Download to read offline
ectopic pregnancy power point presentation
- 1. Ectopic pregnancy DR SWETHA JR1 AARUPADAI VEEDU MEDICAL COLLEGE MODERATOR : DR JESSY VARGHESE
- 2. Ectopic pregnancy •DEFINITION: "Anypregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity". •It represents a serious hazard to a woman's health and reproductive potential, requiring prompt recognition and early aggressive intervention "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 .
- 3. IMPLANTATION SITES EXTRAUTERINE(Tubal 95-96% Ovarian (1:40,000) Abdominal (1:10,000)) Ampulla 70% Isthmus 12% Infundibulum 11% Interstitial & cornual 2% ABDOMINAL PRIMARY SECONDARY Intraperitoneal Extraperitoneal Broad Ligament (rare) UTERINE (Cervical (1:18,000) Angular Corunual Caesarean Scar (<1))
- 4.
- 5. Incidence Increased dueto PID, use of IUCD, Tubal surgeries, and Assisted reproductive techniques (ART). Ranges from 1:25 to 1:250 Average range is 1 in 100 normal pregnancies. Late marriages and late child bearing -> 2% ART -> 5% Recurrence rate - 15% after 1st, 25% after 2 ectopics
- 6. ETIOLOGY: Any factorthat causes delayed transport of the fertilised ovum through the tube. Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired.
- 7. CONGENITAL CAUSES OFECTOPIC Tubal Hypoplasia Tortuosity Congenital diverticuli Accessory ostia Partial stenosis Elongation Intamural polyp Entrap the ovum on its way.
- 8. ACQUIRED CAUSES OFECTOPIC Pelvic Inflammatory disease Chlamydia trachomatis is most common Contraceptive Failure CuT – 0.8-1.2% Progestasart -0.8% Minipills -4-10% Norplant lessthan 0.1%
- 9. CAUSES OF ECTOPIC •Tubalreconstructive surgery (4-5 times) •Assisted Reproductive technique •Ovulation induction, IVF-ET and GIFT •Risk of heterotopic pregnancy •Previous Ectopic Pregnancy •12% chances of repeat ectopic pregnancy
- 10. Other Risk factors Age 35-45 yrs Previous induced abortion Previous pelvic surgeries Cigarette smoking DES Exposure in Utero Infertility Salpingitis Isthmica Nodosa Genital Tuberculosis Fundal Fibroid & Adenomyosis of tube Transperitoneal migration of ovum
- 11. Iffy hypothesis_ "Theoryof reflux" menstrual fluid throw the fertilised ovum into the tube Factors facilitating nidation of ovum in tube: Premature degeneration of zona pellucida Increased decidual reaction Tubal endometriosis
- 12. Evolution Tubal pregnanciesrapidly invade the mucosa, feeding from the tubal vessels, which become enlarged and engorged. The segment of the affected tube is distended as the pregnancy grows. The pregnancy is unable to survive owing to its poor blood supply, thus resulting in a tubal abortion and resorption, or it is expelled from the fimbriated end into the abdominal cavity. The pregnancy continues to grow until the overdistended tube ruptures, with resulting profuse intraperitoneal bleeding. Isthmic - 6-8 wks, Ampullary - 8-12wks, Interstitial -4 months Abortion is common in ampullary pregnancies, whereas rupture is in isthmic.
- 13. CLINICAL APPROACH Diagnosiscan be done by history, detailed examination and judicious use of investigation. H/o past PID, tubal surgery, current contraceptive measures should be asked. Wide spectrum of clinical presentation from asymptomatic patient to others with acute abdomen and in shock.
- 14. ACUTE ECTOPIC PREGNANCY Classical triad is present in 50% of patient with rupture ectopic. PAIN:- most constant feature in 95% patient variable in severity and nature AMENORRHOEA:- there may be delayed period or slight spotting at the time of expected menses. VAGINAL BLEEDING: - scanty dark brown Feeling of nausea, vomiting, fainting attack, syncope attack due to reflex vasomotor disturbance.
- 15. ACUTE ECTOPIC PREGNANCY •O/E:-patient is restless in agony, looks blanched, pale sweating with cold clammy skin. Features of shock, tachycardia, hypotension. •P/A:- abdomen tense, tender mostly in lower abdomen, • shifting dullness, rigidity may be present. •P/S:- minimal bleeding may be present •P/V:- uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain on movement of cervix. POD may be full, uterus floats as if in water.
