Ectopic Pregnancy6

8/17/2019 Ectopic Pregnancy6

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ECTOPIC

PREGNANCY


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ECTOPIC PREGNANCY

In ectopic pregnancy, a fertilized ovum implant

in an area ot!er"t!an t!e endometrial lining of

t!e uteru #ore t!an $%o&o of e'trauterine Pregnancie"

occuri n t!e fallopian tu(e)


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Ampullary70%Interstitialandcornual 2–3%

Isthmic

12%

Ovarian 3% Fimbrial11%Cesarean

scar 1

Abdominal1%

Cervical 1%

*ite of ectopic pregnancie


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incidence !he incidence in the "nited #in$dom has

chan$ed little in the last decade ith &'(ectopics per 1000 pre$nancies in 1&&1–1&&3and 11'0 per 1000 pre$nancies in 2000–2002

!his may be due) at least in part) to a hi$herincidence

o* salpin$itis) an increase in ovularion inductionand assisted reproductive technolo$y) and more

tubal sterili+ation


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Increasing Ectopic Pregnancy RatesA num(er of reaon at leat partially e'plain t!e increaed

rate of ectopic pregnancie in t!e +nited *tate and many

European countrie) *ome of t!ee include

-) Increaing prevalence of e'ually tranmitted infection,

epecially t!oe caued (y Chlamydia trachomatis

.) Identification t!roug! earlier diagnoi of ome ectopic

pregnancie ot!er/ie detined to reor( pontaneouly


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0) Popularity of contraception t!at predipoe pregnancy

failure to (e ectopic

1) Tu(al terilization tec!ni2ue t!at /it! contraceptive

failure increae t!e li3eli!ood of ectopic pregnancy

%) Aited reproductive tec!nology4) Tu(al urgery, including alpingotomy for tu(al pregnancy

and tu(oplaty for infertility)


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MortalityAccording to t!e 5orld 6ealt! Organization 7.889:,

ectopic pregnancy i reponi(le for almot % percent of

maternal deat! in developed countrie)


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,is- *actors *or ectopic pre$nancy.istory o* previous ectopic pre$nancy

/I"C or sterili+ation *ailure

elvic inammatory disease

Chlamydia in*ection

4arly a$e o* intercourse and multiple partners

.istory o* in*ertility

revious pelvic sur$ery

Increased maternal a$e

Ci$arette smo-in$

5trenuous physical e6ercise

In utero DES exposure


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TUBAL PREGNANCY T!e fertilized ovum may lodge in any portion of t!e

oviduct, giving rie to ampullary, it!mic, and intertitial

tu(al pregnancie

In rare intance, t!e fertilized ovum may implant in t!e

fim(riated e'tremity) T!e ampulla i t!e mot fre2uent

ite, follo/ed (y t!e it!mu) Intertitial pregnancy

account for only a(out . percent) ;rom t!ee primarytype, econdary form of tu(o"a(dominal, tu(o"ovarian,

and (roadligament pregnancie occaionally develop)


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Ectopic pregnancy


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Clinical preentation-"u(acute clinical picture of

A) a(dominal pain " a(dominal& pelvic pain may (e localized to t!e iliac foa)

C" !older tip pain indicative of free (lood in t!e a(dominal cavity

?" dizzene 7anaemia:

>imanual e'amination can reveal tenderne in t!e fornice and

t!ere may (e cervical e'citation

." Acute clinical preentation due to rupture ectopic pregnancy /it!

maive intraperitoneal (leeding) T!ey can preent /it! ign of

!ypovolaemic !oc3 < acute a(domen


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InvetigationT!e follo/ing are ueful invetigation for t!e diagnoi of

ectopic pregnancy

-" o(ervation >p, pule ,temperatuer

." la(oratory invetigation

6aemoglo(in) (lood group7prepare (lood forr cro matc!: <

>"6CG

A >"6CG level of le t!an %mI+&ml, i conidered negative for

pregnancy< any t!ing a(ove .% mI+&ml i conidered poitive

for pregnancy

In @% of pregnancy t!e >"6CG level almot dou(le every 1@

!our in normally developing intrautrine pregnancy


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In ectopic pregnancy t!e rie in >"6CG i u(optimal,) 6o/ever

multiple reading are re2uired for comparion purpoe)

