SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY

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SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY

• Kathryn Swan
• April 11th, 2006

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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

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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

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Female Pelvic Anatomy
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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
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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

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• 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

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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

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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

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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

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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

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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

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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

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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

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Serum ßhCG Levels
LOW!!!!!
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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

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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

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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

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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

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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
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Surgical options (contd)

• Laparotomy
• Surgical incision through the abdominal wall
• Pfannensteil incision
• Mainly used for cases involving haemodynamic
  instability

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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

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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

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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)

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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

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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)

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Prognosis for Future Conception

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

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Operative Requirements

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

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

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Patient Positioning

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

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Trocar Placement for Surgery

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

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• 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

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• 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

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Exposure

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

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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

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Anatomical Review

• Medial tubal A.
• Lateral tubal A.
• Uterine A.
• Ovarian A.

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Laparoscopic Salpingectomy

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

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• 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

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

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• 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

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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

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• 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

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The End