ECTOPIC GESTATION

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Ectopic gestation

• Dr. Isaac Makanda

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Introduction

• Definition A pregnancy that occurs outside of
  the uterine cavity.
• The most common site of ectopic pregnancy is the
  fallopian tube.
• Most cases of tubal ectopic pregnancy that are
  detected early can be treated successfully either
  with minimally invasive surgery or with medical
  management using methotrexate.
• However, tubal ectopic pregnancy in an unstable
  patient is a medical emergency that requires
  prompt surgical intervention.

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Epidemiology

• According to the Centers for Disease Control and
  Prevention, ectopic pregnancy accounts for
  approximately 2 of all reported pregnancies .
  However, the true current incidence of ectopic
  pregnancy is difficult to estimate because many
  patients are treated in an outpatient setting
  where events are not tracked, and national
  surveillance data on ectopic pregnancy have not
  been updated since 1992.
• Despite improvements in diagnosis and management,
  ruptured ectopic pregnancy continues to be a
  significant cause of pregnancy-related mortality
  and morbidity.

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Epidemiology.

• In 20112013, ruptured ectopic pregnancy
  accounted for 2.7 of all pregnancy-related
  deaths and was the leading cause of
  hemorrhage-related mortality .
• The prevalence of ectopic pregnancy among women
  presenting to an emergency department with
  first-trimester vaginal bleeding, or abdominal
  pain, or both, has been reported to be as high as
  18.

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In Tanzania

• Ectopic Pregnancy (EP) is a serious complication
  of early pregnancy. In low-income countries (LIC)
  it is a major contributor to maternal mortality,
  although exact incidence rates are unknown, due
  to frequent misdiagnosis .
• For the same reason case fatality rates are also
  not without bias, but reported between 1 and 3.
• In high-income countries, early diagnosis can
  often be made using ultrasound and serum human
  chorionic gonadotropin level.

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Tanzania

• In LIC, it is more difficult to make right
  diagnosis, and therefore delay in diagnosis
  before and after consulting a healthcare worker
• The majority of deaths take place in the
  community or shortly after admission in a health
  institution, making EP a relevant public health
  issue .
• Diagnosis is primarily made with history taking
  and findings on physical examination.
• Diagnostic tests like chorionic gonadotropin
  level, peritoneal aspiration and ultrasound are
  used if available

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Tanzania

• A negative urine pregnancy test can rule out EP.
  Peritoneal aspiration can confirm the presence of
  blood in the abdomen making the suspicion of EP
  very high.
• This can be done with culdocentesis or abdominal
  aspiration, but only possible with a ruptured
  ectopic pregnancy.

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HISTORY

• Ectopic pregnancy was first described in 963 Ad
  by Albucasis.
• 1884 -- Robert Lawson Tait of Birmingham
  performed the first successful Salpingectomy
  operation
• 1953 -- Stromme Conservative surgery of
  Salpingostomy
• 1973 -- Shapiro Adller Laparoscopic
  Salpingectomy
• 1991 -- Young et al Laparoscopic Salpingotomy

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AETIOLOGY

• 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.

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AETIOLOGY

• 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

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SITES OF sitElocatiCTOPIC 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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Aetiology

• The fallopian tube is the most common location of
  ectopic implantation, accounting for more than
  90 of cases.
• Other sites are the abdomen (1),
• The cervix , ovary , and cesarean scar can
  occur, often resulting in greater morbidity
  because of delayed diagnosis and treatment.
• An ectopic pregnancy can also co-occur with an
  intrauterine pregnancy, a condition known as
  heterotopic pregnancy.

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Aetiology

• The risk of heterotopic pregnancy among women
  with a naturally achieved pregnancy is estimated
  to range from 1 in 4,000 to 1 in 30,000, whereas
  the risk among women who have undergone in vitro
  fertilization is estimated to be as high as 1 in
  100

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CLINICAL PRESENTATION

• Ectopic Pregnancy remains asymptomatic until it
  ruptures when it can present in two variations -
  Acute . Chronic
• SYMPTOMS-
• Amenorrhea
• Abdominal Pain
• Syncope
• Vaginal Bleeding
• Pelvic Mass

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DIAGNOSIS

• Pregnancy in the fallopian tube is a black cat
  on a dark night. It may make its presence felt in
  subtle ways and leap at you or it may slip past
  unobserved. Although it is difficult to
  distinguish from cats of other colours in
  darkness, illumination clearly identifies it.
  
• --Mc. Fadyen - 1981

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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

• Note A combination of these methods may have to
  be employed.

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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 the LNMP.
• 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-

1. Demonstration of the gestational sac with or
   without a live embryo (Begels sign) - The GS
   appears as an intact well defined tubal ring by 6
   weeks when it measures 5 mm in diameter.
   Afterwards it can be seen as a complete
   sonolucent sac with the yolk sac and the
   embryonic pole with or without heart activity
   inside.

