ECTOPIC PREGNANCY

ECTOPIC PREGNANCY

In ectopic pregnancy, a fertilized ovum implants

in an area other-than the endometrial lining of

the uterus

More than 95o/o of extrauterine Pregnancies-

occuri n the fallopian tube.

Ampullary 70%Interstitial

andcornual 2–3%

Isthmic 12%

Ovarian 3%Fimbrial 11%Cesarean

scar <1

Abdominal 1%

Cervical <1%

Sites of ectopic pregnancie

incidenceThe incidence in the United Kingdom has

changed little in the last decade with 9.6 ectopics per 1000 pregnancies in 1991–1993 and 11.0 per 1000 pregnancies in 2000–2002

This may be due, at least in part, to a higher incidence

of salpingitis, an increase in ovularion induction

and assisted reproductive technology, and moretubal sterilization

Increasing Ectopic Pregnancy RatesA number of reasons at least partially explain the increased

rate of ectopic pregnancies in the United States and many European countries. Some of these include:

1. Increasing prevalence of sexually transmitted infections, especially those caused by Chlamydia trachomatis

2. Identification through earlier diagnosis of some ectopic

pregnancies otherwise destined to resorb spontaneously

3. Popularity of contraception that predisposes pregnancy failures to be ectopic

4. Tubal sterilization techniques that with contraceptive failure increase the likelihood of ectopic pregnancy

5. Assisted reproductive technology

6. Tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility.

MortalityAccording to the World Health Organization (2007),

ectopic pregnancy is responsible for almost 5 percent of maternal deaths in developed countries.

Risk factors for ectopic pregnancyHistory of previous ectopic pregnancy(IUCD) or sterilization failurePelvic inflammatory diseaseChlamydia infectionEarly age of intercourse and multiple partnersHistory of infertilityPrevious pelvic surgeryIncreased maternal ageCigarette smokingStrenuous physical exerciseIn utero DES exposure

TUBAL PREGNANCYThe fertilized ovum may lodge in any portion of the

oviduct, giving rise to ampullary, isthmic, and interstitial tubal pregnancies

In rare instances, the fertilized ovum may implant in the fimbriated extremity. The ampulla is the most frequent site, followed by the isthmus. Interstitial pregnancy accounts for only about 2 percent. From these primary types, secondary forms of tubo-abdominal, tubo-ovarian, and broadligament pregnancies occasionally develop.

Ectopic pregnancy

Clinical presentation1-subacute clinical picture of

A. abdominal pain &vaginal bleeding in early pregnancy.

Vaginal bleeding is usually dark red, indicative old blood

B- abdominal/ pelvic pain may be localized to the iliac fossa.

C- sholder tip pain indicative of free blood in the abdominal cavity

D- dizzeness (anaemia)

Bimanual examination can reveal tenderness in the fornices and there may be cervical excitation

2- Acute clinical presentation due to rupture ectopic pregnancy with massive intraperitoneal bleeding. They can present with signs of hypovolaemic shock & acute abdomen

InvestigationThe following are useful investigation for the diagnosis of

ectopic pregnancy1- observations :Bp, pulse ,temperatuer2- laboratory investigations:Haemoglobin. blood group(prepare blood forr cross match) &

B-HCGA B-HCG level of less than 5mIU/ml, is considered negative

for pregnancy& any thing above 25 mIU/ml is considered positive for pregnancy

In 85% of pregnancy the B-HCG levels almost double every 48 hours in normally developing intrautrine pregnancy

In ectopic pregnancy the rise in B-HCG is suboptimal,. However multiple readings are required for comparison purposes.

Transvaginal ultrasound scan (TVS)

An intrauterine gestational sac should be visualized at 4.5 weeks

Gestation.the corresponding B-HCG at that gestation is around 1500 mIU/ml.By the time a gestational sac with fetal heart pulsation is detcted (at around 5 weeks gestation)B-HCGlevel should be around 3000 mIU/ml

Thus , if there were discrepancy betwween B-HCG cocentration and that seen on ultrasound scan(e.g.a highB-HCG with no intruterine pregnancy on ultrasound scan), the differential diagnosis of an ectopic pregnancy must be made.

Identification of an intruterine pregnancy(gestational sac, yolk sac, and fetal pole) on TVS effectively excludes the possibility of ectopic pregnancy in most patients except in those patients with rare hterotopic pregnancy.

The presence of free fluid during TVSis suggestive of a ruptured cetopic pregnancy

Lparoscopy:this can be used to diagnose and treat ectopic pregnancy

CuldocentesisThis simple technique was used commonly in the

past to identify hemoperitoneum. The cervix is pulled toward the symphysis with a tenaculum, and a long 16- or 18-gauge needle is inserted through the posterior vaginal fornix into the cul-de-sac. If present, fluid can be aspirated, however, failure to do so is interpreted only as unsatisfactory entry into the cul-de-sac and does not exclude an ectopic pregnancy, either ruptured or unruptured. Fluid containing fragments of old clots, or bloody fluid that does not clot, is compatible with the diagnosis of hemoperitoneum resulting from an ectopic pregnancy. If the blood subsequently clots, it may have been obtained from an adjacent blood vessel rather than from a bleeding ectopic pregnancy.

