Ectopic pregnancy mubiru.pptxnhkvkgilguituil

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1. Ectopic pregnancy Mubiru musa Lecturer: Dr Ngozi

2. Definition The implantation of the blastocyst (fertilized ovum) outside the endometrial lining of the uterine cavity

3. Aetiology Mechanical factors Functional factors Assisted reproduction Failed contraception

4. Mechanical Factors Previous ectopic pregnancy Previous salpingitis -Agglutination of the mucosal aborescent folds with luminal narrowing or formation of blind pockets Reduced ciliation Prior PID especially by Chlamydia trachomatis ( most common risk factor) Peritubal adhesions -Cause tubal kinking and narrowing of the lumen In utero exposure to DES -Developmental tubal abnormalities (diverticula, accessory ostia and hypoplasia) Previous C/S delivery

5. Functional Factors IUD Luteal phase defects Cigarette smoking Vaginal douching Contralateral ovulation

6. Assisted Reproduction Atypical implantations are more common (corneal, extratubal, abdominal, cervical and heterotypic) GIFT IVF

7. Failed Contraception Tubal sterilization –increased 9-fold Following laparoscopic fulguration – highest rate Following hysterectomy – sperm migrated from a fistulous communication in the vaginal vault Increased relative incidence of ectopic pregnancy reported with: progestin-only oral contraceptives postovulatory high-dose estrogens to prevent pregnancy following ovulation induction

8. Tubal Pregnancy Because the tube lacks a submucosal layer, the fertilized ovum promptly burrows through the epithelium, and the zygote comes to lie within the muscular wall. At the periphery of the zygote is a capsule of rapidly proliferating trophoblast that invades and erodes the subjacent muscularis. At the same time, maternal blood vessels are opened, and blood pours into the spaces lying within the trophoblast or between it and the adjacent tissue. The tubal wall in contact with the zygote offers only slight resistance to invasion by the trophoblast, which soon burrows through it . The embryo or fetus in an ectopic pregnancy is often absent or stunted

9. Ovarian Pregnancy Spielberg Criteria The tube on the affected side must be intact The fetal sac must occupy the position of the ovary The ovary must be connected to the uterus by the ovarian ligament Definite ovarian tissue must be found in the sac wall

10. Cervical Pregnancy Rubin’s Criteria Cervical glands Cervical must be present opposite placental attachment Attachment of placenta to cervix must be intimate The placenta must be below the entrance of the uterine vessels or below the peritoneal reflection on the anteroposterior uterine surfaces Fetal elements must not be present in the uterine corpus

11. Heterotypic ectopic pregnancy Tubal pregnancy plus coexisting uterine gestation: After assisted reproduction Persistent or rising HCG after D&C for abortion Uterus larger than dates Multiple corpus luteum No vaginal bleeding with signs/symptoms of ectopic pregnancy Ultrasonographic evidence of uterine & extrauterine pregnancy

12. Uterine Changes in Ectopic Pregnancy Changes of early normal pregnancy, such as softening & enlargement of the cervix and isthmus. Lack of uterine changes does not exclude an ectopic pregnancy. Finding of uterine decidua without trophoblast suggests ectopic pregnancy but is not absolute. Arias-Stella reaction Endometrial changes characterized by hypertrophic, hyperchromatic, lobular & irregularly shaped nuclei, vacuolated, foamy cytoplasm with occasional mitoses Not specific for ectopic and may occur with normal implantation External bleeding – from degeneration & sloughing of uterine decidua

13. Clinical diagnosis Classic Triad: amenorrhea, abdominal/pelvic pain, vaginal bleeding In one study of 147 patients with ectopic pregnancy: Abdominal pain 99% Amenorrhea 74% Vaginal bleeding 56%

14. Physical Exam +/- circulatory changes Abdominal/pelvic pain with palpation 45% generalized 25% bilateral lower quadrants 30% unilateral lower quadrant +/- rebound tenderness Palpable adnexal mass (40% ) Shoulder pain (15%) Low-grade fever (10%)

15. investigation CBC- HB, WBC>30000 HCG (urine, serum) Imaging Abdominal u/s Vaginal u/s Laparascopy progestrone

16. HCG Doubles every 48 to 72 hours until it reaches 10,000 Less than 50% increase in 48 hours almost always associated with nonviable pregnancy However 17% of patients with ectopic pregnancy will have a normal HCG doubling time A falling hCG concentration is most consistent with a failed pregnancy