- 16. CHRONIC ECTOPIC PREGNANCY It can be diagnosed by high clinical suspicion. Patient had previous attack of acute pain from which she has recovered. She may have amenorrhoea, vaginal bleeding with dull pain in abdomen, and with bladder and bowel complaints like dysuria, frequency or retention of urine, rectal tenesmus
- 17. CHRONIC ECTOPIC PREGNANCY •O/E:-patient look ill, varying degree of pallor, slightly raised temperature features of shock are absent. •P/A:- Tenderness and muscle guard on the lower abdomen. A mass may be felt, irregular and tender. •P/V:- Vaginal mucosa pale, uterus may be normal in size or bulky, ill defined boggy tender mass may be felt in one of the fornix
- 18. DIAGNOSIS In recentyears, in spite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate. This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease. This has resulted in early diagnosis and effective treatment. Now the rate of tubal rupture is as low as 20%.
- 19. DIAGNOSIS Blood shouldbe drawn for Hb gm%, blood grouping and cross matching, DC and BT, CT. Should be catheterized to know urine output. Bed side test:- Urine pregnancy test:- positive in 95% cases. Serum ELISA is sensitive to 10-50 mIU/ml of β hCG and can be detected on 24th day after LMP.
- 20. DIAGNOSIS Culdocentesis:- (70-90%) Can be done with 16-18 G lumbar puncture needle through posterior fornix into POD. Positive tap is 0.5ml of non clotting blood. Other Investigations:- Ultra Sonography- a) Transvaginal Sonography (TVS): Is more sensitive It detect intrauterine gestational sac at 4-5wks and at S-β hCG level as low as 1500 IU/L.
- 21. DIAGNOSIS Early gestational sacPseudosac location Eccentric along the burried into endometium cavity line b/w endometrial layer shape usually round May be ovoid borders double ring single layer color flow high avascular Endometrial cavity •A trilaminar endometrial pattern seen •Pseudogestational sac •Decidual cyst may be seen PSEUDOSAC - All pregnancies induce an endometrial decidual reaction, and sloughing of the decidua can create an intracavitary fluid collection called a pseudosac
- 22. DIAGNOSIS DECIDUAL CYST Itis identified as an anechoic area lying within in the endometrium but remote from the canal and often at the endometrial-myometrial border. 15-30% an extrauterine yolk sac or embryo seen in fallopian tubes confirms tubal pregnancy. A halo or tubal ring surrounded by a thin hypoechoic area caused by subserosal edema can be seen. Rectouterine cul-de-sac Free peritoneal fluid with an adnexal mass suggestive of ectopic pregnancy
- 23. DIAGNOSIS Color Doppler Sonography(TV-CDS): Improvethe accuracy. Identify the placental shape (ring-of-fire pattern) and blood flow outside the uterine cavity. Transabdominal Sonography: can identify gestational sac at 5-6 wk S-β hCG level at which intrauterine gestational sac is seen by TAS is 1800 IU/L.
- 24. DIAGNOSIS USG PICTURE 'Bagel' sign - Hyperechoic ring around gestational sac in adnexal region 'Blob' sign - Seen as small mass next to ovary with no evidence of sac or embryo. Adnexal sac with fetal pole and cardiac activity is most specific. Corpus luteum is useful guide when looking for EP as present in 85% cases in Ipsilateral ovary.
- 26. DIAGNOSIS . β-HCGAssay:- a) Single β-HCG: value b) Serial β-HCG: is required when result of initial USG is confusing. When HCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy. Rise of β-HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy. Biochemical pregnancy is applied to those women who have two β-HCG values >10 IU/L . Diagnostic Laparoscopy (Gold standard)- - Can be done only when patient is haemodynamically stable. - It confirms the diagnosis and removal of ectopic mass can be done at the same time.
- 27. DIAGNOSIS . Dilatation &Curettage - Is recommended in suspected case of incomplete abortion vs ectopic pregnancy. Identification of decidua without chorionic villi is suggestive of extra uterine pregnancy. "Arias-Stella" endometrial reaction is suggestive but not diagnostic of ectopic pregnancy. Other hormonal Tests - Placenta protein (PP14) decrease in EP PAPPA (Pregnancy Associated Plasma Protein A), PAPPC (schwangerschaft protein 1) has low value in EP CA-125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic pregnancy.
