4.Ectopic PregnancyAcute presentation of abdominal pain, amenorrhea and vaginal bleeding.ppt

April 12, 2024 Ectopic pregnancy

INTRODUCTION
Ectopic pregnancy is the implantation of
product of conception at sites other than
the endometrial cavity
 It causes:
 major maternal morbidity & mortality
adversely affects future reproductive
function &
economic burden of health care for
women

Conti…
 Ectopic pregnancy was first recognized in
1693 by Busiere when he was examining the
body of a prisoner.
 Gifford of England made a more complete
report in 1731 that described the condition
of a fertilized ovum implanted outside the
uterine cavity.

Conti…
 It is the leading cause of maternal mortality
during 1st trimester which accounts for 10 –14 %
of maternal deaths.
 Nontubal ectopic pregnancies accounts for only 5
% of all EPS, yet they account for 20 % of the
fatalities
 Those who seek medical care error in diagnosis
occur in 49 % of the cases confused with :
1. GI disorder
2. IUP
3. PID

Incidence
 1-2% of all pregnancies
 Cause of maternal mortality
 Rising trend to occur
-Emerging IVF technology
-Increase in STDs
-Increased rate of detection
-Rising number of caesarean section(caesarean scar
pregnancy)

RISK FACTORS
 Risk factors for ectopic pregnancy can be
divided into:
High risk,
Moderate risk, or
low risk.

High risk factors
► Previous ectopic pregnancy(1—10%,>2-25%)
►Tubal pathology and surgery(tubal
reconstructive surgery(tuboplasty)&)
►In-utero DES exposure(3-5*)
►Intrauterine contraception

Moderate risk factors
 Previous genital infections—PID(Chronic
salpingitis(std,TB)—result in tubal anatomy,
fibrosis, tubal occlusion
 Infertility
 Multiple sexual partners
 Smoking

Low risk factors
1. In vitro fertilization:
 increased risk of both ectopic and heterotopic
pregnancy.
 ectopic pregnancy of 2.1 percent.
2.Vaginal douching

Conti…
 Cervical pregnancy:
rare (1 in 50,000 to 1 in 2,400) form of ectopic pregnancy in
which the trophoblast implants in the endocervical canal.
U/S criteria for Dx:
 Echo free Ux
 Hour glass uterine shape
 Ballooned cervical canal
 Sac in the endocervical canal
 Placental tissue in the cervical canal
 Closed internal os and patulous external os

Conti…
Ovarian pregnancy
 occurs in 1:7000 pregnancies.
 appears to be a random event.
 Strict histopathological criteria are used to distinguish
ovarian pregnancies from those originating in the
fallopian tube.

Conti…
Criteria for Dx: (Spiegelberg criteria)
 Intact tube on the affected side
 Fetal sac at the position of the ovary
 Ovary connected to the uterus by ovarian
ligament
 Ovarian tissue in the sac wall => Dx is
confirmed surgically.

Interstitial pregnancy:
 can grow larger
 may be misdiagnosed as intrauterine
A clue to correct diagnosis is its eccentric location.
 ipsilateral salpingectomy is a risk factor specific
for interstitial pregnancy.

Conti…
Hysterotomy (cesarean) scar pregnancy:
 1 in 2000 pregnancies
 6% of ectopic pregnancies among women
with a prior cesarean delivery.
 The pregnancy is located in the scar
outside of the uterine cavity.

Conti…
Heterotopic pregnancy:
 Its incidence is dependent upon the rates of
ectopic pregnancy and dizygotic twinning. 1 in
30,000 pregnancies.
 Has been rising, mainly due to the increasing
number of pregnancies derived from assisted
reproductive technology (ART).

Conti…
Abdominal pregnancy:
 primary or
 secondary.
 7-8 x higher MR than tubal
 90 x higher MR than intrauterine pregnancy
 term abdominal pregnancies
 pressure deformities,
 facial and limb asymmetry

Conti…
Studdiford’s criteria for Dx of
1o abdominal pregnancy:
– Normal tubes and
Ovaries bilaterally
– No uteroplacental
fistula
– Pregnancy is early and
related to peritoneal
surface

Clinical manifestation
History
 classic symptoms: abdominal pain (99%), amenorrhea
(74%), vaginal bleeding (56%)
 Clinical manifestations often appear 6-8 wks after
LNMP but can appear later
 Often see above symptoms with breast tenderness,
frequency urination, and nausea
 Shoulder pain (blood irritating diaphragm), urge to
defecate (blood pooling in cul-de-sac)
 Lightheadedness,dizzness,syncope,nausea,vom
iting, bloating
 Shock

Physical examination
 General Appearance(pale, cold extremities)
 Vital signs (tachycardia,hypotension)
 Abdomen(tenderness,rigidity)
 PV(bulky uterus, adnexal tenderness &mass, cervical
motion tenderness)
 Bulged cul-de-sac
 mild uterine enlargement.

