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Ectopic Pregnancy

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Title: Ectopic Pregnancy


1
Pain in Early Pregnancy
  • Ectopic Pregnancy

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3
ECTOPIC PREGNANCY
4
Case study 1
  • A 22-year-old woman, para 0, was admitted with
    mild vaginal bleeding after 7 weeks of
    amenorrhoea. She had had a positive home
    pregnancy test. Ultrasound scan showed an empty
    uterus, with an adnexal mass around 2 cm.
    quantitative ß-hCG was 2000 iu/ml.

At laparoscopy ectopic pregnancy was confirmed in
the ampulary part of the right tube.
Linear salpengotomy was performed. The patient
was discharged home the following day in good
condition.
5
Case study 2
  • A 22-year-old woman, para 0, was admitted with
    vaginal bleeding after 8 weeks of amenorrhoea.
    She had had a positive home pregnancy test, and
    described passing some tissue per vaginum.
    Ultrasound scan showed an empty uterus, although
    urinary B-hCG was still positive.

A presumptive diagnosis of incomplete abortion
was made, and evacuation of the uterus carries
out uneventfully. She was discharged the
following day
Was readmitted that night with lower abdominal
pain a ruptured ampullary ectopic was found at
laparotomy. Histology of curettage decidua with
Arias-Stella type reaction, no chorionic villi
seen.
6
Case study 3
  • An 33-year old woman para 4, was brought into
    E.R. collapsed with lower abdominal pain. On
    admission she was shocked with blood pr. Of
    60/40, a pulse of 120 bpm and tender rigid
    abdomen. Vaginal exam. Revealed a slight red
    loss, bulky uterus and marked cervical excitation
    with a tender mass in the right fornix.
  • At laparotomy, 3000 ml of fresh blood was
    removed from the peritoneal cavity and a
    ruptured right tubal ectopic pregnancy was found.
    The patient was in irreversible D.I.C. with Hb 0
    .5 gm/dl and eventually died

7
Definition
Any pregnancy occurring outside the uterus
Incidence Increasing due to P.I.D./
infertility 1-2 of all births 9 after IVF-ET
Site of implantation
8
SITES OF ECTOPIC PREGNANCY
Abdomen (lt 2)
Ampulla (gt85)
Isthmus (8)
Cornual (lt 2)
Ovary (lt 2)
Cervix (lt 2)
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
9
Risk Factors
  • Any factor that leads, directly or indirectly,
    to a reduction in tubal motility increases the
    risk for tubal pregnancy
  • History of infertility
  • Pelvic inflammatory disease
  • Pelvic operations tubal appendix failed
    tubal sterilization
  • Previous tubal pregnancy
  • Assisted conception particularly IVF if tubes
    are patent and damaged
  • Failed contraceptive methods
  • Presence of an intra uterine device.

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Pathology of Ectopic Pregnancy
  • Fertilized ovum borrows through the epithelium
  • Zygote reaches the muscular wall
  • Trophoblastic cells at zygote periphery
    proliferate, invade, and erode adjacent
    muscularis
  • Maternal blood vessels disrupted leading to
    hemorrhage
  • Outcome tubal abortion or rupture with hemorrhage

12
Tubal Pregnancy
  • Commonest site of ectopic pregnancy (99)
  • The ampulla is the most frequent location of
  • implantation (64)
  • Symptoms
  • Onset occurs 7 weeks after LMP
  • Abdominal pain
  • Vaginal bleeding
  • Signs
  • Abdominal tenderness (91)
  • 1st trimester bleeding (79)
  • Common associated findings
  • Adnexal tenderness (54) , Amenorrhea
  • Early pregnancy symptoms
  • Cullens sign (Periumbilical bruising)
  • Nausea, vomiting, diarrhea, dizziness

13
  • Other Signs
  • Tachycardia, Low grade fever
  • Chadwicks sign (cervix and vaginal cyanosis)
  • Hegars sign (softened uterine isthmus)
  • Hypoactive bowel sounds
  • Cervical Motion Tenderness
  • Enlarged uterus
  • Tender pelvic or adnexal mass
  • Cul-de-sac fullness
  • Decidual cast (Passage of decidua in one piece)
  • Signs suggestive of ruptured ectopic pregnancy
  • Usually between 6 and 12 weeks gestation
  • Severe abdominal tenderness with rebound,
    guarding
  • Orthostatic hypotension

14
Differential Diagnosis
  • Appendicitis
  • Threatened Abortion
  • Ruptured ovarian cyst
  • PID
  • Salpingitis
  • Endometritis
  • Nephrolithiasis
  • Ovarian torsion
  • Intrauterine pregnancy
  • Alternative diagnoses
  • Dysmenorrhea
  • Dysfunctional uterine bleed
  • UTI
  • Diverticulitis
  • Mesenteric lymphadenitis

15
Symptoms Signs
In a woman of child bearing age with
pelvi-abdominal pain and/ or vaginal bleeding
ALWAYS.think
Ectopic Pregnancy
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DIAGNOSIS
  • In recent years, inspite 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.

18
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.