Tranvaginal ultraound can 7T=*:

An intrauterine getational ac !ould (e viualized at 1)% /ee3

Getation)t!e correponding >"6CG at t!at getation i around -%88

mI+&ml)>y t!e time a getational ac /it! fetal !eart pulation i

detcted 7at around % /ee3 getation:>"6CGlevel !ould (e around

0888 mI+&mlT!u , if t!ere /ere dicrepancy (et//een >"6CG cocentration and

t!at een on ultraound can7e)g)a !ig!>"6CG /it! no intruterine

pregnancy on ultraound can:, t!e differential diagnoi of an

ectopic pregnancy mut (e made)


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Identification of an intruterine pregnancy7getational ac, yol3

ac, and fetal pole: on T=* effectively e'clude t!e poi(ility

of ectopic pregnancy in mot patient e'cept in t!oe patient

/it! rare !terotopic pregnancy)T!e preence of free fluid during T=*i uggetive of a

ruptured cetopic pregnancy

Bparocopyt!i can (e ued to diagnoe and treat ectopic

pregnancy


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Culdocentesis

!his simple techniue as used commonly in thepast to identi*y hemoperitoneum' !he cervi6 is

pulled toard the symphysis ith a tenaculum) anda lon$ 1(8 or 198$au$e needle is inserted throu$hthe posterior va$inal *orni6 into the cul8de8sac' I*present) uid can be aspirated) hoever) *ailure to

do so is interpreted only as unsatis*actory entry intothe cul8de8sac and does not e6clude an ectopicpre$nancy) either ruptured or unruptured' Fluidcontainin$ *ra$ments o* old clots) or bloody uid

that does not clot) is compatible ith the dia$nosiso* hemoperitoneum resultin$ *rom an ectopicpre$nancy' I* the blood subseuently clots) it mayhave been obtained *rom an ad:acent blood vessel

rather than *rom a bleedin$ ectopic pre$nancy'


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Ultrasound;ith the advent o* dia$nostic ultrasound and

the increasin$ use o* conservative treatment)the dia$nosis o* ectopic pre$nancy isincreasin$ly made ithout the help o* sur$ery'


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In omen ith ectopic pre$nancies bleedin$ithin the

uterine cavity may resemble an earlyintrauterine pre$nancy /=pseudosac>'

!he presence o* *ree uid in the pouch o*ou$las is a

*reuent ?ndin$ in omen ith normalintrauterine pre$nancies and it should not beused to dia$nose an ectopic' .oever) thepresence o* blood clots is important and is a

common ?ndin$ in ruptured ectopics


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In omen ith intrauterine pre$nancy on thescan a

possibility o* heterotopic pre$nancy should bee6cluded'

!his is particularly the case in omen hoconceived a*ter stimulation o* ovulation orI@F

/in vitro fertilization).


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Serum Progesterone. A single progesterone measurement

can (e ued to eta(li! /it! !ig! relia(ility t!at t!ere i a

normally developing pregnancy) A value e'ceeding .%ng&mB e'clude ectopic pregnancy /it! $.)%"percent

enitivity )

Converely, value (elo/ % ng&mB are found in only 8)0

percent of normal pregnancie ) T!u, value % ng&mBugget eit!er an intrauterine pregnancy /it! a dead fetu

or an ectopic pregnancy) >ecaue in mot ectopic

pregnancie, progeterone level range (et/een -8 and .%

ng&mB, t!e clinical utility i limited


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Novel Serum Marers. A num!er o"

preliminary stu#ies $ave

(een done to evaluate novel mar3er to detect ectopic

pregnancy) T!ee include vacular endot!elial gro/t!

factor 7=EG;:, cancer antigen -.% 7CA-.%:, creatine

3inae, fetal fi(ronectin, and ma pectrometry"(aed

proteomic None of t!ee are in current clinical ue)


