ectopic pregnancy

A NOTE ON ECTOPIC PREGNANCY.

1. Vishnu narayanan M.R Ectopic Pregnancy

2. Definition Pregnancy where the fertilised ovum is implanted and develops outside the normal endomitrial cavity. commonest site – fallopian tube most important cause of maternal mortality in the past Also called eccysis

3. SITES OF IMPLANTATION

4. Type of EP Definition Tubal pregnancy A pregnancy occurring in the fallopian tube – most often these are located in the ampullary portion of the fallopian tube Interstitial pregnancy A pregnancy that implants within the interstitial portion of the fallopian tube Abdominal pregnancy Primary – the 1 st and only implantation occurs on a peritoneal surface Secondary – implantation originally in the tubal ostia , subsequently aborted and then reimplanted into the peritoneal surface Cervical pregnancy Implantation of the developing conceptus in the cervical canal Ligamentous pregnancy A secondary form of EP in which a primary tubal pregnancy erodes into the mesosalpinx and is located between the leaves of the broad ligament Heterotopic pregnancy A condition in which ectopic and intrauterine pregnancies coexist Ovarian pregnancy A condition in which an EP implants within the ovarian cortex

5. EPIDEMIOLOGY Incidence-1 per 300 normal pregnancy Maternal mortality-10% Increased incidence over past 2 decades esp in developed countries Due to racial factors genetic factors environmental factors social and lifestyle changes

6. AETIOLOGY Delayed transport of fertilized ovum through fallopian tube Fallopian tube offers a congenital environment for implantation M ajor causes Pelvic inflammatory diseases Most important cause Chlamydial infection leads to EP Pelvic TB is another cause Post abortal & puerperal sepsis

7. Congenital factors Tubal tortuosity , accessory ostia , diverticula & partial stenosis In utero exposure to diethyl stilboesterol Salpingitis isthimica nodosa of the tube {SIN} Tubal epithelium invades myosalpinx , forming a diverticulum Aetiology is unknown EP is probably caused by entrapment of ovum in the diverticula

8. SURGICAL PROCEDURES Tubectomy,tubal recanalisation,tuboplasty partial stenosis of the tube ventrosuspension kinking at the isthmic portion of tube Laproscopic cauterization fistulous opening in the medial end of tube 1/3 rd pregnancies after tubal sterilisation turns to be ectopic

9. CONTRACEPTIVE METHODS IUCD prevents intrauterine pregnancy more effecteively than tubal pregnancy Progesterone containing IUCD and progesterone only pills-delay tubal peristalsis and motility PREVIOUS ECTOPIC chance of second ectopic – 12% AGE - Elderly age-more at risk

10. ASSISTED REPRODUCTIVE TECHNOLOGIES-IVF - IVF involves multiple egg transferred with fluid medium. - leads to flushing of one egg into tubular lumen - can also lead to implantation in uterus along with tubal implantation- heterotopic pregnancy INDUCTION OF OVULATION - by gonadotrrophins - multiple pregnancy and ectopic pregnancy

11. FAULTY OVUM Rapid development of trophoblast leads to premature implantation in the tube. TRANSPERITONEAL MIGRATION OF OVUM Transport of ovum from the ovary to the fallopian tube on opposite side. Characterized by corpus luteum on ovary with ectopic pregnancy on opposite tube. 8% cases EXTRANEOUS CAUSES appendicitis endometriosis

12. ventrosuspension

13. Cauterisation Clamping of the tube Salpingitis ishmica nodosa

14. Pathophysiology The trophoblast develops in the fertilized ovum and invades deeply into the tubal wall- INTRAMUSCULAR IMPLANTATION ßhCG production by implanted trophoblast maintains the corpus luteum . The corpus luteum produces oestrogen and progesterone which change the secretory endometrium into decidua. The uterus enlarges up to 8 weeks and becomes soft.

15. Changes in uterus enlarged – myohyperplasia & hypertrophy endometrium shows typical histological pattern – arias stella phenomenon –Hyperplasia of glands with loss of polarity,cytoplasmic vacuolisation,hyperchromatic nucleus. absence of chorionic villi in the endometrial curettings arias stella reaction along with absence of chorionic villi ectopic pregnancy

16. Does not usually proceed to more than 10weeks > lack of decidual reaction in the tube, > the thin wall of the tube, > the inadequacy of tubal lumen, > bleeding in the site of implantation as trophoblast invades . Separation of the gestational sac from the tubal wall leads to its degeneration, and fall of ß hCG level, regression of the corpus luteum and subsequent drop in the oestrogen and progesterone level. Separation of the uterine decidua with uterine bleeding- DECIDUAL CAST

17. DECIDUAL CAST

18. Fate of tubal pregnancy 1- Tubal mole: The gestational sac is surrounded by a blood clot and retained in the tube. may remain for long period in the tube- chronic ectopic pregnancy may be gradually absorbed- involution May be expelled out through the ostia - tubal abortion

