ECTOPIC PREGNANCY

In ectopic pregnancy, implantation occupies at a site other than the endometrium. Ectopic pregnancies are responsible for approximately 10 percent of all maternal mortality. The prognosis for future reproduction is poor. Only one half of women having an ectopic pregnancy are eventually delivered of a liveborn infant. Various factors contribute to ectopic pregnancies, the most common being infection. Unlike intrauterine spontaneous abortions, genetic factors are not paramount in the etiology of ectopic pregnancy.

1. INTRODUCTION Implantation occupies at a site other than the endometrium. Responsible for approximately 10% of all maternal mortality. Poor prognosis for future reproduction. Various factors contribute to ectopic pregnancies, the most common being infection.

2. DEFINITION An ectopic pregnancy is defined as the implantation and development of the blastocyst at a site other than the endometrial lining of the uterine cavity.

3. INCIDENCE The incidence of ectopic pregnancy is about 1% but about 2% in women undergoing assisted reproductive techniques.

4. SITES

5. TUBAL PREGNANCY In this condition pregnancy occurs in the fallopian tube. R easons - Chronic PID, tubal plastic operations, ovulation induction and IUD use. Early diagnosis & therapy reduce maternal deaths. Incidence varies from 1 in 300 to 1 in 150 deliveries.

6. ETIOLOGY Infections Congenital factors Salpingitis isthmica nodosa of the tube Failed contraception Previous tubal surgery Assisted reproductive technology Previous ectopic

7. FATE OF ECTOPIC PREGNANCY Intraperitoneal bleeding Extraperitoneal bleeding with broad ligament hematoma Secondary abdominal pregnancy

8. Mode of termination of tubal pregnancy

9. CLINICAL TYPES C linical types are correlated with the morbid pathological changes in the tube subsequent to implantation and the amount of intraperitoneal bleeding. Three types are described: Acute Unruptured Subacute (chronic or old)

10. ACUTE ECTOPIC PREGNACY An acute ectopic is fortunately less common (about 30%) & it is associated with cases of tubal rupture or tubal abortion with massive intraperitoneal hemorrhage .   Mode of onset - A cute .   Symptoms Abdominal pain (100%) Amenorrhea (75%) Vaginal bleeding (70 %).

11. UNRUPTURED TUBAL ECTOPIC PREGNANCY The physician should include ectopic pregnancy in the differential diagnosis when a sexually active female has abnormal bleeding and/or abdominal pain. Symptoms Delayed period or spotting with features suggestive of pregnancy. Uneasiness on one side of the flank.

12. UNRUPTURED TUBAL ECTOPIC PREGNANCY Signs Bimanual examination: Uterus is usually soft showing evidence of early pregnancy. Pulsatile small, well-circumscribed tender mass may be felt through one fornix separated from the uterus. Investigations: T ransvaginal sonography (TVS), highly sensitive radio- immunoassay of b- hCG and laparoscopy .

13. CHRONIC OR OLD ECTOPIC Onset The onset is insidious. The patient had previous attacks of acute pain from which she had recovered or she had chronic features from the beginning .

14. CHRONIC OR OLD ECTOPIC Symptoms Amenorrhoea Pain Irregular vaginal bleeding Vasomotor symptoms Other symptoms: Features of bladder irritation like dysuria Frequency or even retention of urine Rise of temperature due to infection

15. On Examination : Abdominal Examination : Tenderness and muscle guard on the lower abdomen especially on the affected side are a striking feature. Irregular & Tender m ass felt in the lower abdomen. Cullen‘s sign—Dark bluish discoloration around the umbilicus, if found, suggests intraperitoneal haemorrhage.

16. On E xamination Bimanual E xamination is painful and reveals: Vaginal mucosa—pale. Uterus seems to be normal in size or bulky, often incorporated in the mass occupying the pelvis. Extreme tenderness on movement of the cervix. An ill-defined, boggy and extremely tender mass is felt through the posterolateral fornix extending to the pouch of Douglas. Examination under anaesthesia (EUA) is helpful to evaluate the pelvic findings but accidental tubal rupture may be provoked during manipulation.