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Dierential diagnosis

!he dia$nosis is *rom any other acute abdominal

catastrophe such as rupture o* a viscus or acute

peritonitis' !he clinical picture is so typical that in

most cases dia$nosis presents no diculty' Other

dia$noses hich may con*use areB

inevitable miscarria$eD

bleedin$ ith an ovarian cystD

pelvic appendicitisD acute salpin$itis'


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Management

E t t t


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E%pectant management

E'pectant management !a important advantage over

medical treatment a it follo/ t!e natural !itory of t!e

dieae and i free from eriou ide effect of met!otre'ate)E'pectant management re2uire prolonged follo/"up and it

may caue an'iety to (ot! /omen and t!eir carer)

6o/ever, t!e main limiting factor in t!e ue of e'pectant

management i t!e relatively !ig! failure rate andt!e ina(ility to identify /it! accuracy t!e cae t!at are

li3ely to fail e'pectant management) To minimize t!e

ri3 of failure many aut!or !ave ued very trict election

criteria for e'pectant management uc! a t!e initial

!CG


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EaporatomyIn a case o* severe haemorrha$e in ruptured

ectopic pre$nancy ) the patient must be ta-enimmediately to the operatin$ theatre' Eittle

time should be asted in attemptin$resuscitation hich can prove useless andmay only increase bleedin$' An intravenousdrip should be set up and a blood trans*usion

$iven as soon as possible'


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Surgical Management

Baparocopy i t!e preferred urgical treatment for ectopic

pregnancy unle t!e /oman i !emodynamically

unta(le

!ubal sur$ery is considered

*conservative when there is tubal salva$e'

46amples include salpin$ostomy)salpin$otomy) and ?mbrial e6pression o* theectopic pre$nancy'

Radical surger is de?ned by salpin$ectomy'


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Eaparoscopy techniues e6ist toB

-ill the embryo ith a direct in:ection o*

methotre6ate or mi*epristone alloin$absorption

so reuirin$ no sur$ery on the tubeD

incise the sollen tube over the ectopic

pre$nancy)aspirate the embryo) and achieve

haemostasis /salpin$ostomy'


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Salpingostomy. T$is proce#ure is use# to remove a small

pregnancy t!at i uually le t!an . cm in lengt! and

located in t!e dital t!ird of t!e fallopian tu(e . A &'( to

&)( mm linear inciion i made /it! unipolar needle

cautery on t!e antimeenteric (order over t!e pregnancy)

T!e product uually /ill e'trude from t!e inciion and

can (e carefully removed or flu!ed out uing !ig!"

preure irrigation t!at more t!oroug!ly

remove t!e trop!o(latic tiue


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Binear alpingotomy for ectopic pregnancy


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Salpingotomy. Sel#om per"orme# to#ay* salpingotomy

is essentially t!e ame procedure a alpingotomy e'cept

t!at t!e inciion i cloed /it! delayed"a(or(a(le uture))


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Salpingectomy Tu!al resection may !eused "or !ot# ruptured and unruptured ectopic

pregnancie) 5!en removing t!e oviduct, it i advia(le toe'cie a /edge of t!e outer t!ird 7or le: of t!e intertitial

portion of t!e tu(e) T!i o"called cornual resection is

done in an effort to minimize the rare recurrence of

pregnancy in t!e tu(al tump) Even /it! cornualreection, !o/ever, a u(e2uent intertitial pregnancy i

not al/ay prevented '


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Persistent Trop$o!last. Incomplete removal o"

trop$o!last

may reult in peritent ectopic pregnancy) >ecaue of t!i,adminitered a Dprop!ylactic - mg&m. doe of

met!otre'ate potoperatively) Peritent trop!o(lat

complicate % to .8 percent of alpingotomie and can (e

identified (y peritent or riing !CG level) +ually "!CG level fall 2uic3ly and are at a(out -8 percent of

preoperative value (y day -. ) Alo, if t!e potoperative

day - erum " !CG value i le t!an %8 percent of t!e

preoperative value, t!en peritent trop!o(lat rarely i a pro(lem


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Me#ical Management +it$ Met$otre%ate