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METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5
weeks can be any of the following-

1. Poorly defined tubal ring possibly containing
   echogenic structure and POD typically containing
   fluid or blood.
2. Ruptured ectopic with fluid in the POD and an
   empty uterus.
3. 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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MANAGEMENT

• 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

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

• Hospitalisation
• Resuscitation -
• Treatment of shock
• Lie flat with the leg end raised
• Analgesics
• Blood transfusion

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

• 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

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

• 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, auto-transfusion can
  be done.

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MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY

• INVESTIGATIONS-

• Laboratory/Chemical test
• Serial quantitative beta HCG level by RIA
• Serum progesterone level (lt5 mg/ml in ectopic
  pregnancy)
• Low levels of Trophoblastic proteins such as SPI
  and PAPP-, Placental protein 14 12
• USG- usually haematocele is found
• Laparoscopy

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MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY

• 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

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MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY
OPTIONS -

• SURGICAL-
• Surgically Administered Medical (SAM) Treatment
• Medical Treatment
• Expectant Management

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SURGICAL TREATMENT OF ECTOPIC PREGNANCY

• 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

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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 haemodynamically 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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• 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.

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• 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)

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LAPAROSCOPIC SALPINGOTOMY

• The tubal pregnancy is then evacuated by suction
  irrigation.
• Hemostasis of the trophpblastic bed is ensured.
• The tubal incision is left open.

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PERSISTENT ECTOPIC PREGNANCY (PEP)

• This is a complication of salpingotomy /
  salpingostomy when residual trophoblast continues
  to survive because of incomplete evacuation of
  the ectopic pregnancy.
• Diagnosis is made because of a raised
  postoperative serum HCG
• If untreated, can cause life threatening
  hemorrhage

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PERSISTENT ECTOPIC PREGNANCY (PEP)

• TREATMENT is by-
• Reoperation and further evacuation /
  Salpingectomy
• Administration of IM / oral Methtrexate in a
  single dose of 50 mg/m2 of body surface

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SAM TREATMENT

• Aim- trophoblastic destruction without systemic
  side effects
• Technique- Injection of trophotoxic substance
  into the ectopic pregnancy sac or into the
  affected tube by-
• Laparoscopy or
• Ultrasonographically guided
• Transabdominal
• Transvaginal
• With Falloposcopic control

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SAM TREATMENT

• Trophotoxic substances used-
• Methtrexate
• Potassium Chloride
• Mifiprostone
• PGF2?
• Hyper osmolar glucose solution
• Actinomycin D

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MEDICAL TREATMENT WITH METHOTREXATE

• 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.

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MEDICAL TREATMENT WITH METHOTREXATE

• Ectopic pregnancy size should be lt 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

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MEDICAL TREATMENT WITH METHOTREXATE

• 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

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Contraindications to Methotrexate Therapy

• Absolute Contraindications
• Intrauterine pregnancy
• Evidence of immunodeficiency
• Moderate to severe anemia, leukopenia, or
  thrombocytopenia
• Sensitivity to methotrexate
• Active pulmonary disease
• Active peptic ulcer disease

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ABSOLUTE C/I

• Clinically important hepatic dysfunction
• Clinically important renal dysfunction
• Breastfeeding
• Ruptured ectopic pregnancy
• Hemodynamically unstable patient
• Inability to participate in follow-up

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Relative Contraindications

• Embryonic cardiac activity detected by
  transvaginal ultrasonography
• High initial hCG concentration
• Ectopic pregnancy greater than 4 cm in size as
  imaged by transvaginal ultrasonography
• Refusal to accept blood transfusion

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EXPECTANT TREATMENT

• Tubal Pregnancies are known to Abort / Resolve
• Before the advent of salpingectomy in 1884,
  ectopic pregnancies were being treated
  expectantly with 70 mortality.
• Today only selected cases are managed
  expectantly, screened and identified by high
  resolution ultrasound scanner and monitored by
  serial serum HCG assay

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EXPECTANT TREATMENT

• Identification criteria (Ylostalo et al , 1993)-
• Diameter of ectopic pregnancy lt4 Cm.
• No sign of intrauterine pregnancy
• No sign of rupture by TVS
• No sign of acute bleeding by TVS
• Falling level of serum HCG at 2 day intervals
• If any deviation from the above criteria occurs,
  then emergency treatment is necessary.

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EXPECTANT TREATMENT

• Spontaneous resolution occurs in 72,while 28
  will need laparoscopic salpingostomy
• In spontaneous resolution, it may take 4-67 days
  (mean 20 days) for the serum HCG to return to non
  pregnant level.
• The percentage fall in serum HCG by day 7 is a
  better indicator than the percentage fall by day
  2.
• Warning - Tubal pregnancies have been known to
  rupture even when Serum HCG levels are low.

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SUMMARY

• 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.

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Thank you