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SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY

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In normal pregnancy, the blastocyst (fertilized ovum) implants in the ... Diverticulitis. Mesenteric lymphadenitis. Pathology of Ectopic Pregnancy ... – PowerPoint PPT presentation

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Title: SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY


1
SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY
  • Kathryn Swan
  • April 11th, 2006

2
Ectopic Pregnancy
  • In normal pregnancy, the blastocyst (fertilized
    ovum) implants in the endometrial lining of the
    uterine cavity
  • ECTOPIC Implantation of the blastocyst outside
    the uterine cavity
  • Risk Factors
  • High Tubal corrective surgery, tubal
    sterilization, previous ectopic, in
    utero DES exposure, Intrauterine device,
    tubal pathology
  • Moderate Infertility, previous genital
    infection, multiple partners
  • Slight Previous pelvic/abdominal surgery,
    smoking, douching, intercourse prior to
    18 years of age

3
Epidemiology
  • 2 of all pregnancies each year in the Unites
    States
  • Increasing incidence due to
  • Increasing prevalence of STIs
  • Early diagnosis
  • Contraception that predisposes failures to be
    ectopic
  • Use of tubal sterilization techniques
  • Use of assisted reproductive techniques
  • Tubal surgery (salpingotomy, tuboplasty)
  • Commonest cause of maternal mortality within the
    1st trimester
  • Overall incidence in non-white women is 1.4 times
    higher than in Caucasian women

4
Female Pelvic Anatomy
5
Types of Ectopic Pregnancy
Interstitial gestation implants in the
interstitial portion of the fallopian tube.
Cervical Vaginal Broad ligament
Abdominal (0.1) implantation within the
peritoneal cavity (can occur secondary to tubal
pregnancy)
 Angular A gestation that extends beyond the
interstitium into the adjacent uterine cavity
6
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

7
  • 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

8
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

9
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

10
Case History
  • Presenting Complaint
  • 23 year old female at 8 weeks gestation admitted
    for observation following a 2 week history of
    abnormal serum ßhCG levels
  • ßhCG 858U/L (normal 7000-20000 U/L)
  • Positive pregnancy test 20/12/05
  • LMP 12/11/05
  • EDD 19/08/06
  • Para 0, gravida 5

11
Other significant details of the history
  • Hx of p/c
  • ßhCG levels closely monitored for 2/52
  • No pain
  • Intermittent bleeding PV for 1/52, no clots
  • Past medical hx
  • 5 previous miscarriages
  • Chlamydia 2 yr. ago risk factor
  • Tx given, husband treated as well
  • Retest was negative
  • Medication none
  • NKDA
  • Social hx
  • married
  • Smoker (pack years unknown) risk factor
  • Other important facts that are not known
  • Sexual history ( coitrache, of partners, etc.)
  • Past menstrual hx

12
Examination
  • General appearance comfortable, no pallor
  • Vitals signs within normal limits
  • BP 95/60mmHg
  • CVS exam heart sounds 1 and 2 present, no added
    sounds or murmurs
  • Resp exam normal vesicular breath sounds
  • Abdominal
  • Normal on inspection, no visible swellings,
    scars, etc.
  • No pain on palpation
  • Bowel sounds present

13
Initial Management
  • Initial Investigations Labs and Radiology
  • Indications for procedure
  • Contraindications for Surgery
  • Patient Outcome Discussion
  • Procedure
  • Desired outcome
  • Potential Complications
  • Short Term Injury
  • Long term Injury
  • Pre-op Instructions
  • Rx/lifestyle/nutritional needs or changes
  • Psychological management
  • Legal issues

