ECTOPIC PREGNANCY obstetrics and gynaecological nursing

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1. ECTOPIC PREGNANCY PRESENTED BY G. SIVAGAMI M.Sc (N) II YEAR GCON, CHIDAMBARAM

2. INTRODUCTION The fertilization takes place in the distal portion of the fallopian tube and the ovum is subsequently transported by the contractions of the tube into the uterine cavity, aided by the fluid current imparted by the ciliated epithelium. The journey takes 3 to 4 days to reach the uterine cavity. During this period the developing ovum is nourished by the cells of the corona radiata and the secretion of the cells lining the fallopian tube. The fertilized ovum (blastocyst) normally implants in the endometrial lining of the uterine cavity. In about 95% cases ectopic gestation occurs in the fallopian tube.

3. DEFINITION An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal uterine cavity. D.C. Dutta. The fertilized ovum implants in an area other than the endometrial lining of the uterus, it is termed as ectopic pregnancy. Sadhana gupta .

4. INCIDENCE The prevalence is estimated at 1 in 40 pregnancies, or approximately 25 cases per 1000 pregnancies. In India it happens in about 0.02% pregnancies.

5. TYPES OF ECTOPIC PREGNANCY

6. SITES OF IMPLANTATION

7. PATHOPHYSIOLOGY

8. Pathophysiology cont.,

9. TUBAL PREGNANCY The incidence has increased. Almost all (97%) of extra uterine pregnancies occur in the fallopian tube. The sites in order of frequency are Ampullary Isthmic Fimbrial Interstitial

10. The reasons for tubal pregnancy are: Increased prevalence of chronic pelvic inflammatory disease. Tubal plastic operations Ovulation induction IUD use

11. ETIOLOGY Factors which are responsible for the fertilized ovum to remain in the tube are: Factors preventing or delaying the migration of the fertilized ovum to the uterine cavity Factors facilitating nidation of the fertilized ovum in the tubal mucosa. Factors preventing or delaying the migration Pelvic inflammatory disease Iatrogenic

12. IATROGENIC CAUSES Contraception failure IUD Tubal surgery sterilisation operation Intrapelvic adhesions use of progestin only pill ART : ovulation induction & IVF-ET , GIFT procedure others : Previous ectopic pregnancy Prior induced abortion Developmental defects Transperitoneal migration of the ovum.

13. FACTORS FACILITATING NIDATION IN THE TUBE Early resumption of the trophoblastic activity is probably due to premature degeneration of the zona pellucida. Increased decidual reaction Tubal endometriosis.

14. RISK FACTORS OF ECTOPIC PREGNANCY History of PID History of tubal ligation Contraception failure Previous ectopic pregnancy Tubal reconstructive surgery History of infertility ART particularly if the tubes are patent but damaged IUD use Previous induced abortion.

15. MODE OF TERMINATION

16. Depending upon the site of rupture, it is known as Intra peritoneal rupture Extra peritoneal rupture (common) (rare) The rent is situated on the roof The rent lies on the floor of or sides of the tube. the tube where the broad ligament is attached.

17. SECONDARY ABDOMINAL PREGNANCY The pre- requisities for the continuation of fetal growth outside the tube are: Perforation of the tubal wall should be a slow process Amnion must be intact Placental chorion should escape injury from the rupture Herniation of the amniotic sac with the lining ovum and the placenta should occur through the rent. Placenta gets attached to the neighbouring structures and new vascular connection should be re- established. Intestine, omentum and adjacent structures get adherent to the secondary sac.

18. Secondary broad ligament pregnancy The growth of the pregnancy is limited between the two layers of the peritoneum which may be stripped off the pelvic floor. FATE OF SECONDARY ABDOMINAL PREGNANCY Death of the ovum with complete absorption Catastrophe may occur due to separation of the placenta leading to the death of the ovum with massive intraperitoneal hemorrhage . The gestational sac may be infected & a fistulous communication with the intestine bladder, vagina or through the umbilicus may occur. The fetus die and undergoes mummification or adipocere formation or becomes calcified to form lithopaedion. Rarely, it may continue to term.

19. CLINICAL FEATURES ACUTE ECTOPIC Incidence is maximum between the age of 20 – 30 years. Prevalence is mostly limited to nulliparity or following long period of infertility. SYMPTOMS Short period of amenorrhoea of 6 -8 weeks Abdominal pain CAUSES Distension of the tube by blood Colic of the tubal muscles Peritoneal irritation

20. Clinical features cont., Vaginal bleeding Feeling of nausea, vomiting, fainting attacks even to the extent of syncope. ON EXAMINATION The patient lies quiet and conscious perspires and looks blanched. Pallor Features of shock Abdominal examination reveals – tense, tumid & tender.

21. BIMANUAL EXAMINATION Findings : Vaginal mucosa – blanched Uterus seems normal in size or slightly bulky. Extreme tenderness on fornix palpation or on movement of the cervix No mass is usually felt through the fornix The uterus floats as it in water.

