ECTOPIC PREGNANCY
By Dr.Tahani Ali* Ectopic Pregnancy
* ECTOPIC PREGNANCYDEFINITION Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.
* Ectopic Pregnancy
* INCIDENCE >1 in 100 pregnancies.Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries. USA-5 fold UK-2 fold France 15/1000 pregnancies India-1in100 deliveries Recurrence rate - 15% after 1st, 25% after 2 ectopics
* Ectopic Pregnancy
* AETIOLOGYAny factor that causes delayed transport of the fertilised ovum through the fallopian tubes. Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired.
* Ectopic Pregnancy
* 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
* Ectopic Pregnancy
* SITES OF ECTOPIC PREGNANCY1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal
Ampulla (>85%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)
* Ectopic Pregnancy
* CLINICAL PRESENTATIONEctopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic SYMPTOMS- Amenorrhea Abdominal Pain Syncope Vaginal Bleeding Pelvic Mass
Tubal Pregnancy
Commonest site of ectopic pregnancy (99%)The ampulla is the most frequent location of implantation (64%)Symptoms:Onset occurs ~7 weeks after LMPAbdominal pain Vaginal bleedingSigns:Abdominal tenderness (91%) 1st trimester bleeding (79%) Common associated findings:Adnexal tenderness (54%) , Amenorrhea Early pregnancy symptoms Cullen’s sign (Periumbilical bruising) Nausea, vomiting, diarrhea, dizzinessOther Signs: Tachycardia, Low grade fever 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
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* Ectopic Pregnancy
* METHODS OF EARLY DIAGNOSISImmunoassay utilising monoclonal antibodies to beta HCGUltrasound scanning – Abdominal & Vaginal including Colour DopplerLaparoscopySerum progesterone estimation not helpful A combination of these methods may have to be employed.
* Ectopic Pregnancy
* METHODS OF EARLY DIAGNOSISTVS 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.
At 4-5 weeks-
* Ectopic Pregnancy
* METHODS OF EARLY DIAGNOSISThe USG features of ectopic pregnancy after 5 weeks can be any of the following-
Demonstration of the gestational sac with or without a live embryo (Begel’s 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.
USG :ges sac out side the uterus
*
* Ectopic Pregnancy
* METHODS OF EARLY DIAGNOSISPoorly 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.
The USG features of ectopic pregnancy after 5 weeks can be any of the following-
* Ectopic Pregnancy
* INVESTIGATIONS-Laboratory/Chemical test –Serial quantitative beta HCG level by RIA Serum progesterone level (<5 mg/ml in ectopic pregnancy)Low levels of Trophoblastic proteins such as SPI and PAPP-, Placental protein 14 & 12USG- usually haematocele is foundLaparoscopy
Initial Investigations
Monitor βhCG levelsβhCG- hormone produced by the placenta (and fetal kidney)Detectable in plasma and urine following blastocyst implantationBlood levels rise rapidly, doubling every 2d and plateaus at 8-10 weeks gestation Serum βHCG levels correlate with the size and gestational age in normal embryonic growthβHCG with inadequate increase may suggest ectopic pregnancy**βhCG level does not predict ruptured ectopic, ruptured ectopic may occur at any βHCG level* Ectopic Pregnancy
* MANAGEMENTDepends on the stage of the disease and the condition of the patient at diagnosis.Options-Surgery – Laparoscopy / LaparotomyMedical – Administration of drugs at the site / systemicallyExpectant – Observation
* Ectopic Pregnancy
* MANAGEMENT OF ACUTE ECTOPIC PREGNANCYHospitalisation Resuscitation - Treatment of shock Lie flat with the leg end raised Analgesics Blood transfusion
* Ectopic Pregnancy
* MANAGEMENT OF ACUTE ECTOPIC PREGNANCYLaparotomy should be done at the earliest. Salpingectomy is the definitive treatment. No benefit from removing Ovary along with the tube
* Ectopic Pregnancy
* MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCYSURGICAL- SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT MEDICAL TREATMENT EXPECTANT MANAGEMENT
OPTIONS: -
* Ectopic Pregnancy
* MEDICAL TREATMENT WITH METHOTREXATEEctopic pregnancy size should be < 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
* Ectopic Pregnancy
* MEDICAL TREATMENT WITH METHOTREXATEAdvantages –Minimal Hospitalisation.Usually outdoor treatmentQuick recovery 90% success if cases are properly selectedDisadvantages-Side effects like GI & SkinMonitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative
* Ectopic Pregnancy
* EXPECTANT TREATMENTToday only selected cases are managed expectantly, screened and identified by high resolution ultrasound scanner and monitored by serial serum HCG assay Chriteria for this mangmtent. intial HCG less than 250 I.U plus other chriteria for medical treatmen It has high success rate reaching 70-80%