Ectopic pregnancy 1

ECTOPIC PREGNANCY

DR.CHADUVULA SURESH BABU PROFESSOR

DEPT.OF OBGYNCollege of Medicine, Abha, KKU, KSA

ECTOPIC PREGNANCY Definition:

Any pregnancy where the fertilized ovum OR blastocyst is implanted and developed outside the normal uterine cavity

Incidence – 1 in 150 to 300 deliveries Incidence is increasing because of 1] Ovulation induction 2] IVF technologies 3] Tubal surgeries 4] IUCD usage 5] Increase in PID or STDs 6] Early diagnosis

FEMALE PELVIC ANATOMY

RISK OF RECURRENCE

15% with 1 ectopic

25% with 2 ectopics

AETIOLOGY Any factor that causes delayed transport of

the fertilised ovum through the fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy.

These factors may be Congenital or Acquired.

AETIOLOGY

CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis

ACQUIRED - Inflammatory: PID, Septic Abortion, Puerperal

Sepsis, MTP (lntraluminal adhesion)Surgical: Tubal reconstructive surgery,

Recanalisation of tubes Neoplastic: Broad ligament myoma, Ovarian

tumourMiscellaneous Causes: IUCD , Endometriosis,

ART (IVF & & GIFT), Previous ectopic

04/11/2023 09:46 PMEctopic Pregnancy 8

SITES OF ECTOPIC PREGNANCY

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%)


CLINICAL PRESENTATION

Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic

SYMPTOMS-AmenorrheaAbdominal PainSyncopeVaginal BleedingPelvic Mass

SIGNS- Abdominal tenderness, Cullen’s sign, Adnexal tenderness, Cervical motion tenderness

SIGNS AND SYMPTOMS IN RUPTURED ECTOPIC Severe abdominal pain Cullen’s sign – Periumbilical bruising Rebound tenderness and guarding Abdominal fullness with decreased

bowel sounds Vaginal exam: Fullness in pouch of

douglas

DIFFERENTIAL DIAGNOSIS Appendicitis Threatened Abortion Ruptured ovarian cyst PID Salpingitis Endometritis Nephrolithiasis Ovarian torsion Intrauterine pregnancy


METHODS OF EARLY DIAGNOSIS Immunoassay utilising monoclonal

antibodies to beta HCG Ultrasound scanning – Abdominal & Vaginal

including Colour Doppler Laparoscopy Serum progesterone estimation not helpful

A combination of these methods may have to be employed.


METHODS OF EARLY DIAGNOSIS

TVS can visualise a gestational sac as early as 4-5 weeks from LMP.

During this time the lowest serum beta HCG is 2000 IU/Lt.

When beta HCG level is greater than this and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected.

In such a situation, when the value of beta HCG does not double in 48 hours ectopic pregnancy will be confirmed.

At 4-5 weeks-

TRANSABDOMINAL ULTRASOUND (ON ADMISSION) Empty Uterus Free fluid Distended portion of left

Fallopian tube No evidence of rupture Adenexal mass:

1.7 x 1.6cm adjacent and anterior to left ovary

Cervical excitation Tenderness over left iliac

fossa on deep palpation with the probe

OTHER LABS: Complete blood count

Leukocytosis

Urinalysis with microscopic exam

Blood Type and RhesusA negative

Therefore, must give anti-D (RhoGAM) prior to surgery


MANAGEMENT

Depends on the stage of the disease and the condition of the patient at diagnosis.

Options-Surgery – Laparoscopy / LaparotomyMedical – Administration of drugs at the site /

systemicallyExpectant – Observation


MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY

SURGICAL- SURGICALLY ADMINISTERED MEDICAL (SAM)

TREATMENT MEDICAL TREATMENT EXPECTANT MANAGEMENT

OPTIONS: -


MEDICAL TREATMENT

Trophotoxic substances used-Methtrexate (Pansky, 1989)Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486)PGF2 (Limblom, 1987)Hyper osmolar glucose solutionActinomycin D


MEDICAL TREATMENT WITH METHOTREXATE Resolution of tubal pregnancy by systemic

administration of Methotrexate was first described by Tanaka et al (1982)

Mostly used for early resolution of placental tissue in abdominal pregnancy. Can be used for tubal pregnancy as well

Mechanism of action- Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the trophoblast.