UltrasoundWith the advent of diagnostic ultrasound and

the increasing use of conservative treatment, the diagnosis of ectopic pregnancy is increasingly made without the help of surgery.

Gestational sac with a live embryo and a yolk sacUterus

In women with ectopic pregnancies bleeding within the

uterine cavity may resemble an early intrauterine pregnancy (‘pseudosac’).

The presence of free fluid in the pouch of Douglas is a

frequent finding in women with normal intrauterine pregnancies and it should not be used to diagnose an ectopic. However, the presence of blood clots is important and is a common finding in ruptured ectopics

In women with intrauterine pregnancy on the scan a

possibility of heterotopic pregnancy should be excluded.

This is particularly the case in women who conceived after stimulation of ovulation orIVF (in vitro fertilization).

Serum Progesterone. A single progesterone measurement

can be used to establish with high reliability that there is a normally developing pregnancy. A value exceeding 25 ng/mL excludes ectopic pregnancy with 92.5-percent sensitivity .

Conversely, values below 5 ng/mL are found in only 0.3 percent of normal pregnancies . Thus, values 5 ng/mL suggest either an intrauterine pregnancy with a dead fetus or an ectopic pregnancy. Because in most ectopic pregnancies, progesterone levels range between 10 and 25 ng/mL, the clinical utility is limited

Novel Serum Markers. A number of preliminary studies have

been done to evaluate novel markers to detect ectopic pregnancy. These include vascular endothelial growth factor (VEGF), cancer antigen 125 (CA125), creatine kinase, fetal fibronectin, and mass spectrometry-based proteomics None of these are in current clinical use.

Differential diagnosisThe diagnosis is from any other acute abdominalcatastrophe such as rupture of a viscus or acuteperitonitis. The clinical picture is so typical that inmost cases diagnosis presents no difficulty. Otherdiagnoses which may confuse are:• inevitable miscarriage;• bleeding with an ovarian cyst;• pelvic appendicitis;• acute salpingitis.

Management

Expectant managementExpectant management has important advantages over

medical treatment as it follows the natural history of the disease and is free from serious side effects of methotrexate. Expectant management requires prolonged follow-up and it may cause anxiety to both women and their carers.

However, the main limiting factor in the use of expectant

management is the relatively high failure rate and

the inability to identify with accuracy the cases that are

likely to fail expectant management. To minimize the

risk of failure many authors have used very strict selection

criteria for expectant management such as the initial

hCG <250 IU

Surgery

Surgery has been traditionally used both for the diagnosis and treatment of ectopic pregnancy.

With recent advances in operative laparoscopy, the minimally invasive approach has also become accepted as the method of choice to treat most tubal ectopic pregnancies.

There are important advantages of laparoscopic over open surgery which include less post-operative pain, shorter hospital stay and faster resumption of social activity

LaporatomyIn a case of severe haemorrhage in ruptured

ectopic pregnancy , the patient must be taken immediately to the operating theatre. Little time should be wasted in attempting resuscitation which can prove useless and may only increase bleeding. An intravenous drip should be set up and a blood transfusion given as soon as possible.

Surgical Management

Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless the woman is hemodynamically unstable

Tubal surgery is considered *conservative when there is tubal salvage.

Examples include salpingostomy, salpingotomy, and fimbrial expression of the ectopic pregnancy.

*Radical surgery is defined by salpingectomy.

Laparoscopy techniques exist to:• kill the embryo with a direct injection ofmethotrexate or mifepristone allowing

absorptionso requiring no surgery on the tube;• incise the swollen tube over the ectopic

pregnancy,aspirate the embryo, and achievehaemostasis (salpingostomy).

Salpingostomy. This procedure is used to remove a small pregnancy that is usually less than 2 cm in length and located in the distal third of the fallopian tube . A 10- to 15- mm linear incision is made with unipolar needle cautery on the antimesenteric border over the pregnancy. The products usually will extrude from the incision and can be carefully removed or flushed out using high-pressure irrigation that more thoroughly

removes the trophoblastic tissue

Linear salpingostomy for ectopic pregnancy

Salpingotomy. Seldom performed today, salpingotomy is essentially the same procedure as salpingostomy except that the incision is closed with delayed-absorbable suture..

Salpingectomy. Tubal resection may be used for both ruptured and unruptured ectopic pregnancies. When removing the oviduct, it is advisable to excise a wedge of the outer third (or less) of the interstitial portion of the tube. This so-called cornual resection is done in an effort to minimize the rare recurrence of pregnancy in the tubal stump. Even with cornual resection, however, a subsequent interstitial pregnancy is not always prevented .