14
Initial Investigations
  • Monitor ßhCG levels
  • ßhCG- hormone produced by the placenta (and fetal
    kidney)
  • Detectable in plasma and urine following
    blastocyst implantation
  • Blood levels rise rapidly, doubling every 2d and
    plateaus at 8-10 weeks gestation
  • Serum ßHCG levels correlate with the size and
    gestational age in normal embryonic growth
  • ßHCG with inadequate increase may suggest ectopic
    pregnancy
  • Sensitivity 36
  • Specificity 65
  • ßhCG level does not predict ruptured ectopic,
    ruptured ectopic may occur at any ßHCG level

15
Serum ßhCG Levels
LOW!!!!!
16
Other Labs
  • Complete blood count
  • Leukocytosis
  • Urinalysis with microscopic exam
  • Blood Type and Rhesus
  • A negative
  • Therefore, must give anti-D (RhoGAM) prior to
    surgery

17
Imaging Studies
  • US imaging confirms the clinical diagnosis of
    suspected ectopic, location, and size
  • Findings suggestive of ectopic pregnancy
  • Absence of gestational sac at ßHCG 1800
    IU/L
  • Free fluid present (71 likelihood of ectopic)
  • Echogenic mass at adnexa (85 likelihood)
  • Echogenic mass with free fluid (100 likelihood)
  • Transvaginal vs. Transabdominal

18
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

19
Management Options
  • Expectant Management Indications
  • Minimal pain or bleeding in reliable patient
  • bHCG less than 1000 IU/L and falling
  • No signs of tubal rupture
  • Adnexal mass lt3 cm
  • No embryonic heart beat
  • Medical Management Methotrexate
    (anti-metabolite)
  • Stable vital signs with normal LFTs, CBC,
    platelets
  • Unruptured ectopic pregnancy without cardiac
    activity
  • Ectopic mass lt4 cm
  • ßHCG lt5000 IU/L
  • Surgical Management Indications
  • Failed or contraindicated non-surgical management
  • Nondiagnostic Transvaginal US and ßHCG gt1500
  • Hemoperitoneum
  • Diagnosis unclear
  • Advanced ectopic pregnancy

20
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21
Surgical Options
  • Laparoscopy
  • Key hole surgery
  • Recommended approach

Advantages Less blood loss, decreased number of
transfusions, less recovery time, less post-op
analgesia, cost effective Contraindications Absol
ute ruptured EP, haemodynamic instability,
surgeons lack of experience Relative previous
multiple pelvic surgeries, unruptured
interstitial EP, morbid obesity
22
Surgical options (contd)
  • Laparotomy
  • Surgical incision through the abdominal wall
  • Pfannensteil incision
  • Mainly used for cases involving haemodynamic
    instability

23
Actual Management
  • Day 1
  • Admitted for observation following US diagnosis
    of left tubal pregnancy
  • Day 2
  • BhCG preformed (slightly increased)
  • No change in symptoms
  • Day 3 4pm
  • Examination
  • soft abdomen
  • mild lower abdominal and suprapubic pain on
    palpation
  • Left iliac fossa pain on palpation
  • Scheduled laparoscopic removal of ectopic
    pregnancy
  • 5pm BP 110/80 mmHg, HR 84 bpm
  • ? abdominal pain ? OR within 30 min

24
Radical vs. Conservative Surgery
  • Salpingostomy (Conservative)
  • Small pregnancy (lt2cm) located in distal
    fallopian tube
  • Maximizes preservation of affected tube
  • Associated with a 5 risk or recurrence
  • Risk of tubal scarring due to incision
  • Salpingotomy
  • Same as above only incision is sutured closed
  • Salpingectomy (Radical)
  • Tubal resection
  • Segmental resection and anastomosis

25
Pre-Operative Work-Up
  • Full blood count (leukocytosis)
  • Blood group serology
  • Coagulation workup
  • Vital signs ? stable for surgery
  • Review tests
  • ßhCG- ectopic still present
  • US imaging- location, size
  • Medications
  • NKDA, GA (no allergy)