MEDICAL TREATMENT WITH METHOTREXATE Ectopic pregnancy size should be < 3.5 cm. Can be given IV/IM/Oral, usually along with

Folinic acid Recent concept is to give Methtrexate IM in a

single dose of 50mg/m2 without Folinic acid. If serum HCG does not fall to 15% with in 4-7 days, then a second dose of Methtrexate is given and resolution confirmed by HCG estimation


MEDICAL TREATMENT WITH METHOTREXATE Advantages –

Minimal Hospitalisation.Usually outdoor treatmentQuick recovery 90% success if cases are properly selected

Disadvantages-Side effects like GI & SkinMonitoring is essential- Total blood count, LFT &

serum HCG once weekly till it becomes negative


MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Hospitalisation Resuscitation -

Treatment of shockLie flat with the leg end raisedAnalgesicsBlood transfusion


MANAGEMENT OF ACUTE ECTOPIC PREGNANCYCuldocentesis: - Most Helpful in Emergent Situations to

Confirm Diagnosis Highly Specific if performed and Interpreted

Correctly: - Presence of Free-Flowing, NON-Clotting Blood

Negative Tap Inconclusive Remains Controversial


MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Laparotomy should be done at the earliest.

Salpingectomy is the definitive treatment.

No benefit from removing Ovary along with the tube

If blood is not available, auto-transfusion can be done.


SURGICAL TREATMENT OF ECTOPIC PREGNANCY Carried out either by Laparoscopy /

Laparotomy. The procedures are: -

Salpingectomy / Cornual resection / ExcisionConservative surgery (in cases of Infertility &

desire for pregnancy) Linear salpingostomy Linear salpingotomy Segmental resection and anastomosis Milking of the tube


SURGICAL TREATMENT OF ECTOPIC PREGNANCY

LAPAROTOMY?

VS.

LAPAROSCOPY?

SALPINGECTOMY?

VS

SALPINGOSTOMY / SALPINGOTOMY?

The debate goes on


SALPINGECTOMY VS

SALPINGOSTOMY / SALPINGOTOMY

All tubal pregnancies can be treated by partial or total Salpingectomy

Salpingostomy / Salpingotomy is only indicated when:

1. The patient desires to conserve her fertility

2. Patient is haemodinmically stable3. Tubal pregnancy is accessible4. Unruptured and < 5Cm. In size5. Contralateral tube is absent or damaged

ANATOMICAL REVIEW

1. Medial tubal A.

2. Lateral tubal A.

3. Uterine A.

4. Ovarian A.

LAPAROSCOPIC SALPINGECTOMYMain Risk: devascularization of the ovary Operate close to the tube, away from

ovarian vessels and suspensory ligament

1. Proximal tube division Isthmus is held upwards and

outwards Isthmus is cauterized Take care not to cauterized the

internal ovarian A. and ovarian branch of the uterine A.

Divide tube with scissors

2. Mesosalpinx Division Divide the mesosalpinx

with scissors

Cauterize and divide the infundibulo-ovarian ligaments and the lateral tubal A.

3. Extraction of the tube Remove tube through an

extraction bag Verification of hemostasis Careful lavage Removal of equipment Suture/ Steri-strip

laparoscopic incisions

Caution:

• Endometriosis

• Utero-peritoneal fistula


It is carried out by laparoscopic scissors and 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 a tissue removal bag.

LAPAROSCOPIC SALPINGECTOMY


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

– Co2 laser (Paulson, 1992)– Argon laser (Keckstein et al; 1992) – Laparoscopic scissors and ablating the bleeding

points with bipolar diathermy. – Fine diathermy knife (Lundorff, 1992)

LAPAROSCOPIC SALPINGOTOMY


The tubal pregnancy is then evacuated by suction irrigation.

Hemostasis of the trophpblastic bed is ensured.

The tubal incision is left open.

LAPAROSCOPIC SALPINGOTOMY


MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY

INVESTIGATIONS- Laboratory/Chemical test –

Serial quantitative beta HCG level by RIA Serum progesterone level (<5 nanog/ml

in ectopic pregnancy)Low levels of Trophoblastic proteins such

as SPI and PAPP-, Placental protein 14 & 12

USG- usually haematocele is found Laparoscopy


MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY

TREATMENT – ALWAYS SURGICAL

Salpingectomy of the offending tube If pelvic haematocele is infected,

posterior. colpotomy is to be done to drain the pelvic abscess

Salpingo-oophorectomy


SUMMARY - KEY POINTS Incidence of ectopic pregnancy is rising while

maternal mortality from it is falling. Early diagnosis is the key to less invasive

treatment. The choice today is Laparoscopic treatment of

unruptured ectopic pregnancy. The trend is towards conservative treatment. Careful monitoring and proper counselling of

patients is mandatory. Ruptured ectopics should be unusual with

compliant patients and appropriate medical care.

THANK YOU

Date post:	07-May-2015
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Ectopic pregnancy 1

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