Published on March 8, 2014
DR.CHADUVULA SURESH BABU PROFESSOR DEPT.OF OBGYN College of Medicine, Abha, KKU, KSA
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
15% with 1 ectopic 25% with 2 ectopics
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.
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 tumour Miscellaneous Causes: IUCD , Endometriosis, ART (IVF & & GIFT), Previous ectopic
SITES OF ECTOPIC PREGNANCY Abdomen (< 2%) Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Cervix (< 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 Ectopic Pregnancy 07/03/2014 16:07 8
Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic SYMPTOMS- Amenorrhea Abdominal Pain Syncope Vaginal Bleeding Pelvic Mass SIGNS- Abdominal tenderness, Cullen’s sign, Adnexal tenderness, Cervical motion tenderness Ectopic Pregnancy 07/03/2014 16:07 9
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
Appendicitis Threatened Abortion Ruptured ovarian cyst PID Salpingitis Endometritis Nephrolithiasis Ovarian torsion Intrauterine pregnancy
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. Ectopic Pregnancy 07/03/2014 16:07 12
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. Ectopic Pregnancy 07/03/2014 16:07 13
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
Complete Leukocytosis Urinalysis Blood blood count with microscopic exam Type and Rhesus A negative Therefore, must give anti-D (RhoGAM) prior to surgery
Depends on the stage of the disease and the condition of the patient at diagnosis. Options Surgery – Laparoscopy / Laparotomy Medical – Administration of drugs at the site / systemically Expectant – Observation Ectopic Pregnancy 07/03/2014 16:07 16
OPTIONS: SURGICAL SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT MEDICAL TREATMENT EXPECTANT MANAGEMENT Ectopic Pregnancy 07/03/2014 16:07 17
Trophotoxic substances used- Methtrexate (Pansky, 1989) Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486) PGF2 (Limblom, 1987) Hyper osmolar glucose solution Actinomycin D Ectopic Pregnancy 07/03/2014 16:07 18
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. Ectopic Pregnancy 07/03/2014 16:07 19
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 Ectopic Pregnancy 07/03/2014 16:07 20
Advantages – Minimal Hospitalisation.Usually outdoor treatment Quick recovery 90% success if cases are properly selected Disadvantages Side effects like GI & Skin Monitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative Ectopic Pregnancy 07/03/2014 16:07 21
Hospitalisation Resuscitation - Treatment of shock Lie flat with the leg end raised Analgesics Blood transfusion Ectopic Pregnancy 07/03/2014 16:07 22
Culdocentesis: 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 Ectopic Pregnancy 07/03/2014 16:07 23
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, autotransfusion can be done. Ectopic Pregnancy 07/03/2014 16:07 24
Carried out either by Laparoscopy / Laparotomy. The procedures are: Salpingectomy / Cornual resection / Excision Conservative surgery (in cases of Infertility & desire for pregnancy) Linear salpingostomy Linear salpingotomy Segmental resection and anastomosis Milking of the tube Ectopic Pregnancy 07/03/2014 16:07 25
The debate goes on LAPAROTOMY? VS. LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY? Ectopic Pregnancy 07/03/2014 16:07 26
SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY All tubal pregnancies can be treated by partial or total Salpingectomy Salpingostomy / Salpingotomy is only indicated when: 1. 2. 3. 4. 5. The patient desires to conserve her fertility Patient is haemodinmically stable Tubal pregnancy is accessible Unruptured and < 5Cm. In size Contralateral tube is absent or damaged Ectopic Pregnancy 07/03/2014 16:07 27
1. Medial tubal A. 2. Lateral tubal A. 3. Uterine A. 4. Ovarian A.
Main 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
LAPAROSCOPIC SALPINGECTOMY 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. Ectopic Pregnancy 07/03/2014 16:07 33
LAPAROSCOPIC SALPINGOTOMY 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) Ectopic Pregnancy 07/03/2014 16:07 34
LAPAROSCOPIC SALPINGOTOMY The tubal pregnancy is then evacuated by suction irrigation. Hemostasis of the trophpblastic bed is ensured. The tubal incision is left open. Ectopic Pregnancy 07/03/2014 16:07 35
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 Ectopic Pregnancy 07/03/2014 16:07 36
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 Ectopic Pregnancy 07/03/2014 16:07 37
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. Ectopic Pregnancy 07/03/2014 16:07 38
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