Ectopic Pregnancy

By PASCAL MUGEMANGANGO

Supevised by

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Content Case presentation Differential Introduction Incidence and location Risk factors Clinical features Diagnosis Management

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Case PresentationA 37 o G5P3013 with LMP 8 weeks ago presents to

the ED with RLQ pain, nausea and vomiting, and vaginal spotting. The ED provider was concerned that the patient may have appendicitis because of her history, as well as her past surgical history significant for a tubal ligation. Initial lab work revealed a positive Hcg.

what are your differentail diagnosis?

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Differential diagnosis

Ectopic Pregnancy „ Ovarian Torsion „ Salpingitis „ Pelvic Inflammatory Disease „ Spontaneous Abortion „ Ruptured Ovarian Cysts „ Endometriosis „ Leiomyoma

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Introduction Ectopic pregnancy, the implantation of a fertilized

ovum outside of the endometrial cavity.

it may be due to obstruction or dysfunction of tubal transport

mechanisms intrinsic abnormality of the fertilized ovum conception late in cycle transmigration of fertilized ovum to contralateral

tube

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Incidence and location

1 to 2 in 100 of all pregnancies and to 1 in 30 in high risk population arising with number of cases of chlamydia infection

Most common site is within fallopian tube 98%, in the distal ampulla than in the proximal isthmus, followed by corneal 2% and abdominal1.4%, ovarian 0.15% and cervical os 0.15%

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Locations of Etopics

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Risk factors Previous PID – STDs(chlamydia) Previous ectopic pregnancy Tubal ligation Previous tubal surgery Intrauterine device Prolonged infertility Diethylstilbestrol (DES) exposure in-utero Multiple sexual partners Smoking Increased age

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Clinical presentation Vaginal Bleeding or Spotting „ History of Missed Menses „ Abdominal or pelvic pain, unilaterally

If ruptured,

• acute abdomen with increasing pain

• abdominal distension

• symptoms of shock

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Physical examination hypovolemia/shock guarding and rebound tenderness bimanual examination

• cervical motion tenderness

• adnexal tenderness (unilat vs bilateral in PID)

• palpable adnexal mass (< 30%)

• uterine enlargement (rarely increases beyond 6-8 wks gestation)

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Diagnosis

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Diagnosis -β hCG levels

–Intrauterine (IU) pregnancy should be observed by -β hCG level.

„ If <1500mIu/mL, patient must return for reevaluation,„ If >1500mIu/mL and no IU gestational sac present on ultrasound, most likely non-viable IU pregnancy or ectopic.

-β hCGlevels reliably double every 48hrs with normal pregnancy.

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Progesterone levels

–>25ng/mL excludes ectopic–<5ng/mL suggestive of non-viable intrauterine pregnancy or ectopic–However, levels 5-25ng/mL are not conclusive.

„ Endometrial Curettage

–Endometrial currettage of a pregnant uterus will reveal chorionic villi and products of conception. „ If no products of conception retrieved, pregnancy is extrauterine.–Termination of pregnancy must be desired.

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Imaging diagnosis

Transabdomial U/S ƒAllows deeper

tissuepenetration but less detail

ƒRequires full bladder ƒImaging of uterine

fibroids, cysts, blood clots Benefits: No radiation,

inexpensive, bedside exam

Transvaginal U/S ƒAllows detailed

exploration of ovaries,adnexa, and uterus.

ƒDetection of early pregnancies; ~5wks

ƒEmpty Bladder ƒLess bowel gas

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Radiological findings „ Absence of IU gestational sac „ Adnexal mass „ Free fluid in pelvis or peritoneum „ Adnexal ring and “ring of fire” on

Doppler „ Pseudogestationalsac

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Adnexal ring sign

„Rounded hypoechoic center surrounded by a thick echogenic ring.

„Present in 40-68% of tubal pregnancies

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Ring of fire

Represents the vascular flow around the ectopic pregnancy.

„ Directly related to the amount of viable trophoblastic tissue.

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Surgical diagnosis

Exploratory Laparoscopy Can convert to surgical treatment Laparatomy should not be delayed in patients who

are hemodynamically unstable or there is evidence of abdominal hemorrhage.

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Treatment Options

Medical Management

→ Methotrexate - folic acid antagonist- effective against rapidly proliferating trophoblast

- success rate ↑ : < GA 6 weeks, <3.5cm, β-hCG<6,000 mIU/mL,

fetus is dead

→ Anti-D immunoglobulin(RhoGAM) for all women who are Rh-

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Contraindications of MTX Absolute C/I Intrauterine pregnancy Evidence of immunodeficiency Severe anemia,leukopenia,thrombocytopenia Sensitivity to MTX PUD Hepatic/renal dysfunction breastfeeding Ruptured ectopic pregnancy

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Relative C/I Embryonic cardiac actiity detected by US High initial hCG( >5000mIU/Ml) Ectopic pregnancy >3.5cm in size on US Refusal to accept blood transfusion

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Surgical management - laparoscopy > laparotomy (if stable)

- salpingostomy < 2cm incision, distal third of tube,small bleeding – electrocautery

incision is left unsutured

- salpingotomy

: incision is closed with Vicryl 7-0

- salpingectomy : tubal resection (wedge of the outer third of the interstitial portion)

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Take home message

In most circumstances, ectopic pregnancy can be diagnosed before symptoms develop and treated definitively with few complications.

Quantitative hCG testing, ultrasonography, and curettage allow early diagnosis of ectopic pregnancy and use of medical therapy as the initial therapy option.

Surgery is the treatment of choice for hemorrhage, medical failures, neglected cases, and when medical therapy is contraindicated.

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References

DANFORTH’s Obstetrics and Gynecology (10th Edition)

ACOG, Uptodate.com

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