- 28. DIFFERENTIAL DIAGNOSIS Normalintrauterine pregnancy Bleeding into a corpus luteual cyst Twisted ovarian cyst Pelvic inflammatory disease Torsion / degeneration of pedunculated fibroid Incomplete/threatened abortion Acute Appendicitis Perforated peptic ulcer Renal colic Splenic rupture
- 29. MANAGEMENT Expectantmanagement Medical management Systemic Methotrexate Local (USG or Laparoscopic) salpingocentesis Methotrexate Potassium chloride Prostagladin(PGF2alpha) Hyperosmolar glucose Actinomycin D Mifepristone Surgical management Radical Salpingectomy Conservative -Salpingostomy -Salpingotomy -Segmental resection -Milking or fimbrial expression
- 30. MANAGEMENT OF RUPTUREDECTOPIC PRINCIPLE: Resuscitation and Laparotomy ANTI SHOCK TREATEMENT: IV line made patent, crystalloid is started Blood sample for Hb, blood grouping & cross matching, BT, CT Foley's catheterization done Colloids for volume replacement LAPAROTOMY: Principle is 'Quick in and Quick out' Rapid exploration of abdominal cavity is done Salpingectomy is the definitive surgery (sent for HP study) Blood transfusion to be given
- 31. MANAGEMENT OF UNRUPTUREDECTOPIC PREGNANCY SURGICAL SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT MEDICAL TREATMENT EXPECTANT MANAGEMENT
- 32. MANAGEMENT OF UNRUPTURED ECTOPICPREGNANCY EXPECTANT MANAGEMENT IDENTIFICATION CRITERIA (Ylostalo et al, 1993):- Tubal ectopic pregnancies only Haemodynamically stable Initial β HCG <1500 IU/L and falling in titre SUCCESS RATE PROTOCOL: Hospitalization with strict monitoring of clinical symptom Daily Hb estimation Serum β HCG monitoring 3-4 days until it is <10 IU/L TVS to be done twice a week
- 33. MEDICAL MANAGEMENT •MEDICAL MANAGEMENT Surgeryis the mainstay of T/t worldwide Medical M/m may be tried in selected cases •CANDIDATES FOR METHOTREXATE (MTX) •Hemodynamically stable Unruptured sac < 4cm without cardiac activity S-HCG < 5000 IU/L Persistant Ectopic after conservative surgery No intrauterine pregnancy
- 34. METHOTREXATE: METHOTREXATE: Itcan be used as oral, intramuscular, intravenous usually along with folinic acid. Mechanism of action- Methotrexate is a folic acid antagonist that inactivates the enzyme dihydrofolate reductase, interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the necrosed.
- 35.
- 36. MANAGEMENT •SURGICALLY ADMINISTERED MEDICALTt (SAM) •Aim- trophoblastic destruction without systemic side effects •Technique- Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by- •Laparoscopy or •Ultrasonographically guided •Transabdominal) •Transvaginal Trophotoxic substances used- Methotrexate Potassium Chloride Mifipristone PGF2alpha Hyper osmolar glucose solution Actinomycin D
- 37. MANAGEMENT SURGICAL MANAGEMENTOF ECTOPIC Conservative Surgery Can be done Laparoscopically or by laparotomy INDICATION: Patient desires future fertility Contralateral tube is damaged or surgically removed previously CHOICE OF TECHNIQUE: depends on Location and size of gestational sac Condition of tubes Accessibility
- 38. SURGICAL MANAGEMENT SALPINGECTOMYVS SALPINGOSTOMY / SALPINGOTOMY All tubal pregnancies can be treated by partial or total Salpingectomy Salpingostomy / Salpingotomy is only indicated when: The patient desires to conserve her fertility Patient is haemodinamically stable Tubal pregnancy is accessible Unruptured and < 5cm. In size Contralateral tube is absent or damaged
- 39. SURGICAL MANAGEMENT Laparotomy VsLaparoscopy Laparoscopy is reserved for pt who are hemodynamically stable. Ruptured Ectopic does not necessarily require Laparotomy, but if large clots are present Laparotomy should be considered. Reproductive outcome Is similar in pt treated with either Laparoscopy or Laparotomy. Identical rates of 40% of IUP, around 12% risk of recurrent pregnancy with either radical or conservative pregnancy.
- 40. SURGICAL MANAGEMENT LAPAROSCOPIC SALPINGECTOMY •Itis carried out by laparoscopic scissors & diathermy or Endo-loop. •After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is tightened and then •the tubal pregnancy is cut distal to the loop stitch. •The excised tissue is removed by piece meal or in tissue removal bag LAPAROSCOPIC SALPINGOTOMY •To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal saline is injected into the •mesosalpinx. •Then the tube is opened through an antimesenteric longitudinal incision over the tubal pregnancy by a •Co laser (Paulson, 1992) ₂ •Argon laser (Kirkkstein et al; 1992) •Laparoscopic scissors and ablating the bleeding points with bipolar diathermy. •Fine diathermy knife (Lundorff, 1992) •The tubal pregnancy is then evacuated by suction irrigation.
