Looking For Love in All the Wrong Places

1
Looking For Love in All the Wrong Places

• Greg Gard
• Romy Busbridge
• Andrew McLennan
• Alastair Morris
• Collette Johnson

2
Mrs AG

• 27 years old
• Lives with Husband
• No children
• Wishing to start a family

3
Past Medical History

• Fit and well
• One previous pregnancy
• 2006 Spontaneous Abortion
• 7 weeks gestation
• Suction Curettage
• Pap tests regular, normal
• Regular 28 day cycles

4
Social History

• Medication
• Nil regular medication
• Allergies
• Nil known allergies
• Non-smoker
• Non-drinker

5
Presentation

• Initially presented to General Practitioner
• Gravida 2 Para 0
• 73 weeks gestation
• 1 week history of vaginal bleeding
• 3 day history of mild pelvic pain
• Ultrasound Left cornual pregnancy
• Seen at RNSH Same Day
• Further vaginal bleeding
• Nil abdominal pain
• Regular 28 day cycle
• Haemodynamically stable

6
Investigations

• Hb 118 EUC Normal
• FBC LFTs Normal
• ßHCG 17180
• Transabdominal Transvaginal ultrasound
• Left cornual pregnancy
• Gestational sac at the left cornual area ,
  containing single live embryo
• Gestational sac 72x48x61mm
• Embryo crown rump length (CRL) 9mm
• Gestational age 7 weeks
• Heart motion detected
• Blood within uterine cavity
• No haemoperitoneum

7
Cornual (interstitial) ectopic pregnancy

• Andrew McLennan
• VMO, Maternal Fetal Medicine Unit, RNSH
• Partner, Sydney Ultrasound for Women

8
The sonologists credo

1. All women are pregnant until proven otherwise
2. All pregnancies are ectopic until proven otherwise

On average, one woman dies in Australia each year
due to complications arising from ectopic
pregnancy. Most women will NOT have risk factors.
9
Typical referral

• LMP uncertain, ßhCG 210 iu/l, pelvic pain
  bleeding exclude ectopic
• ßhCG ve 9 days post-conception
• Rarely see an intrauterine gestational sac on
  ultrasound until ßhCG gt 1000 iu/l
• Need to differentiate early IUP from failing
  pregnancy (IUP or ectopic) from ectopic
• Classic triad of pain, bleeding and adnexal mass
  present in only 45 of ectopics
• Uncommon to achieve diagnosis in this
  circumstance at the first scan - most need serial
  ßhCG assessments and review ultrasound

10
Where is the pregnancy?
IUP GS vs pseudogestational sac Heterotopic
twin pregnancy
11
When is a mass an ectopic?

• Mass position, character
• Ring of fire
• Mobility
• Bowel
• Free fluid

Mass LO
12
Ectopic sites types
13
Insterstitial region

• The component of the Fallopian tube within the
  myometrium

14
Cornual (interstitial) ectopic

• 3 of ectopics -gt 1 in 6000 pregnancies
• GS not surrounded by at least 5mm of myometrium
  in all planes

15
Cornual (interstitial) ectopic

• Morbidity / mortality higher
• Later diagnosis
• Potential for massive haemorrhage

16
Surgical options in the management of tubal
ectopic pregnancy

• Alastair R. Morris
• MBChB, MRCOG, FRCSEd, FRANZCOG, MD
• 30th June 2009

17
General comments

• Increased frequency
• Change in presentation
• Advances in equipment
• Improved training
• Confidence with newer techniques

18
From de Mouzon et al, 1988
19
Indications for surgical treatment

• Haemodynamic instability
• Rupture likely

• Heterotopic pregnancy
• Tubal disease?IVF
• Contraception

• Medical therapy
• Not available
• Contraindications
• Failed
• Compliance unlikely
• Ease of access

20
Advantages of surgical treatment

• May be lifesaving
• Still leading direct cause of maternal mortality
  in first trimester
• Rapid resolution
• Generally day case surgery
• Allows inspection of pelvis
• Appearance of tubes
• Other pathology
• Endometriosis
• PID
• Salpingectomy if proceeding to ART

21
Disadvantages of surgical management

• General anaesthetic
• Intraperitoneal procedure
• Operative complications
• Bowel
• Vascular
• Ureteric
• Infection
• Scarring