19. Tubal mole

20. 2-Tubal abortion: Common in ampullary pregnancy Separation of the gestational sac is followed by its expulsion into the peritoneal cavity through the tubal ostium with variable amount of haemorhage Complete expulsion blood collected in pouch of douglas - pelvic hematocele Incomplete expulsion diffuse intraperitoneal haemorrhage

21. 3-Tubal rupture: More common in isthmic and interstitial implantation Isthmic rupture---6-8 weeks Ampullary rupture---8-12 weeks Interstitial rupture---4 months Rupture may occur in the anti-mesenteric border of the tube→ intraperitoneal haemorrhage . If rupture occurs in the mesenteric border of the tube, broad ligament haematoma → intraligamentous pregnancy Secondary abdominal pregnancy

22. P resentation Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks

23. Clinical traid (3As) Amenorrhea ECTOPIC PREGNANCY Abdominal pain Abnormal vaginal bleeding

24. S ymptoms 1.Pain and discomfort Mainly due to intraperitoneal bleeding In the Lower back , abdomen, or pelvis. Acute agonizing/colicky Usually unilateral Shoulder pain – accumulation of blood in subdiaphramatic regions → stimulate phrenic nerve→shoulder tip pain Pain while urinating and passing bowels

25. 2.Bleeding Vaginal bleeding usually mild. Withdrawal bleeding due to decreased progesterone from corpus luteum in the failing ectopic pregnancy Internal bleeding ( haemaoperitoneum ) is due to hemorrhage from the affected tube. Dizziness, headache, weakness, fainting all may happen due to bleeding Irregular bleeding in a sexually active women should always suggestive of ectopic, until proved otherwise 3.Amenorrhea Not always present 4.Retention of urine 5.Fever,vomiting,fainting attacks

26. S igns General examination: Weakness, pallor, hypotension,thready pulse with tachycardia, tachypnea,cold extremities-features of shock S igns of early pregnancy (breast tenderness, nausea and vomiting, change of apettite …) Abdominal examination: Lower abdominal tenderness and rigidity especially on one side may be present. No mass felt Shifting dullness Distended bowels Muscle guarding-usually absent

27. Vaginal examination: 1.RUPTURED Vaginal spotting with blanched white mucous Bluish vagina and bluish soft cervix. Uterus is slightly enlarged and soft. Extreme tenderness on fornix palpation or on movement of cervix No mass usually felt Uterus floats as in water 2.UNRUPTURED Ill-defined mass with arterial pulsations Speculum or bimanual examination should not be performed unless facilities for resuscitation are available, as this may induce rupture of the tube

28. Diagnosis of ruptured ectopic patient may be in shock with pallor , tachycardia , hypotension & cold clammy extrimities Abdominal examination - all signs of intra abdominal haemorrhage cullens sign may be present Abdomen – distended with tenderness , guarding , rigidity& shifting dullness Vaginal examination – normal or bulky uterus with tenderness on moving the cervix

29. Culdocentesis A needle is inserted into the space at the top of the vagina, behind the uterus and in front of the rectum to aspirate fluid Determines if there is blood in the space behind the uterus If non-clotting blood is aspirated from the Douglas pouch , intraperitoneal haemorrhage is diagnosed. But if not, ectopic pregnancy cannot be excluded.

30. Diagnosis of unruptured ectopic pregnancy test is + ve TVS β hCG Curettage laproscopy

31. 1.TVS Intrauterine gestational sac with a yolksac and double decidual sign---INTRAUTERINE PREGNANCY Psuedosac ---ECTOPIC PREGNANCY Diagnosis made by An empty uterus An empty uterus with adnexal mass Bagel sign Presence of a gestational sac in adnexa with fetal heart

32. BAGEL SIGN

33. R ing sign — a hyperechoic ring around an extrauterine gestational sac. D

34. 2.Serum β- hCG If the test is negative (generally less than 5 IU/L), normal and abnormal pregnancy including ectopic are excluded. Test positive with 1500IU/L WITH and an intrauterine gestational sac seen—intrauterine pregnancy w/o any intrauterine sac---ectopic pregnancy If β- hCG < 1500IU/L, second assay after 48hrs If doubling after 48hrs---intrauterine pregnancy No doubling---failing/ectopic pregnancy

35. Change in the hCG Level in Intrauterine Pregnancy, Ectopic Pregnancy, and Spontaneous Abortion. An increase or decrease in the serial hCG level in a woman with an ectopic pregnancy is outside the range expected for that of a woman with a growing intrauterine pregnancy or a spontaneous abortion 71% of the time. However, the increase in the hCG level in a woman with an ectopic pregnancy can mimic that of a growing intrauterine pregnancy 21% of the time, and the decrease in the hCG level can mimic that of a spontaneous abortion 8 % of the time.