- 41. PERSISTENT ECTOPIC PREGNANCY Thisis a complication of salpingotomy / salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy. •Diagnosis is made because of a raised postoperative β HCG •If untreated, can cause life threatening hemorrhage •Risk Factors: (Seifer 1997) 1.Early ectopic pregnancy (< 6 wks amenorrhoea) 2.Smaller size < 2 cm (Incomplete removal) 3.Preoperative high serum β HCG (> 3,000 IU/L) and postoperative Day1 titre is < 50% of preoperative level, is predictor of persistent EP. 4.Implantation medial to the salpingostomy site. •Treatment •surgery •Total or partial salpingectomy •Medical (selected Asymptomatic pt) •MTX + Leukovorin
- 42. OVARIAN ECTOPIC PREGNANCY Incidence: 1:40,000 Risk factor: - IUCD Endometriosis on surface of ovary Course: C/F are same as tubal pregnancy ruptures within 2-3 wks Diagnosis: On Laparotomy Spiegelberg's Criteria Ipsilateral tube is intact and separate from sac Sac occupies the position of the ovary Connected to uterus by ovarian ligament Ovarian tissue found on its wall on HP study Ruptured Laparotomy Oophorectomy Unruptured M/M Ovarian wedge resection Ovarian Cystectomy
- 43. ABDOMINAL PREGNANCY Incidence:Rarest H/O: - Irregular bleeding, spotting Nausea, vomiting, flatulence, constipation, diarrhoea, abdominal pain. Fetal movement may be painful and high in the abdomen O/E: - Abnormal fetal position, easy in palpating fetal parts. uterus palpated separate from sac no uterine contraction after oxytocin infusion
- 44. ABDOMINAL PREGNANCY •Diagnosis: Confirmedby USG •TYPE •Primary •Studiford's criteria 1.Both tubes and ovaries normal 2.Absence of Uteroperitoneal fistula 3.Pregnancy related to Peritoneal surface • Secondary •Intraperitoneal •Extraperitoneal •Broad ligament Management •Urgent Laparotomy irrespective of period of gestation •Ideal to remove entire sac fetus, placenta, membrane •Placenta may be left if attached to vital organs, get absorbed by aseptic autolysis
- 45. CERVICAL PREGNANCY Implantation occursin cervical canal at or below internal Os. Incidence: 1 in 18,000 RISK FACTORS: Previous induced abortion Previous caesarean deliver Asherman's syndrome IVF DES exposure Leiomyoma
- 46. CERVICAL PREGNANCY Diagnosis: CLINICAL CRITERIA: Paulman & McElilin Uterine bleeding, no cramping, following amenorrhoea Cervix distended, thin walled, soft consistency Enlarged uterine fundus may be palpated. Internal Os is closed External Os is partially opened USG CRITERIA: American Journal of O&G Echo-free uterine cavity/ pseudo-gestational sac Barrel shaped cervix Hourglass uterus with ballooned cervical canal Gestational sac below the level of internal os Closed internal Os Absence of sliding sign ,blood flow around the sac
- 47. CERVICAL PREGNANCY HISTOPATHOLOGIC CRITERIA:Rubin's Cervical glands present opposite to placenta Placental attachment to the cervix must be below the entrance of uterine vessels . Fetal element absent from corpus uteri. Management Previously always hysterectomy Medical treatment with multiple dose Methotrexate regimen is first choice If it fails radiological uterine artery embolization followed by evacuation Patient should be informed about the possibility of hysterectomy
- 48. CORNUAL PREGNANCY SITE: Implantationoccurs in rudimentary horn of Bicornuate uterus COURSE : Rupture of horn occurs by 12-20 wks D/D : Interstitial tubal pregnancy Painful leiomyoma along with pregnancy Ovarian tumor with pregnancy Asymmetrical enlargement of uterus. Implantation into cornu of normal uterus is sometime called Angular pregnancy. TREATEMENT: Affected cornu with pregnancy is removed Hysterectomy Hysteroscopically guided suction curettage if communication with Cx is patent
- 49. HETEROTOPIC PREGNANCY Co-existingintrauterine and extra uterine pregnancies Incidence: 1 : 30,000 With ART - 1:7000 With ovulation induction - 1:900 a) Ass. reproductive technique b) Rising HCG titre after D & C M/M : Depends on the site. Ectopic site may be removed with continuation of IU pregnancy
- 50. INTERSTITIAL PREGNANCY (2%) It defines as implantation in the proximal interstitial part of fallopian tube It ruptures at last 3-4 months gestation. Fatal rupture - severe bleeding as both uterine & ovarian artery supply. Early & Unruptured - Local or IM MTX with followup Cornual resection by Laparotomy may be done. There is high risk of uterine rupture in subsequent pregnancy. Rupture - Hysterectomy is indicated
- 51. CAESAREAN SCAR ECTOPICPREGNANCY Implantation into the myometrial defect occurring at the site of previous uterine incision Recently reported USG slows on empty uterine cavity and gestational sac attached low to the lower segment caesarean scar. C/F : similar to threatened or inevitable abortion Diagnosis : Doppler imaging confirms T/t : Methotrexate injection Hysterectomy in a multiparous women. In young pt resection & suturing of scar may be done (high risk of rupture).
- 52. OTHER RARE TYPES Multiple Ectopic pregnancy Pregnancy after hysterectomy Primary splenic pregnancy Primary hepatic pregnancy Retroperitoneal pregnancy Diaphragmatic pregnancy
- 53.