Ectopic Pregnancy

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Pain in Early Pregnancy

• Ectopic Pregnancy

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ECTOPIC PREGNANCY
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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.
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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.
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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

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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
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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
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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

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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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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.

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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.

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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

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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

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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
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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

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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

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Surgical Management

• Conservative,
• Open vs laparoscopic.. Linear salpengotomy
  vs milking of the tube

• Radical,
• laparoscopic vs open . salpengectomy

• Fertility post ectopic surgery

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SURGICAL TREATMENT OF ECTOPIC PREGNANCY
The debate goes on

• LAPAROTOMY?
• VS.
• LAPAROSCOPY?
• SALPINGECTOMY?
• VS
• SALPINGOSTOMY / SALPINGOTOMY?

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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
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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

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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.

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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

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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.

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• 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.

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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
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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

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