22
Possible surgical pathways
Laparotomy
Laparoscopy
vs
Salpingectomy
Salpingostomy
Fimbrial evacuation Milking
Nil false positive or tubal miscarriage
23
Practical considerations in selecting the
surgical approach

• Experience of surgeon
• Experience of the team
• Physical characteristics of patient
• BMI
• Previous surgery
• Equipment
• Location of hospital
• Backup

24
Laparotomy vs laparoscopy
Level 1a evidence to support the use of
laparoscopy

• 3 randomised trials (n228)
• Shorter operating time
• Less blood loss
• Shorter hospital stay
• Reduced analgesic requirement

Lundorff et al Fertil Steril 199155911-5 Murphy
AA et al Fertil Streil 1992571180-5 Vermesh et
al Ostet Gynecol 198973400-4
25
The unstable patient

• Generally laparotomy
• However, laparoscopy possible if has
• Adequate resuscitation
• Blood available
• Experienced surgeon
• Good assistant
• Rapid entry guaranteed
• Suitable equipment
• Suction
• Anaesthetist happy !!!!!!!

26
Salpingostomy or salpingectomy?

• Depends on
• Past history
• Possibility of ART
• Patient wishes
• Surgical circumstances

However, no RCTs available
27
What if the contralateral tube appears healthy?
Level 2a evidence to support salpingostomy

• Silva et al Fertil Steril 199381710-5
• N143, salpingectomy 55.9, salpingostomy 36.4
• Subsequent IUP rate 60 vs 54, RR1.11 95 CI
  0.74-1.68
• Recurrent ectopic 18 vs 8, RR 2.38, 95 CI 0.57
  10.01
• Bangsgaard et al BJOG 2003110765-70
• N276 followed over 7 years
• Cumulative pregnancy rate 89 vs 66 (plt0.05)
• Hazard ratio for IUP less after salpingectomy
• 0.63 (95 CI 0.421-0.940)

28
What if the contralateral tube appears healthy?

• Job-Spira et al Hum Reprod 19961199-104
• N155, 60 conservative, 30 salpingectomy, 10
  ruptured
• Mean follow up 16 months
• Overall 70 pregnancy rate in next 12 months in
  those trying
• 72.4 after conservative Rx
• 56.3 after salpingectomy
• Hazard ratio 1.22, 95 CI 0.68-2.20

From Job-Spira et al, 1996
29
What if the contralateral tube is damaged?
Level 2a evidence to support salpingostomy

• Shows a trend toward higher pregnancy rates with
  salpingostomy
• Silva et al 1993
• 49 vs 27
• Mol et al 1998
• FRR 3.1 (95 CI 0.76 12)
• Bangsgaard et al 2003
• Hazard ratio 0.463 (95 0.262 0.820)

30
The down side of salpingostomy

• Actually quite difficult
• Damage from excessive diathermy
• Tracking of HCG
• Non resolution in 8

31
Live births per blastocyst transfer at 5 days
Adapted from web site, large local infertility
service
32
Surgery for cornual ectopics

• Uncommon
• Traditionally laparotomy and wedge resection
• Needs experienced laparoscopic surgeon and team
• Equipment crucial
• Vasopressin highly desirable
• Caesarean section

33
Take home messages

• If surgery is undertaken, a laparoscopic approach
  should be underaken
• No RCTs comparing salpingectomy vs salpingostomy
• Status of contralateral tube is important
• Over 90 of spontaneous pregnancies after
  surgical Rx of EP are within 18 months
• Consider ART for older patients with risk factors

34
Medical ManagementEarly Pregnancy Assessment
Service (EPAS)

• Collette Johnson
• Registrar

35
RNS Early Pregnancy Assessment Service (EPAS)

• Phone- 9926 5799
• Fax- 9926 5795
• Level 3, Outpatients Dept.
• Royal North Shore Hospital

36
EPAS Aims

• Reduce the need for inpatient care
• Reduce the need for emergency intervention
• Facilitate the early diagnosis of ectopic
  pregnancy
• To provide support for those who suffer a
  pregnancy loss
• Reassure patient with ongoing pregnancies.