DDX
 Spontaneous Abortion
 Ruptured Corpus luteal cyst
 Tubo Ovarian Abscess
 Ovarian Tortion
 Pelvic Inflammatory Disease
 Acute Appendicitis
 Acute Pylonephritis
 Renal calculi

Histologic Characteristics
 Chorionic villi, usually found in the
lumen, are pathognomic findings of tubal
pregnancy.
 Gross or microscopic evidence of an
embryo is seen in two thirds of cases
 An unruptured tubal pregnancy is
characterized by irregular dilation of the
tube, with a blue discoloration caused by
hematosalpinx.

 The natural progression of tubal
pregnancy is
=>either expulsion from the fimbriated
end (tubal abortion)
=> involution of the conceptus,
=>or rupture(usually around 8th wks).
 Hemoperitoneum is nearly always
present but is confined to the cul-de-sac
unless tubal rupture has occurred

DIAGNOSIS
 the wide spectrum of presentation asymptomatic
acute abdomen Hypovolaemic shock.
 upt
 The diagnosis is usually made clinically, based on the
results of:
 the imaging studies (ultrasound) and
 laboratory tests (hCG)
 Evaluation begins with TVS and quantitative hCG level.
TVS alone is diagnostic if a yolk sac, embryo, or
embryonic cardiac activity is demonstrable.

diagnosis conti…
 TVS
 Serum hCG
 Other diagnostic tests (e.g., serum progesterone level,
Doppler US, curettage, laparoscopy, culdocentesis, MRI) do
not provide additional clinically useful information.
- permit definitive Dx in almost all cases at
early stage.

Diagnosis conti…
• TVS:
– Empty utrine cavity
– is used to detect the + or - of a GS within or
outside of the uterus and thereby establish a
diagnosis.

Conti…
Diagnosis of extrauterine pregnancy:
 Visualization of an extrauterine gestational sac
containing a yolk sac or embryo.
 A complex adnexal mass with cardiac activity in
a positive pregnancy test and empty uterus is
definitive diagnosis of an extrauterine gestation and
is the most common sonographic abnormality.

Diagnosis conti…
Human chorionic gonadotropin (hCG):
hCG can be detected 8 days after the LH surge.
rises in a linear fashion until 41 days of gestation.
doubling time 1.4 to 2.1 days
In viable intrauterine pregnancies:
 rises by at least 66 percent every 48 hours.
 The slowest rise over 48 hours with a viable intrauterine
pregnancy was 53 %.
-15%IUP <66%
-15%EP >66%

Discriminatory zone:
 the serum hCG level above which a gestational sac
should be visualized by ultrasound examination if an
intrauterine pregnancy is present.
 This serum hCG level is >1500 with TVS and >6500
IU/L with TAS.
The absence of an IU GS at hCG level above the
discriminatory zone strongly suggests an ectopic or
nonviable intrauterine pregnancy.

 A negative ultrasound examination at hCG levels
below the discriminatory zone is consistent with:
 an early viable intrauterine pregnancy or
 an ectopic pregnancy or
 Non viable intrauterine pregnancy.
 Such cases are termed "pregnancy of unknown
location" and 8 to 40 percent are ultimately
diagnosed as ectopic pregnancies.

 The discriminatory zone is dependent upon:
 the skill of the ultrasonographer,
 the quality of the ultrasound equipment,
 the presence of physical factors (e.g. fibroids),
and
 the laboratory characteristics of the hCG assay.

 Curettage:
 the use of curettage as a diagnostic tool is limited by
the potential for disruption of a viable pregnancy.
 Some recommend performing curettage only on
women with:
 a hCG concentration below the DZ and
 a low doubling rate.
 30 % ~ nonviable IU gestation and
 70% ~ an ectopic pregnancy.

Doppler:
Blood flow is 20 to 45 percent higher.
Color Doppler may demonstrate a ring of blood flow.
 These findings on Doppler support the diagnosis of ectopic
pregnancy—ring of fire sign
Laparoscopy:
 is rarely required for diagnostic purposes only.
 However, an ectopic pregnancy detected at laparoscopy should
be treated immediately by surgery.
Culdocentesis.

SCREENING ASYMPTOMATIC WOMEN:
• reduced the frequency of risk of adverse outcome &
permit treatment options less invasive than surgical
excision.
• Screening only appeared to be cost-effective in
populations with a high prevalence (at least 8
percent) of ectopic pregnancy.

Management
I. Expectant management
II. Medical and
 traditionally involves the antimetabolite methotrexate.
III. Surgical approaches include mainly
 salpingostomy
 salpingectomy.
38

Management conti…
 Depends on:
 clinical circumstances,
 the site of the ectopic pregnancy, and
 the available resources.

management
Treatment
Surgical Medical
Laparoscopic Systemic
 Salpingectomy Local
 Salpingostomy
Laparotomy
 Salpingectomy
 Salpingostomy
Expectant
 Decreasing hCG titers (less than
1500 mIU/mL )
 Tubal location
 No evidence of rupture or
significant bleeding
 size < 35 mm with no visible
heart beat
 Highly motivated patient with
strong desire to avoid both
surgery and medical
management
 Hemodynamically stable healthy
woman and pain free
 Follow up bhcg at 48hr,day4 ,day
7 then weekly until -ve

