ECTOPIC PREGNANCY معدلة word

ECTOPIC PREGNANCY

DEFINITION

Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.

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

AETIOLOGY

Any 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.

CONGENITAL - Tubal Hypoplasia, Tortuosity, Congenital diverticuli, Accessory ostia, Partial stenosis

ACQUIRED -

Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (intraluminal adhesion)

Surgical: Tubal reconstructive surgery, Recanalisation of tubes

Neoplastic: Broad ligament myoma, Ovarian tumour

Miscellaneous Causes: IUCD, Endometriosis, ART (IVF & & GIFT),

Previous ectopic

CLINICAL PRESENTATION

Ectopic 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%) and 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


Cullen’s sign (Periumbilical bruising)

Nausea, vomiting, diarrhea, dizziness

Other 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

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.

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.

The 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.


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.

(here methods of early diagnosis end)

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 & 12

USG- usually haematocele is found

Laparoscopy

Initial Investigations


Monitor βhCG levels

βhCG- hormone produced by the placenta (and fetal kidney)

Detectable in plasma and urine following blastocyst implantation

Blood 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 growth

βHCG with inadequate increase may suggest ectopic pregnancy

** β-hCG level does not predict ruptured ectopic, ruptured ectopic may occur at any

β-HCG level

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

MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

Hospitalisation

Resuscitation -

Treatment of shock

Lie flat with the leg end raised

Analgesics

Blood transfusion

Laparotomy should be done at the earliest.


Salpingectomy is the definitive treatment.

(No benefit from removing Ovary along with the tube)

Options

SURGICAL-

SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT

MEDICAL TREATMENT

EXPECTANT MANAGEMENT

MEDICAL TREATMENT WITH METHOTREXATE

Ectopic 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 50 mg/m2 without Folinic acid. If serum HCG does not fall to 15% within 4-7 days, then a second dose of Methtrexate is given and resolution confirmed by HCG estimation


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

EXPECTANT TREATMENT

Today only selected cases are managed expectantly, screened and identified by high resolution ultrasound scanner and monitored by serial serum HCG assay

Criteria for this management:

initial HCG less than 250 I.U plus other criteria for medical treatment


It has high success rate reaching 70-80%.