19
Diagnostic modalities
  • Pregnancy test.
  • Urinary B-hCG sensitive, detects 25-50 ml
    I.U/ml.. Positive before missing the next period
  • Serum B-hCG Mainly used for quantitative rather
    than qualitative purposes

In 85 normal pregnancy B-hCG doubles every 2-3
days In 85 ectopic pregnancy B-hCG 65 Increase
every 2-3 days
  • 2. Pelvic ultrasound scan
  • Abdominal. Sac at 5 wks F.H. at 7 wks.. Needs
    full bladder
  • Transvaginal. A wk earlier than abdo empty
    bladder

20
METHODS OF EARLY DIAGNOSIS
At 4-5 weeks-
  • 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.

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METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5
weeks can be any of the following-
  • Poorly defined tubal ring possibly containing
    echogenic structure and POD typically containing
    fluid or blood.
  • Ruptured ectopic with fluid in the POD and an
    empty uterus.
  • In Colour Doppler, the vascular colour in a
    characteristic placental shape, the so-called
    fire pattern, can be seen outside the uterine
    cavity while the uterine cavity is cold in
    respect to blood flow

24
Diagnostic modalities
  • If early pregnancy problems. Urine B-hCG AScan
  • Intra-uterine pregnancy .GOOD
  • No Intra-uterine gestation Seen serum B-hCG
    TVS.
  • with serum B-hCG of 1500-2000 ml I.U/ml Intra
    uterine gestation should be seen using TVS
    otherwise suspect Ectopic pregnancy

3. Diagnostic Laparoscopy.
Early Pregnancy Assessment Clinic EPAC
25
Diagnostic modalities
Early Pregnancy Assessment Clinic EPAC
With Advance in diagnosis and improvement in
patient awareness ectopic pregnancy is more and
more being diagnosed in its early stages. So, to
reduce the incidence of maternal mortality and
serious morbidity this dedicated clinic is a must
in regional hospitals.
  • Patients with early pregnancy problems to report
    to
  • Facilities to perform urine and serum P.T.
    onsite
  • Facilities and expertise in performing TVS
  • Access to operating theatre and blood bank

.
26
MANAGEMENT
  • Depending on the presentation
  • Acute with ruptured ectopic and intra-abdominal
    bleeding. ABC,,, surgical approach.
  • Early stages, with intact ectopic
  • Expectant decreasing B-hCG . Tubal abortion
  • Medical Depending on size of ectopic and level
    of B-hCG.. Use methotrexate.. Not common
    approach
  • Surgical

27
Surgical Management
  • Conservative,
  • Open vs laparoscopic.. Linear salpengotomy
    vs milking of the tube
  • Radical,
  • laparoscopic vs open . salpengectomy
  • Fertility post ectopic surgery

28
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
The debate goes on
  • LAPAROTOMY?
  • VS.
  • LAPAROSCOPY?
  • SALPINGECTOMY?
  • VS
  • SALPINGOSTOMY / SALPINGOTOMY?

29
COMPARING LAPAROTOMY Vs LAPAROSCOPY
Ltomy Lscopy Hospital cost More? Less? Po
st operative adhesions More Less Risk of future
ectopic Same Same Future fertility Same
Same Experience of Surgeon Trained Special
Instruments General Special
30
SALPINGECTOMY VS 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 haemodinmically stable
  • Tubal pregnancy is accessible
  • Unruptured and lt 5Cm. In size
  • Contralateral tube is absent or damaged

31
SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY
  • The choice of surgical treatment does not
    influence the post treatment fertility, but prior
    history of infertility is associated with a
    marked reduction in fertility after treatment
  • Making the choice Chapron et al (1993) have
    described a scoring system, based on the
    patients previous gynaecological history and the
    appearance of the pelvic organs, to decide
    between salpingostomy / salpingotomy and
    salpingectomy.

32
SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY
  • Fertility reducing factor
    Score
  • Antecedent one Ectopic pregnancy 2
  • Antecedent each further
    Ectopic pregnancy 1
  • Antecedent Adhesiolysis 1
  • Antecedent Tubal micro surgery 2
  • Antecedent Salpingitis 1
  • Solitary tube 2
  • Homolateral Adhesions 1
  • Contralateral Adhesions 1

33
SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY
  • The rationale behind the scoring system is to
    decide the risk of recurrent ectopic pregnancy.
  • Conservative surgery is indicated with a score of
    1-4 only, while radical treatment is to be
    performed if the score is 5 or more.

34
  • Fertility post ectopic surgery
  • The overall subsequent conception rate in women
    with ectopic pregnancies is about 60
  • less than half of these pregnancies result in
    another ectopic or spontaneous abortion, so only
    about one third of women with ectopic pregnancies
    have subsequent live births
  • . The subsequent fertility rate is significantly
    higher in parous women younger than 30 years. If
    the ectopic pregnancy is a women's first
    pregnancy, her subsequent conception rate is only
    about 35. On the other hand, women with high
    parity (more than three pregnancies) who develop
    an ectopic pregnancy have a relatively high rate
    of conception (80). The subsequent conception
    rate is lower in women who have a history of
    salpingitis and in those who have gross evidence
    of damage to the opposite oviduct as a result of
    previous salpingitis. Future fertility is
    significantly higher in women who have unruptured
    tubal pregnancies than in those who have ruptured
    ectopic pregnancies hence, early diagnosis with
    serial hCG and ultrasound is desirable.

35
Repeat Ectopic Pregnancy
The rate of repeat ectopic pregnancy after a
single ectopic pregnancy ranges from 8 to 20,
with a mean of 15. Only about one of three
nulliparous women who have an ectopic pregnancy
ever conceives again (35), and about one third
have another ectopic pregnancy (13). After two
ectopic pregnancies, infertility rates as high as
90 have been reported
36
REMEMBER
  • Ectopic pregnancy is a life threatening
    condition on the increase
  • Not all cases present with a classical picture
  • ALWAYS suspect ectopic pregnancy in a woman of a
    child-bearing age c/o pain and/or p.v. bleeding
  • Early diagnosis and management is feasible
    EPAC, which should be available in referral
    centers
  • Tailor your management on the patient
    presentation./_ F.up

37
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