Persistent Trophoblast. Incomplete removal of trophoblast

may result in persistent ectopic pregnancy. Because of this, administered a “prophylactic” 1 mg/m2 dose of methotrexate postoperatively. Persistent trophoblast complicates 5 to 20 percent of salpingostomies and can be identified by persistent or rising hCG levels. Usually -

hCG levels fall quickly and are at about 10 percent of preoperative values by day 12 . Also, if the postoperative day 1 serum - hCG value is less than 50 percent of the preoperative value, then persistent trophoblast rarely is a problem

Medical Management with Methotrexate

This folic acid antagonist is highly effective against rapidly proliferating trophoblast, and it has been used for more than 40 years to treat gestational trophoblastic disease

Selection criteria for conservative management of ectopic pregnancy

1. Minimal clinical symptoms

2. Certain ultrasound diagnosis of ectopic

3. No evidence of embryonic cardiac activity

4. Size <5 cm

5. No evidence of haematoperitoneum on ultrasound scan

6. Low serum hCG (methotrexate <3000 IU/l; expectant

7. <1500 IU/l)

The followin are resonable indications for methotrexate use

1-cornual pregnancy2-Prsistant trophoblastic disorders3- patient with one fallopian tubeand fertility

desired .4-patient who refuse surgery or whome

surgery is risky5-treatment of ectopic pregnancy where

trophoblast is adherent to bowel or blood vessel

Contrindications of medical treatment1- chronic liver, renal or haematological disordes2- active infection3-immunodeficency4- breast feedingSide effect of methotrexatenausea.vomiting ,stomatitis, cojuctivitis, GI upset,

photosensitive skin reaction Abdominal painAdvise the women to take contraception for three

months after methotreate. It is also important to avoid alcohol & exposure to sunlight during treatment

Non-tubal ectopics

Interstitial ectopics

The implantation of the conceptus in the proximal portion

of the Fallopian tube, which is within the muscularwall

of the uterus, is called an interstitial pregnancy. The incidence of interstitial ectopic is 1 in 2500–5000 live births and it accounts for2–6% of all ectopic pregnancies

Ruptured interstitial pregnancy usually presents dramatically with severe intra-abdominal bleeding, which

requires urgent surgery. Haemostasis can usually be

achieved by removing the pregnancy tissue and suturing

the rupture site. However, in cases of extreme bleeding a

cornual resection or in rare cases a hysterectomy may be

necessary to arrest the bleeding.

The sac is completely surrounded by a myometrial mantle, which is typical of

interstitial pregnancy.

Pregnancies located below the internal os –cervical

and Caesarean scar ectopics Cervical pregnancy is defined as the

implantation of the conceptus within the cervix, below the level of the internal os. Caesarean scar pregnancy is a novel entity, which refers to a pregnancy implanted into a deficient uterine scar following previous lower segment Caesarean section

An attempt to remove cervical or Caesarean section

pregnancy is likely to cause severe vaginal bleeding and

hysterectomy rates of 40% have been described when

a D&C was attempted without pre-operative diagnosis

of cervical pregnancy

Ovarian pregnancyOvarian pregnancy is defined as the

implantation of theconceptus on the surface of the ovary or inside

the ovary,away from the fallopian tubes. The diagnosis of ovarian pregnancy is rarely

achievedpre-operatively; hence most women are treated

surgically as the diagnosis is reached only at operation

Abdominal pregnancyAbdominal pregnancy is a rarity that only a fewgynaecologists will encounter during their professionalcareer. Most abdominal pregnancies are the result of

reimplantation of ruptured undiagnosed tubal ectopic pregnancies.

With the increasing accuracy of first-trimestertransvaginal scanning it is likely the prevalence ofadvanced abdominal pregnancy will decrease even

furtherin the future.

The clinical and ultrasound features

of an early abdominal pregnancy are very similar to

tubal ectopic pregnancies. However, viable abdominal

pregnancies, which progress beyond the first trimester,

are typically missed on routine transabdominal scanning.

Abdominal pregnancy should be suspected in women

with persistent abdominal pain later in pregnancy and

in those who complain of painful fetal movements.

Treatment of abdominal pregnancy is surgical. In advanced abdominal pregnancies

accompanied by normal fetal development diagnosed in the late second trimester termination of pregnancy may be delayed for a few weeks until the fetus reaches viability.

At surgery the gestational sac should be opened carefully

avoiding disruption of the placenta. The fetus should be

removed, the cord cut short and the placenta should be left in situ .

Any attempt to remove the placenta may resultin massive uncontrollable haemorrhage.

Adjuvant treatment with methotrexate is not necessary and the residual placental tissue will absorb slowly over a period of many months, sometimes a few years. The placental tissue left in situ may become infected leading to the formation of a pelvic abscess, which may require drainage.