17. After 48-72 hours if: hCG rising normally Evaluate with TVUS HCG not rising normally pregnancy is abnormal ( ie ectopic or failed intrauterine pregnancy) HCG falling consistent with failed pregnancy

18. Discriminatory Zone Discriminatory zone is defined as the serum hCG level above which a gestational sac should be visualized by US if an intrauterine pregnancy is present In most institutions, this serum hCG level is 1500 or 2000 IU/L with TVUS Level is higher (6500 IU/L) with transabdominal ultrasound Depends on skill of ultrasonagrapher and US equipment

19. Above the discriminatory zone: absence of an intrauterine gestational sac strongly suggests an ectopic or nonviable intrauterine pregnancy Below the discriminatory zone: absence of an intrauterine gestational sac is nondiagnostic ( ie could be early viable intrauterine pregnancy, ectopic pregnancy, or nonviable intrauterine pregnancy)

20. Below discriminatory zone B-hCG, in conjunction with repeat vaginal sonography, may prove useful.

21. Imaging US signs of ectopic pregnancy include: an empty uterus cystic/solid adnexal mass dilated or thick-walled fallopian tube free echogenic fluid in pelvis extrauterine gestational sac

22. Vaginal U/S as early as 1 week after missed menses. When B-HCG >1000 mIU/mL, a gestational sac is seen half the time. Criteria include identification of a 1- to 3-mm or larger gestational sac, eccentrically placed in the uterus, and surrounded by a decidual–chorionic reaction.

23. Abd U/S A small sac suggestive of a very early pregnancy or a collapsed sac suggesting a dead fetus may actually be a blood clot or decidual cast A uterine pregnancy usually is not recognized using abdominal ultrasound until 5 to 6 menstrual weeks or 28 days after timed ovulation. Conversely, demonstration of an adnexal or cul-de-sac mass by sonography is not necessarily helpful. Corpus luteum cysts and matted bowel can have the sonographic appearance of tubal pregnancies

24. Serum Progesterone Levels A value exceeding 25 ng /mL excludes ectopic pregnancy with 97.5-percent sensitivity Values below 5 ng /mL occur in only 0.3 percent of normal pregnancies assisted reproductive techniques may be associated with higher than usual serum progesterone levels. serum levels of at least 25 ng /mL after spontaneous conception provide reassurance that an ectopic pregnancy is unlikely

25. Uterine curettage Used to differentiate between incomplete abortion and ectopic pregnancy (lacy fronds-floats in the water nd has no trophoblastic tissue in histology)

26. Medical managment Optimal candidates: willing and able to comply with post-treatment follow-up HCG concentration ≤5000 mIU/mL no fetal cardiac activity ectopic mass size less than 3 to 4 cm

27. Absolute contraindications: Hemodynamically unstable Signs of impending or ongoing ectopic mass rupture ( ie , severe or persistent abdominal pain or >300 mL of free peritoneal fluid outside the pelvic cavity) Abnormal hematologic, renal or hepatic laboratory values Immunodeficiency, active pulmonary disease, peptic ulcer disease Coexistent viable intrauterine pregnancy Breastfeeding Unwilling/unable to be compliant with post-therapeutic monitoring Do not have timely access to a medical institution

28. Relative contraindications:  High hCG concentration (>5000 more likely to experience treatment failure) Fetal cardiac activity Large ectopic size (≥3.5 cm) Peritoneal fluid

29. Medical treatment Methotrexate Folic acid antagonist Inactivates dihydrofolate reductase causes depletion of tetrahydrofolate (needed for RNA and DNA synthesis) Results in inhibition of growth of rapidly dividing cells

30. Prior to administering Methotrexate: Determine blood type Give Rhogam if indicated Obtain CBC, LFTs, renal function tests Consider uterine curettage S/E Nausea/vomiting Diarrhea, gastric upset Elevated LFTs Neutropenia (rare)

31. Single dose vs. multi-dose treatments Benefits of single dose are: decreased cost less side effects improved patient compliance no need for leucovorin rescue Benefit of multi-dose regimen is lower failure rate (success 89% vs 93%)

