Ectopic pregnancy 1

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Information about Ectopic pregnancy 1

Published on March 8, 2014

Author: sureshbabuchad



 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


 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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