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Title: ectopic gestation


1
Ectopic gestation
  • Dr. Isaac Makanda

2
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.

3
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.

4
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.

5
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.

6
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

7
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.

8
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

9
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.

10
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

11
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
12
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.

13
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

14
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

15
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

16
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.

17
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.

18
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.

19
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.

20
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

21
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

22
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23
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24
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY
  • Hospitalisation
  • Resuscitation -
  • Treatment of shock
  • Lie flat with the leg end raised
  • Analgesics
  • Blood transfusion

25
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

26
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.

27
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

28
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

29
MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY
OPTIONS -
  • SURGICAL-
  • Surgically Administered Medical (SAM) Treatment
  • Medical Treatment
  • Expectant Management

30
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

31
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
32
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

33
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.

34
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

35
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.

36
  • 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.

37
  • 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)

38
LAPAROSCOPIC SALPINGOTOMY
  • The tubal pregnancy is then evacuated by suction
    irrigation.
  • Hemostasis of the trophpblastic bed is ensured.
  • The tubal incision is left open.

39
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

40
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

41
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

42
SAM TREATMENT
  • Trophotoxic substances used-
  • Methtrexate
  • Potassium Chloride
  • Mifiprostone
  • PGF2?
  • Hyper osmolar glucose solution
  • Actinomycin D

43
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.

44
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

45
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

46
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

47
ABSOLUTE C/I
  • Clinically important hepatic dysfunction
  • Clinically important renal dysfunction
  • Breastfeeding
  • Ruptured ectopic pregnancy
  • Hemodynamically unstable patient
  • Inability to participate in follow-up

48
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

49
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

50
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.

51
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.

52
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.

53
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