T!i folic acid antagonit i !ig!ly effective againt rapidly

proliferating trop!o(lat, and it !a (een ued for more

t!an 18 year to treat getational trop!o(latic dieae


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*election criteria for conervative management of ectopic

pregnancy

-) #inimal clinical ymptom

.) Certain ultraound diagnoi of ectopic

0) No evidence of em(ryonic cardiac activity

1) *ize


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!he *olloin are resonable indications *ormethotre6ate use

18cornual pre$nancy

28rsistant trophoblastic disorders

38 patient ith one *allopian tubeand *ertilitydesired '

8patient ho re*use sur$ery or homesur$ery is ris-y

G8treatment o* ectopic pre$nancy heretrophoblast is adherent to boel or blood

vessel


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Contrindications o* medical

treatment18 chronic liver) renal or haematolo$ical disordes

28 active in*ection

38immunode?cency

8 breast *eedin$

5ide eHect o* methotre6ate

nausea'vomitin$ )stomatitis) co:uctivitis)


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Non(tu!al ectopics

Interstitial ectopics

T!e implantation of t!e conceptu in t!e pro'imal portionof t!e ;allopian tu(e, /!ic! i /it!in t!e mucular/all

of t!e uteru, i called an intertitial pregnancy) T!e

incidence of intertitial ectopic i - in .%88F%888 live

(irt! and it account for.F4 of all ectopic pregnancie


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,uptured interstitial pre$nancy usually presents

dramatically /it! evere intra"a(dominal (leeding, /!ic!

re2uire urgent urgery) 6aemotai can uually (e

ac!ieved (y removing t!e pregnancy tiue and uturing

t!e rupture ite) 6o/ever, in cae of e'treme (leeding a

cornual reection or in rare cae a !yterectomy may (e

neceary to arret t!e (leeding)


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!he sac is completely surrounded by amyometrial mantle) hich is typical o*

interstitial pre$nancy'


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Pregnancies located !elo$ t#e internal os%cer&ical

and Caesarean scar ectopics

Cervical pre$nancy is de?ned as theimplantation o* the conceptus ithin thecervi6) belo the level o* the internal os'

Caesarean scar pre$nancy is a novel entity)hich re*ers to a pre$nancy implanted into ade?cient uterine scar *olloin$ previous loerse$ment Caesarean section


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An attempt to remove cervical or Caesareansection

pre$nancy is li-ely to cause severe va$inalbleedin$ and

hysterectomy rates o* 0% have beendescribed hen

a C as attempted ithout pre8operativedia$nosis

o* cervical pre$nancy


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'&arian pregnancy

Ovarian pre$nancy is de?ned as theimplantation o* the

conceptus on the sur*ace o* the ovary or insidethe ovary)

aay *rom the *allopian tubes

' !he dia$nosis o* ovarian pre$nancy is rarelyachieved

pre8operativelyD hence most omen are treatedsur$ically as the dia$nosis is reached only at

operation


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A!dominal pregnancy

Abdominal pre$nancy is a rarity that only a *e

$ynaecolo$ists ill encounter durin$ their pro*essional

career' Jost abdominal pre$nancies are the result o*reimplantation o* ruptured undia$nosed tubal ectopicpre$nancies'

;ith the increasin$ accuracy o* ?rst8trimester

transva$inal scannin$ it is li-ely the prevalence o* advanced abdominal pre$nancy ill decrease even

*urther

in the *uture'


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T!e clinical and ultraound feature

of an early a(dominal pregnancy are very imilar to

tu(al ectopic pregnancie) 6o/ever, via(le a(dominal pregnancie, /!ic! progre (eyond t!e firt trimeter,

are typically mied on routine trana(dominal canning)

A(dominal pregnancy !ould (e upected in /omen

/it! peritent a(dominal pain later in pregnancy and

in t!oe /!o complain of painful fetal movement)


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Ectopic Pregnancy6

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