17. INVESTIGATIONS Routine blood examination should be done for: Haemoglobin ABO or Rh grouping Total white cell count and differential count ESR: ESR may be high. Human chorionic gonadotropin assays Laparoscopy Laparotomy

18. INVESTIGATIONS Ultrasound imaging : Transvaginal ultrasonography ( TVS) An empty uterus. An adnexal mass S light fluid in the cul-de-sac due to leaking from an unruptured ectopic. Bagel sign. Foetal heart in adnexal mass can be seen in 10% cases. Colour Doppler ( ring-of-fire pattern). Corpus luteum is usually on the same side in an ectopic

19. MANAGEMENT OF ECTOPIC PREGNANCY Evolved from a radical operative approach (salpingectomy) to a more conservative surgical or medical treatment. Type of treatment must be individualized and depends more on clinical presentation

20. ACUTE ECTOPIC Antishock treatment: Ringer’s solution (crystalloid) is started. Blood transfusion. After drawing the blood samples for grouping and cross matching, volume replacement with colloids ( hemaccel ) is to be done. Laparotomy: Indications of laparotomy are: Patient hemodynamically unstable. Laparoscopy contraindicated. Evidence of rupture. The principle in laparotomy is “quick in quick out”.

21. CHRONIC ECTOPIC All cases of chronic or suspected ectopic are to be admitted as an emergency. Patient is kept under observation, investigations are done and the patient is put up for laparotomy. The affected tube is identified and salpingectomy is commonly done.

22. UNRUPTURED TUBAL PREGNANCY EXPECTANT MANAGEMENT: Where only observation is done hoping spontaneous resolution. Indications are: Initial serum hCG level less than 1,000 IU/L and the subsequent levels are falling. Gestation sac size less than 4 cm. No foetal heart beat on TVS. No evidence of bleeding or rupture on TVS.

23. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE MANAGEMENT : May be either medical or surgical. Otherwise salpingectomy is done. The advantages of conservative management are: Significant reduction in operative morbidity. Improved chance of subsequent intrauterine pregnancy. Less risk of recurrence.

24. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE MEDICAL MANAGEMENT : Number of chemotherapeutic agents have been used either systemic or direct local as medical management of ectopic pregnancy. The drugs commonly used for salpingocentesis are: Methotrexate Potassium chloride Prostaglandin (PGF2α) Hyperosmolar glucose or actinomycin .

25. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE MEDICAL MANAGEMENT : The patient must be: Hemodynamically stable. Serum hCG level should be less than 3,000 IU/L. Tubal diameter should be less than 4 cm without any foetal cardiac activity. There should be no intra-abdominal hemorrhage . For systemic therapy, a single dose of methotrexate (MTX) 50 mg/M2 is given intramuscularly.

26. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE MEDICAL MANAGEMENT : Monitoring is done by measuring serum b- hCG on day 4 and day 7. If the decline is less than 15%, a second dose of MTX 50 mg/M2 is given on day 7. Variable dose methotrexate (MTX) includes: MTX – 1 mg/kg IM on day 1,3,5,7 Leucovorin 0.1 mg/kg IM on day 2,4,6,8 Serum b- hCG is monitored weekly until less than 5.0 mIU / mL.

27. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE SURGICAL MANAGEMENT : Indications : Cases not fulfilling the criteria of medical therapy. Cases where b- hCG levels are not decreasing despite medical therapy. persistent foetal cardiac activity.

28. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE SURGICAL MANAGEMENT : Different types of conservative surgery - Linear Salpingostomy Linear Salpingotomy Segmental Resection Fimbrial Expression: ideal in cases of distal ampullary ( fimbrial ) pregnancy. Salpingectomy is done when whole of the affected tube is damaged contralateral tube is normal future fertility is not desired.

29. UNRUPTURED TUBAL PREGNANCY CONSERVATIVE MANAGEMENT : . Estimation of b- hCG should be done weekly till the value becomes less than 5.0 mlU / mL. Following laparoscopic salpingostomy , persistent ectopic pregnancy ranges between 4% and 20%. Persistent ectopic pregnancy is due to incomplete removal of trophoblast. It is high after fimbrial expression and in cases where initial serum b- hCG level is greater than 3,000 IU/L. Prophylactic single dose MTX (1 mg/kg) IM is effective to resolve the problem.

30. Prevention of recurrence of Tubal Pregnancy Incidence of subsequent intrauterine pregnancy (IUP) is 60–70 %. I ncidence of subsequent ectopic pregnancy is about 10–20% and successful conception is about 60%. Salpingostomy done decrease the risk of ectopic pregnancy compared to salpingectomy. Conservative surgery for unruptured tubal ectopic pregnancy is beneficial. Future advice: Whenever there is amenorrhea, pregnancy test is done and if positive, high resolution TVS is done to know the site of pregnancy.