37
EPAS

• Early assessment of PV bleeding in pregnancy
  without triage
• Access to nursing and obstetric care
• Access to social work
• Access to tertiary ultrasound, blood tests and
  timely review.
• Access to conservative, medical and surgical
  management options.

38
Ectopic PregnancyAdvantages of Medical Therapy

• Outpatient treatment
• Avoid surgery
• Cost effective
• Preservation of tube

39
RNSH Current Criteria for Methotrexate

• Haemodynamically stable
• Baseline serum ß-hCG lt3000IU
• Ectopic lt3cm on transvaginal US
• No fetal heart rate on TV US
• No significant haemoperitoneum

40
Exclusion Criteria

• Active liver disease
• Aplastic anaemia
• Thrombocytopenia
• Potential non-compliance to follow-up
• Presence of fetal heart motion
• Mass gt3cm or significant haemoperitoneum

41
Methotrexate

• Folic acid antagonist, inhibiting the action of
  dihydrofolate reductase, thereby blocking
  conversion of folate to folinic acid.
• Single IM dose of 50mg/m²
• Folinic acid rescue given 24 hours after dose

42
Methotrexate

• For cornual and cervical ectopics, a multi-dose
  regime may be considered
• Side effects include mouth ulcers and ulceration
  of the GIT, conjunctivitis, diarrhoea and skin
  rashes
• It takes between 8-109 days for serum ß-hCG to
  normalise

Interventions for tubal ectopic pregnancy
(Review) The Cochrane Library 2006, Issue 4
43
Outcomes

• 14 will require a second dose
• 10 will require an operation
• 70 of patients will get some pain as the
  pregnancy involutes
• Single dose regime- 87 success
• Repeat dose regime- 93 success but more side
  effects

Interventions for tubal ectopic pregnancy
(Review) The Cochrane Library 2006, Issue 4
44
RNSH Data 2007-2009

• 25 cases treated with MTX
• 21 meet current criteria
• 16 required a single dose
• 5 required 2 doses
• 7-88 days for ß-hCG to normalise
• No complications documented

45
RNSH Data 2007-2009

• 4/25 did not meet current criteria
• 1 case ß-hCG gt3000
• 3 pregnancies gt3cm size
• All single dose therapy
• No complications
• 26-45 days to resolve

46
Cornual Ectopic Pregnancies

• 4 cases treated with methotrexate
• 2 cases
• Resolved with a single dose
• Time to resolution 63, 64 days
• No complications

47
Cornual Ectopic Pregnancies

• 1 case- heterotopic pregnancy,
• US- left cornual pregnancy and failed
  intrauterine gestation at diagnosis
• Single dose of methotrexate
• ß-hCG plateau and ongoing vaginal bleeding
• US showed resolution of cornual pregnancy, but
  missed miscarriage
• Curettage attended day 12

48
Cornual Ectopic

• 39 year old woman
• Cornual Pregnancy at 9 weeks gestation
• Treated with repeated Methotrexate
• bHCG declined but plateau
• Admitted at 17 weeks gestation with abdominal
  pain
• Haemoperitoneum, impending rupture
• Hysterectomy performed

49
Management

• Ultrasound guided dilatation and evacuation of
  uterus
• General Anaesthetic
• Cervix dilated (Hegar No 8)
• Sac ruptured with forceps
• Products of conception removed with forceps
  suction
• Laparoscopy performed to exclude perforation
• No free fluid seen in pelvis
• Foley catheter balloon inflated in uterine cavity
• Products of conception confirmed via
  histopathology

50
Management

• Day 0 post DC
• Methotrexate 50mg/m2 IM
• No pain
• Minimal per vaginal bleeding
• Day 1 post DC
• Folinic acid rescue 7.5Mg PO QID
• Foley catheter removed
• Minimal abdominal pain
• Day 2 post DC
• Pain free
• Discharged for follow-up in gynaecology clinic in
  1week

51
Follow-up

• Gynaecology Clinic
• 1 week post op
• Nil complaints
• Repeat ßhCG 17000 (? 17180)
• 3 months for bHCG to normalise
• Subsequent hysterosalpingogram shows blocked tube
  on left side. Normal patency on right

52
Conclusion

• Cornual pregnancy is difficult management dilemma
• Patient care is individualised
• Novel technique which is safe and reproducible