36. 3.Curettage Curettage of the uterus Flotation test---floating of chorionic villi in water Confirmed by microscopic examination of presence of villi CHORIONIC VILLI ABSENT IN ECTOPIC PREGNANCY

37. 4-laparoscopy an endoscope is inserted through a small incision in the woman’s abdomen This allows you to see the fallopian tubes and other organs This takes place in an operating room with anaesthesia Gold standard

38. DIFFERENTIAL DIAGNOSIS

39. (1) NON GYNECOLOGICAL

40. (2) Gynecologic disorders

41. Patient usually in shock- resusciation done Immediate arrangements of laparotomy with necessary arrangements like blood If tubal rupture-immediate salpingectomy If rupture at isthmial region –segmental resection of ruptured site Cornual rupture—hysterectomy TREATMENT OF RUPTURED ECTOPIC

42. Treatment of unruptured ectopic

43. INDICATIONS Clinically stable asymptomatic women Initial ß hCG < 1000IU/L and subsequent falling levels Gestational sac size <4cm No fetal heartbeat on TVS No evidence of rupture/bleeding Proper monitering of ß hCG twice weekly EXPECTANT MANAGEMENT

44. INDICATIONS Similar as in expectant management Only difference— hCG level<4000IU/L ADVANTAGES Avoidance of surgery and anaesthesia Less expense Less tubal damage Less chance of future sterility MEDICAL MANAGEMENT

45. Dosage of methotrexate SINGLE DOSE REGIME 50mg/m2 –IM/IV Baseline investigations—full bloodcount,LFT,RFT May develop abdominal cramps initially ß hCG monitoring on day 4 and 7—15% fall by 7days Folicacid tablets-C/I Postmethotrexate abdominal pain MULTIPLE DOSE REGIME Methotrexate and folinic acid on alternate days Also in persistant trophoblastic disease Less popular Ideal for cornual and cervical pregnancy

46. Laparoscopy has become the recommended approach in most cases. Laparotomy is usually reserved for patients: who are hemodynamically unstable patients with cornual ectopic pregnancies. Extensive abdominal and pelvic adhesions making laproscopy difficult SURGICAL MANAGEMENT

47. 1.Conservative surgery Indicated when woman not completed her family 5%cases— persistant ectopic noted hCG monitoring and single dose methotrexate continued after surgery Includes--1.linear salpingostomy 2.segmental resection 3.milking of the tube 2.Radical surgery—salpingectomy Indications- When the tube is not salvageable Recurrent ectopic Childbearing completed Previous sterilisation

48. Other sites

49. heterotopic pregnancy ectopic pregnancy coexist with intra uterine pregnancy incidence has ↑ sed due to ART Surgical management with continuation of intrauterine pregnancy

50. 2.Interstitial pregnancy implantation – interstitial part of tube pregnancy advance to a later date – myometrium abdominal pain & collapse – rupture of uterine wall TREATMENT-immediate laprotomy with salpingectomy wedge resection of cornua reconstruction of uterine wall if severe uterinewall damage-hysterectomy

51. 3. Intraligamentous pregnancy Rare due to penetration of tubal wall by the trophoblast & its advancement b/w the two layers of broad ligament 2 º to tubal pregnancy clinical findings are similar to abdominal pregnancy

52. 4. cornual pregnancy seen in rudimentary horn of bicornuate uterus condn very difficult to diagnose before rupture rupture is inevitable around 12 – 20 weeks with massive intraperitonial haemorrhage during laprotomy it may be confused with interstitial pregnancy round ligament is attached lateral to the sac Excision of rudimentary horn if diagnosed earlier

53. 5. Abdominal pregnancy as itself is rare –satisfy studiford criteria - 1.normal tubes &ovaries 2. no uteroperitoneal fistula 3. Pregnancy related exclusively to peritoneal surface seen secondarily after early tubal rupture or abortion implantation – peritoneum usual outcome is early rupture or death of fetus – suppuration or calcification - LITHOPEDIAN uncomfortable with nausea & abdominal pain { fetus moves } Fetal malpositions and abnormalities Braxton hicks contractions-not felt Diagnosis by ultrasound Management- laprotomy

54. Abdominal pregnancy

55. 6. Cervical pregnancy implantation – endocervical canal below the internal os rarely continues beyond 20wks & is complicated by bleeding R ubins criteria were used in the past for diagnosis 1.cervical glands opposite to placental attachment 2.placental attacment to cervix below the entrance of uterine vessels or below peritoneal reflection 3.fetal elements entirely in the endocervix 4.closed internal os and partially opened external os now first trimester US is done

56. Ultrasound criteria for cervical pregnancy Empty uterus Hourglass shape of uterus Balloned out cervical canal Gestational sac and placental tissue in cervical canal Internal os closed

57. MANAGEMENT Choice of treatment -multiple dose methotrexate Failure of medicine--

58. 7. Ovarian pregnancy very rare consequence – early rupture speigelberg criteria is used for its diagnosis 1.intact tube on affected site 2.fetal sac must occupy position of ovary 3.ovary connected to uterus by ovarian ligament 4.definite ovarian tissue in the sac wall Management-methotrexate for unruptured ovariotomy if rupture occurs

59. 8.Caesarian scar ectopic pregnancy Recently reported Ultrasound-empty uterus and cervix gestational sac attached low to the lower segment caesarian scar Diagnosis confirmed by doppler imaging Gestational sac embedded in myometrium Fibrosis of the pregnancy Management-surgery