Medical management
CANDIDATES:
 hemodynamically stable and no significant
pain
 willing and able to comply with post treatment
follow-up,
 B hCG ≤ 5000 mIU/mL,
 Unruptured tubal ectopic size < 3.5cm with no
visible heart beat

Methotrexate
Single dose protocol
 success rate 89 to 91 %
 Patient selection:
- asymptomatic
- Serum hCG level (<5000)
- tubal size < 3.5cm
 Less side effects
 Less cost
 Doesn’t require folinic
acid rescue
Multiple dose protocol
 Success rate 86 to 93 %
 Patient selection:
 asymptomatic
 interstitial ectopic
 cervical ectopic
 more side effects
 Expensive
 Requires folinic acid
rescue Rx

Rx day Single dose protocol
1 MTX 50 mg/m2 BSA IM
4 hCG
7
hCG
If <15 percent hCG decline from day 4 to 7 (OR <25 percent
decline from day 1 to 7), give additional dose of MTX 50
mg/m2 IM
If 15 percent hCG decline from day 4 to 7 (OR 25 percent
decline from day 1 to 7), draw hCG concentration weekly
until hCG is undetectable
14
hCG
If <15 percent hCG decline from day 7 to 14, give additional
dose of MTX 50 mg/m2 IM
If 15 percent hCG decline from day 7 to 14, check hCG
weekly until undetectable
21 and 28 If 3 doses have been given and there is a <15 percent hCG
decline from day 21 to 28, proceed with laparocopic
surgery

Rx day
Multiple dose protocol
1 MTX 1mg/kg bodyweight IM
2 LEU 0.1 mg/kg PO
3 - hCG
- If <15 percent hCG decline from day 1 to 3, give MTX 1 mg/kg IM
- If 15 percent decline from day 1 to 3, begin weekly hCG
4 LEU 0.1 mg/kg PO
5 hCG
If <15 percent decline from day 3 to 5 MTX, give MTX 1 mg/kg IM
If 15 percent decline from day 3 to 5, begin weekly hCG
6 LEU 0.1 mg/kg PO

Rx day Multiple dose protocol
7
hCG
If <15 percent hCG decline from day 7 to 14, give additional dose
of MTX 1 mg/kg IM (give LEU 0.1 mg/kg PO on day 15)
If 15 percent hCG decline from day 7 to 14, check hCG weekly
until undetectable
8 LEU 0.1 mg/kg PO
14
hCG
If <15 percent hCG decline from day 7 to 14, give additional dose
of MTX 1 mg/kg IM (give LEU 0.1 mg/kg PO on day 15)
If 15 percent hCG decline from day 7 to 14, check hCG weekly
until undetectable
21 and 28 If 5 doses have been given and there is a <15 percent hCG
decline from day 14 to 21, proceed with laparoscopic surgery

Success rates by hCG
Serum b-hCG Success rate
<1000 98% (118/120)
1000–1999 93% (40/43)
2000–4999 92% (90/98)
5000–9999 87% (39/45)
10,000–14,999 82% (18/22)
O15,000 68% (15/22)

Surgical treatment
INDICATIONS:
 Hemodynamic instability,
 Contraindications to use of medical Rx,
 Coexisting intrauterine pregnancy,
 Not able or willing to comply with medical
therapy
 Lack of timely access to a medical institution
for management of tubal rupture
 Desire for permanent contraception
 Failed medical therapy

Surgery conti…
 Advantages:
 less time for resolution of the ectopic
pregnancy and
 avoidance of the need for prolonged
monitoring.

Surgery conti…
Laparotomy versus Laparoscopy
 no significant differences in overall tubal patency.
 higher rates of ipsilateral adhesions in the
laparotomy group.
 similar number of subsequent uterine pregnancies.
 fewer subsequent ectopic pregnancies with
laparoscopy, although this was not significant.

Laparotomy Laparoscopy
 hemodynamically unstable
 interstitial pregnancies
 ovarian and abdominal
pregnancies
 Extensive surgical Hx and
known dense adhesions
 Obesity
 Absence of trained surgeon in
laparoscopy
 Laparoscopy instruments not
available
 Hemodynamically stable
 shorter operation time,
 less perioperative blood loss,
 shorter duration of hospital
stay,
 shorter convalescence time,
and,
 higher rate of persistent
trophoblast

Salpingostomy versus salpingectomy
 No RCTs to date comparing these procedures.
Salpingostomy:
1. risk of persistent trophoblast
2. risk of repeat tubal pregnancy.
3. review of cohort studies it appears there is no
reproductive benefit.
Salpingectomy:
1. tube is severely damaged
2. there is uncontrolled bleeding
3. recurrent ectopic pregnancy in the same tube
4. Large tubal pregnancy
5. the woman has completed her family

cornual resection of
interstitial pregnancy  Cornual resection and removal of
interstitial pregnancy.

Chronic ectopic pregnancy
 Salient minor ruptures or abortions of an ectopic
pregnancy instead of a single episode of bleeding, incites
an inflammatory response often leading to the formation
of a pelvic mass.
 Its clinical features are often confusing, and
 laboratory evaluations are often misleading.
 Surgery difficult since chronic inflammatory changes and
adhesions distort the normal anatomy.

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