26
Patient Preparation
  • Pre-op nutrition- fasting (unless emergency)
  • Bowel prep- enema
  • Shave suprapubic hair
  • Patient information
  • Risks and complications
  • Risks of conversion to laparotomy
  • Risks of salpingectomy

27
Surgical Complications
  • The patient MUST be made aware of these risks
    when informed consent is obtained
  • Hemorrhage and hypovolemic shock
  • Infection
  • Loss of reproductive organs following surgery
  • Infertility
  • Urinary and/or intestinal fistulas following
    complicated surgery
  • Disseminated intravascular coagulation (rare)

28
Prognosis for Future Conception
  • Conception rate post-ectopic 77
  • Recurrent ectopic pregnancy risk
  • After 1st ectopic 5-20 risk
  • After 2nd ectopic 32 risk

29
Operative Requirements
  • Equipment
  • Surgical Instrument (preference list)
  • Patient Positioning
  • Procedure Overview
  • Objective laparoscopic salpingectomy
  • Procedure
  • Opening
  • Landmarks
  • Trocar placement
  • Localisation, Identification, Excision
  • Wound Closure

30
Equipment
Laparoscopic Tools
Video monitor
31
  • Bipolar grasper
  • Atraumatic grasper
  • Grasping forceps
  • Toothed forceps
  • Sharp-tipped monopolar device
  • 5-10mm suction-irrigation device
  • Scissors

32
Patient Positioning
  • Low lithotomy position
  • 30 degree Trendelenburg
  • Urinary catheter
  • NG tube (?)
  • Uterine cannulation

33
Trocar Placement for Surgery
  • 12mm optical trocar placed at umbilical level
  • and C) 5mm lateral operative trocars placed 3
    fingerbreadths above the symphysis pubis

34
  • Peritoneum is inflated with CO2
  • Needle inserted at the umbilical level (primarily
    used) OR at Palmers point (3cm below costal
    margin in midclavicular line)
  • Pressure should not exceed 14 mmHg- respiratory
    compromise

35
  • Trendelenburg postion
  • Caused the small intestine loops and sigmoid to
    move cephalically
  • Exposes the pelvis
  • Should not exceed 30 degrees
  • Uterine Manipulation
  • Anteversion (exposure of rectouterine pouch)
  • Displaced to contralateral side of ectopic

36
Exposure
  • 1st Assistant
  • Holds laparoscope
  • Pushes intestinal loops cephalically using
    grasping forceps
  • 2nd Assistant
  • Anteverts uterus and pushes it CL to the ectopic
    pregnancy

37
Exploration
  • To determine the precise location of the ectopic
    pregnancy
  • To evaluate the extent of hemoperitoneum
  • To determine the condition of the adnexa
  • Visualize active bleeding
  • Rule out any other associated pathology
  • Examine contralateral tube to rule out retrograde
    reflux and haematosalpinx

38
Anatomical Review
  • Medial tubal A.
  • Lateral tubal A.
  • Uterine A.
  • Ovarian A.

39
Laparoscopic Salpingectomy
  • Main Risk devascularization of the ovary
  • Operate close to the tube, away from ovarian
    vessels and suspensory ligament

40
  • 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

41
  • Mesosalpinx Division
  • Divide the mesosalpinx with scissors
  • Cauterize and divide the infundibulo-ovarian
    ligaments and the lateral tubal A.

42
  • 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

43
Post-operative Plan
  • Remove urinary catheter and NG tube
  • Observation and analgesia
  • Remove IV on the evening of the procedure
  • Food on evening of procedure
  • Discharge following day
  • Discuss use of contraceptives
  • Pregnancy 2-3 months post-op (2-3 cycles)
  • Information regarding the risk of ectopic
    recurrence

44
  • Follow-Up
  • Smoking cessation
  • Folic acid
  • Early pregnancy clinic _at_ 6/52 gestation in
    subsequent pregnancy
  • Investigation regarding underlying pathology due
    to past obstetrical hx

45
The End
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