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Ectopic pregnancy- Define, Type, Etiology, Sign and Symptoms, Treatment, Surgery
An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tubes. It is becoming more common, with a 1 in 100 incidence of deliveries in India. Risk factors include pelvic inflammatory disease and previous tubal/pelvic surgeries. Ultrasound and beta-hCG levels can help diagnose ectopic pregnancies early before rupture. Treatment options include medical management with methotrexate or surgical intervention like salpingostomy to remove the ectopic pregnancy laparoscopically or laparotomically. The goal is to preserve future fertility when possible.
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Ectopic pregnancy- Define, Type, Etiology, Sign and Symptoms, Treatment, Surgery
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- 2. ECTOPIC PREGNANCY Definition An EctopicPregnancy is one in which fertilized ovum is implanted and develops outside the normal uterine cavity. Type • Acute Ectopic • Chronic Ectopic
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- 5. INCIDENCE • Recent evidenceindicates that the incidence of ectopic pregnancy has been rising in many countries. • USA- 5 fold: UK- 2 fold • India - 1 in 100 deliveries • Recurrence rate 15% after 1 ectopic pregnancy 25 % after 2 ectopic pregnancies
- 6. AETIOLOGY Factors Preventing ORdelaying migration of fertilized ovum. CHRONIC PID DEFECT OF TUBE IATROGENIC TRANS PERITONIAL MIGRATION TUBAL SPASM
- 7. Chronic PTD • Lossof Cilia • Narrowing of tubal lumen • Adhesions between mucosal Folds • Kinking Peritubal adhesions Defects of tube • Elongation • Diverticula's • Accessory Ostia
- 8. Iatrogenic Surgery • Tubal ligation •Microsurgery of tube • IUCD
- 9. Factors facilitating nidationin tube Premature degeneration of zona pellucida Increased decidual reaction Tubal endometriosis
- 10. Tubal Mole • Completeabsorption • Abortion Tubal Abortion • Complete • Incomplete
- 11. Tubal Rupture • Floor •Roof Tubal Perforation • Secondary abdominal Pregnancy • Secondary intra ligamentary Pregnancy
- 12. Acute Ectopic :Clinical Presentation • Reproductive age • Stable to shock • Amenorrhoea • Abdominal pain • Fainting attack • Vaginal bleeding
- 13. Signs • Pallor • Tachycardia •Hypotension • Tenderness / Guarding / Rigidity • Cx Movement Tenderness • Fornixial Tenderness
- 14. Differential Diagnosis • AcutePID • Acute Appendicitis • Rupture corpus luteal cyst • Twisted ovarian tumour
- 15. Diagnosis • Routine BloodInvestigations • UPT • Culdocentesis • Ultrasonography • Laproscopy
- 16. EARLY DIAGNOSIS At 4-5weeks: • TVS can visualize a G-sac • serum beta HCG levels are > 1600 mIU/ml • When Beta HCG levels are greater than above levels and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected. • when the value of Beta HCG does not double in 48 hrs, ectopic pregnancy is suggestive
- 17. EARLY DIAGNOSIS After 5weeks • tubal ring by 6 wks. • After 5 mm D : as a complete sonoluscent sac with the yolksac & embryonic pole with or without fetal heart activity. • Demonstration of the G sac with or without a live embryo (Begel’s sign)- • Ruptured ectopic with fluid in POD and an empty uterus. color doppler, the vascular colour in a characteristic placental shape fire pattern can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow.
- 18. Management RUPTURED ECTOPIC • Treatmentof shock • Laprotomy UNRUPTURED ECTOPIC • Conservative Management Medical Surgery
- 19. Medical • Methotrexate, folinicacid • GA less than 6 wks • Tubal mass is less than 3.5cm diameter • Fetus is dead • Intramuscular Methotrexate 1.0mg /kg • Alternating folinic acid 0.1mg/kg • Monitoring of B-HCG levels daily / Alternate day Monitor • HMG • RFT • LFT
- 20. • Methotrexate ORPotassium Chloride into amniotic sac through laparoscopy OR Sonography guidance Surgical Conservative Management Laparoscopic • Linear Salpingectomy • Salpingectomy • Segmental resection Anastomosis • Fimbrial Evacuation – Milking
- 21. Surgical Treatment • Salpingostomy/Salpingotomy indicated when • Pt Desire to conserve her fertility • Patient is haemodinamically stable • Tubal preg is accessible • Unruptured & < 5 cm Size • Contralateral tube absent or damaged. • Chapron et al (1993) have described a scoring system to decide which surgical treatment to be taken up based on patients previous gynae history & appearance of pelvic organs-
- 22. FERTILITY REDUCING FACTORSCORE • Antecedent one ectopic 2 • Antecedent each further ectopic 1 • Antecedent Adhesiolysis 1 • Antecedent Tubal microsugery 2 • Antecedent salpingitis 1 • Solitary tube 2 • Homolateral Adhesions 1 • Contralateral Adhesions 1 • Conservative surgery is indicated with a score of 1-4 only, while radical treatment to be performed if score is 5 or more. • Rationale behind the scoring system is to decide the risk of recurrent ectopic preg.
- 23. • Medical Treatmentby Methotrexate • The Antineoplastic drug which acts as a folic acid antagonist and is highly effective against rapidly proliferating trophoblast. • Used when 1. Ectopic mass size < 3.5 cm 2. Preg < 6 wks. 3. beta HCG levels < 15,000 MIU/ ml. • Dose – Single dose - 50 mg / m2 IM. Measure beta HCG levels on days 4 & 7 . If difference is > 15% : repeat weekly until undetectable If Difference is < 15% : repeat 2nd dose of methotrexate & begin now day 1 If fetal cardiac activity present on day 7, repeat dose & begin day 1. Surgical treatment if beta HCG levels not decreasing or fetal cardiac activity present after 3 doses.
- 24. PERSISTENT ECTOPIC PREGNANCY(PEP) • This is a complication of salpingotomy/ salpingostomy • When residual trophoplast continues to survive because of incomplete evacuation of ectopic preg. • Diagnosis made because of raised postoperative beta HCG. • Treatment reoperation & Salpingectomy Administration of IM/ oral Methotrexate in a single dose of 50 mg/m2
- 25. CHRONIC ECTOPIC PREGNANCY •INVESTIGATIONS : 1. Laboratory/ Chemical Test- • Serial quantitative beta HCG level by RIA • Serum progesterone level ( < 5 ng / ml in ectopic ) • Low levels of tropholastic proteins such as SPI & PAPP – Placental protein 14 & 12. 2. USG – usually haematocele is found. 3. Laparoscopy • TREATMENT : Mainly Surgical • Salpingectomy of the offending tube • If pelvic haematocele is infected, posterior colpotomy is to be done to drain the pelvic abscess. • Salpingoopherectomy
- 26. Surgical Laparotomy Laparoscopy • HospitalCost More? Less? • Post op Adhesions More Less • Recurrence Same Same • Future fertility Same Same • Experience Surgeon Trained Special