32. Singe dose regimen Day 1: MTX 50mg/m2 IM Day 4: HCG Day 7: repeat MTX if HCG decrease <15% from day 4 HCG level

33. Multidose regimen: Day 1: MTX 1mg/kg IM Day 2: leucovorin 0.1mg/kg Day 3: MTX 1mg/kg IM Day 4: leucovorin 0.1mg/kg Day 5: MTX 1mg/kg IM Day 6: leucovorin 0.1mg/kg Day 7: MTX 1mg/kg IM  

34. Methotrexate counseling Avoid vaginal intercourse and new conception until hCG is undetectable Avoid sun exposure to limit risk of MTX dermatitis Avoid foods and vitamins containing folic acid Avoid NSAIDs (interaction with MTX may cause bone marrow suppression, aplastic anemia, or gastrointestinal toxicity)

35. HCG should drop by at least 15% from day 4 to day 7 Approximately 15-20% of patients will require second dose of MTX (on single dose regimen) 10% risk of tubal rupture during treatment Treatment failure is defined as need for subsequent surgical intervention

36. Surgical Management Salpingostomy Used to remove a small pregnancy usually <2 cm in length and located in the distal third of the fallopian tube A 10-15 mm linear incision is made on the antimesenteric border immediately over the ectopic pregnancy, and is left unsutured to heal by secondary intention Readily performed through a laparoscope Gold standard surgical method used for unruptured ectopic pregnancy

37. Salpingotomy Procedure is the same as salpingostomy except that the incision is closed with a suture Surgical Resection & Anastomosis Sometimes used for an unruptured isthmic pregnancy

38. Cervical ectopic Cerclage Curettage and tamponade – suction curettage followed by insertion of foley catheter and vaginal pack Uterine artery embolization with gelfoam Methotrexate – first line therapy in stable women Hysterectomy – if other interventions fail

39. Persistent Trophoblast Factors that increase the risk of persistent ectopic pregnancy Small pregnancies, less than 2 cm Early therapy, before 42 menstrual days Β-hCG serum levels exceeding 3000mIU/mL Implantation medial to the salpingostomy site

40. Expectant Management Criteria: Decreasing serial β-hCG levels Tubal pregnancies only No evidence of intra-abdominal bleeding or rupture as assessed by vaginal sonography Diameter of the ectopic mass not greater than 3.5 cm

41. Outcome of Ectopic Pregnancy Tubal Pregnancy Tubal Abortion common in ampullary Abdominal pregnancy Resorbed Developing pregnancy Encapsulated mass calcified to form a lithopedian Tubal Rupture in first few weeks = isthmus up to 16 weeks = interstitial spontaneous or caused by trauma with coitus or bimanual examination

42. Abdominal pregnancy

43. Pathogenesis Almost all cases follow early rupture or abortion of a tubal pregnancy into the peritoneal cavity The growing placenta, after penetrating the oviduct wall, maintains its tubal attachment but gradually encroaches upon and implants in the neighboring serosa. Meanwhile, the fetus continues to grow within the peritoneal cavity The incidence is increased after gamete intrafallopian transfer, in vitro fertilization, induced abortion, endometriosis, tuberculosis and intrauterine devices

44. Fetal outcome Fetal malformation and deformations – facial or cranial asymmetry, or both, various joint abnormalities, limb deficiency and CNS anomalies If the fetus dies after reaching a size too large to be resorbed, it may undergo Suppuration Mummification/ Lithopedian formation Calcification

45. diagnosis Laboratory tests - An unexplained increase in the serum alpha-fetoprotein value Sonographic Criteria for abdominal pregnancy Visualization of the fetus separate from the uterus Failure to visualize uterine wall between the fetus and urinary bladder Close approximation of fetal parts to maternal abdominal wall Eccentric position (relation of fetus to uterus) or abnormal fetal attitude (relation of fetal parts to one another) & visualization of extrauterine placental tissue MRI – used to confirm abdominal pregnancy following a suspicious sonographic examination CT – superior to MRI but its use is limited because of the concern for fetal radiation

46. management In-hospital expectant management if pregnancy is diagnosed after 24 weeks Surgery may precipitate torrential hemorrhage due to the lack of constriction of hypertrophied blood vessels after placental separation Adequate blood must be immediately available and techniques for monitoring the adequacy of the circulation should be employed

47. Leaving the placenta inside the abdominal cavity may cause infection, abscess, adhesion, intestinal obstruction, and wound dehiscence, but it may be less grave than the hemorrhage that sometimes result from placental removal during surgery Methotrexate has been recommended to hasten placental involution, however its use is controversial.