>
  14. 14. Endometrium <ul><li>Under Hormonal Effect of the Ectopic Pregnancy it Hypertrophies and Converted into a Decidua </li></ul>
  15. 15. Clinical Course <ul><li>Unruptured (Progressive) - without specific sings </li></ul><ul><li>Tubal Abortion - minimal sings </li></ul><ul><li>Tubal Rupture (into the peritoneal cavity or between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock </li></ul>
  16. 16. Evaluation and Diagnosis <ul><li>The diagnosis of ectopic gestation often presents great difficulty and it is usually missed because it is NOT suspected. </li></ul><ul><li>“ Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it.” - Mc. Fadyen - 1981 </li></ul>
  17. 17. Evaluation and Diagnosis <ul><li>Women, during the childbearing period of life complaining of pain in the lower abdomen associated with continuous vaginal bleeding should be suspected of ectopic gestation </li></ul>
  18. 18. Evaluation and Diagnosis <ul><li>History and Physical Exam </li></ul><ul><li>Vaginal Examination </li></ul><ul><li>CBC, T+S </li></ul><ul><li>Serial Quantitative  -hCG (BSU) </li></ul><ul><li>Ultrasound TAS & TVS </li></ul><ul><li>Progesterone Level? </li></ul><ul><li>Culdocentesis </li></ul><ul><li>Laparoscopy </li></ul><ul><li>D&C </li></ul><ul><li>HSG </li></ul>
  19. 19. Serial BSU’s <ul><li> -hCG* Levels Double Every 48 Hrs </li></ul><ul><li>< 66% Rise / 48 Hrs Consistent With Ectopic Pregnancy </li></ul><ul><li>Single Determination Not Helpful </li></ul><ul><li>Best If Done Within Same Laboratory </li></ul><ul><li>Never Rules Out Ectopic Pregnancy </li></ul><ul><li>* generally greater than > 6 500 miu/mL </li></ul>
  20. 20. Ultrasound <ul><li>May or May Not Be Helpful </li></ul><ul><li>Discriminatory Zone: </li></ul><ul><li>TVS: 1500-2000 mIU/ml (5th Week of Gestation) </li></ul><ul><li>TAS: 6500 mIU/ml </li></ul><ul><li>+IUP: Generally Excludes Ectopic </li></ul>
  21. 21. Culdocentesis <ul><li>Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood </li></ul><ul><li>Negative Tap Inconclusive </li></ul><ul><li>May Obviate U/S </li></ul><ul><li>Most Helpful in Emergent Situations to Confirm Diagnosis, But Remains Controversial </li></ul>
  22. 22. Progesterone Levels <ul><li>> 15 ng/ml a/w IUP </li></ul><ul><li>< 15: SAb or Ectopic </li></ul><ul><li>May Take Several Days for Result </li></ul><ul><li>Clinical Use Not Yet Widespread </li></ul>
  23. 23. Differential diagnosis <ul><li>Appendicitis (Perforated) </li></ul><ul><li>PID </li></ul><ul><li>Rupture of Follicle or Corpus Luteum Cyst </li></ul><ul><li>Threatened Abortion </li></ul><ul><li>Splenic Rupture </li></ul><ul><li>Perforated Gastric or Duodenal Ulcer </li></ul>
  24. 24. Differential diagnosis <ul><li>Acute Pancreatities </li></ul><ul><li>Myocardial Infarct </li></ul><ul><li>Pyosalpinx </li></ul><ul><li>Septic Abortion </li></ul><ul><li>Pelvic Abcess </li></ul><ul><li>Retroverted Gravid Uterus </li></ul><ul><li>Twisted Ovarian Cyst </li></ul><ul><li>Rupture of Chocolate cyst </li></ul>
  25. 25. Treatment <ul><li>Observation </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Laparotomy </li></ul><ul><li>MTX </li></ul><ul><li>Hyperosmolar Glucose </li></ul><ul><li>KCl </li></ul><ul><li>RU-486 </li></ul><ul><li>Prostaglandin F2 alfa </li></ul>
  26. 26. Observation <ul><li>Many Tubal Pregnancies Abort </li></ul><ul><li>Israeli Study: Majority of Untreated Ectopics Resolve </li></ul><ul><li>Not Yet Acceptable Standard of Care in US </li></ul>
  27. 27. Laparotomy <ul><li>Acute Ectopic Gestation </li></ul><ul><li>Salpingoectomy </li></ul><ul><li>Secondary Abdominal Pregnancy </li></ul><ul><li>Interstial Pregnancy </li></ul><ul><li>Cornual Pregnancy </li></ul><ul><li>Cervical Pregnancy </li></ul><ul><li>Auto-Transfusion </li></ul>
  28. 28. Laparoscopy <ul><li>Allows Diagnosis and Treatment </li></ul><ul><li>Salpingostomy </li></ul><ul><li>Salpingectomy (Total / Partial) </li></ul><ul><li>Cornual Resection </li></ul><ul><li>Minimally Invasive, Unlike Laparotomy </li></ul><ul><li>Few Contraindications: Unstable Patient (Possibly) </li></ul>
  29. 29. MTX <ul><li>Toxic to Trophoblast Cells </li></ul><ul><li>Minimal Side Effects </li></ul><ul><li>May Preserve Fertility in Cases of Cervical Pregnancy </li></ul><ul><li>Requires Compliant Patient, Time </li></ul><ul><li>Pain Not Uncommon </li></ul><ul><li>BSU May Rise Initially </li></ul><ul><li>25-50 mg into Gestational Sac </li></ul>
  30. 30. MTX <ul><li>Tubal Patency is Restored in 82% cases </li></ul><ul><li>Oral - 50-100 mg (toxicity on GIT) </li></ul><ul><li>Intramusculary 1 mg/kg </li></ul><ul><li>NB. Laparoscopic Injection of MTX, Prostaglandin F2 alfa, RU 486 (anti-progesterone), Potassium Chloride into gestational sac is possible only if the sac measures less than 3 cm, and fetal heart is absent </li></ul>
  31. 31. Persistent Trophoblast <ul><li>Most Often A/W Salpingostomy </li></ul><ul><li>Laparoscopic ~ 3% </li></ul><ul><li>Minilap <1% </li></ul><ul><li>Most Easily Treated With MTX </li></ul>
  32. 32. Cervical Pregnancy <ul><li>Incidence ~1:1 000 </li></ul><ul><li>Profuse painless bleeding following a short period of Amenorrhea </li></ul><ul><li>PE: a patulous external os and productsmof conception in the cevical canal, internal os is closed and the uterus is firm and normal in size </li></ul>
  33. 33. Cervical Pregnancy <ul><li>US helps in the correct diagnisis </li></ul><ul><li>Treatment: - Suction Evacuation and Tamponade by inserting a distended Foley Catheter for 24 hours - Hysterectomy - Hysteroscopic Resection using Resectoscope - MTX </li></ul>
  34. 34. Outcomes <ul><li>15% Repeat Ectopic Rate </li></ul><ul><li>Ќ 2 Ectopics: </li></ul><ul><li>33% Pregnancy Rate </li></ul><ul><li>25% Ectopic </li></ul><ul><li>No Benefit To Removing Ovary Along With Tube </li></ul>
  35. 35. Summary <ul><li>Ectopic Pregnancy is a Common, Treatable Problem </li></ul><ul><li>Sensitive BSU Assays Allow Early Detection </li></ul><ul><li>Surgical and Medical Options Exist </li></ul><ul><li>Ruptured Ectopics Should be Unusual with Compliant Patients and Appropriate Medical Care </li></ul>

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