22. UNRUPTURED TUBAL ECTOPIC SYMPTOMS Presence of delayed period or spotting with features suggestive of pregnancy Uneasiness on one side of the flank which is continuous or at times colicky in nature. SIGNS BIMANUAL EXAMINATION Uterus is slightly smaller than the period of amenorrhea Pulsatile small, well circumscribed tender mass may be felt through one fornix separated from the uterus. INVESTIGATIONS Transvaginal sonography Highly sensitive radio immunoassay of hcG Laparoscopy

23. USG FINDINGS BAGEL SIGN -Donut appearance TUBAL RING OF FIRE SIGN vascular around the tube sac

24. CHRONIC OR OLD ECTOPIC The onset is insidious. The patient had previous attacks of acute pain from which she had recovered or she has chronic features from the beginning. SYMPTOMS Amenorrhea Lower abdominal pain Vaginal bleeding Other symptoms : bladder irritation Dysuria, frequency or even retention of urine

25. ON EXAMINATION The patient looks ill Varying degree of pallor is present Persistent high pulse rate even during rest is a conspicuous finding. Features of shock are absent Temperature may be slightly elevated to 38 c. ABDOMINAL EXAMINATION Tenderness & muscle guard on the lower abdomen A mass in the lower abdomen may be felt which is irregular and tender CULLEN’S SIGN : dark bluish discolouration surrounding the umbilicus, if found, suggests intraperitoneal hemorrhage .

26. BIMANUAL EXAMINATION Painful and reveals Vaginal mucosa – pale Uterus seems to be normal in size or bulky. 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 . Rectal examination corroborates the pelvic findings.

27. DIAGNOSIS OF ECTOPIC PREGNANCY DIFFERENTIAL DIAGNOSIS Acute appendicitis Perforated peptic ulcer Twisted ovarian tumour Ruptured endometrial cyst Ruptured corpus luteal cyst

28. SUBACUTE (ECTOPIC) Increased awareness on the part of the clinicians is the sheet anchor in the diagnosis of old ectopic. The confusing features are : Absence of amenorrhoea Absence of vaginal bleeding Vaginal bleeding followed by pain Apparently normal general condition Presence of bilateral mass on internal examination Previous history of tubectomy operation or IUD insertion.

29. Investigations for the diagnosis of tubal ectopic pregnancy BLOOD EXAMINATION Haemoglobin ABO & Rh grouping Total white cell count & differential count ESR URINARY PREGNANCY TEST ELISA are sensitive to 10 – 50 mIU /dl of ꞵ hcG and are positive in 95% of ectopic pregnancies. .

30. WEEKS ꞵHCG NORMAL VALUE 3 weeks 5 – 50 mIU / ml 4 weeks 5 – 426 mIU / ml 5 weeks 18 – 7340 mIU / ml 6 weeks 1080 – 56500 mIU / ml 7 – 8 weeks 7650 – 229000 mIU /ml 9 – 12 weeks 25700 – 288000 mIU / ml 13 – 16 weeks 13300 – 254000 mIU / ml 17 – 24 weeks 4060 – 165400 mIU / ml 25 – 40 weeks 3640 – 117000 mIU / ml SERUM HCG ASSAYS ꞵ hcG is a glycoprotein produced by trophoblastic tissues, can be measured in the serum within 8- 12 days after fertilization. During the first 6 – 7 weeks the serum ꞵ hcG level approximately doubles every in 90% of viable intrauterine pregnancies

31. SPECIAL EXAMINATION Ultrasound Abdominal sonography / transvaginal sonography The diagnostic features are: Absence of intrauterine pregnancy with a positive pregnancy test Fluid in the pouch of douglas Adnexal mass clearly separated from the ovary Rarely cardiac motion may be see in an unruptured tubal ectopic pregnancy. Colour doppler sonography – can identify the placental shape and blood flow pattern outside the uterine cavity.

32. Combination of quantitative ꞵ hcG value and sonography TVS provides visualisation of a well formed intrauterine gestational sac as early as 4 – 5 weeks from the last menstrual period. The lowest level of serum ꞵ hcG at which a gestational sac is consistently visible using TVS is 1500 IU /l , ꞵ hcG & TAS is 6000 IU /l When the ꞵ hcG value is greater than 1500 IU /l and there is an empty uterine cavity, ectopic pregnancy is more likely. Failure to double the value of ꞵ hcG by 48 hours along with an empty uterus is very much suggestive.

33. Cont., Serum progesterone Level greater than 25 ng / ml is suggestive of viable intrauterine pregnancy whereas level less than 5 ng/ml suggests an ectopic or abnormal intrauterine pregnancy. LAPAROSCOPY Offers benefit in cases of confusion with other pelvic lesions It should be employed only when the patient is hemodynamically stable. ADVANTAGES ARE : Confirmation of diagnosis Removal of the ectopic mass using operative procedures at the same time Direct injection of chemotherapeutic agents into the ectopic mass- when medical management is decided.

34. Cont., DILATATION & CURRETTAGE Identification of decidua without villi structure is very much suggestive chorionic villi that float in normal saline as lacy fronds, is diagnostic of intrauterine pregnancy. CULDOCENTESIS Transvaginal passage of a 18 gauze needle into the posterior culde – sac in order to determine whether free blood is present in the abdomen.

35. INTERSTITIAL PREGNANCY Implantation within the tubal segment that penetrates the uterine wall results in an interstitial or cornual pregnancy. It account for about 3% of all tubal gestation Tubal rupture may not occur upto 16 weeks As the implantation located between the ovarian and uterine arteries, there is severe hemorrhage . The diagnosis before rupture is very difficult Asymmetrical enlargement of the uterus specially detected during contraction is a conspicuous finding. Hysterectomy is commonly done.

36. Management of ectopic pregnancy The type of treatment must be individualised and depends more on clinical presentation. It can be treated either medical or surgically. Both methods are effective. EXPECTANT MANAGEMENT Many ectopic pregnancies resolve spontaneously and with ꞵ hcG and endovaginal sonography ectopic pregnancy. In asymptomatic complaint patient or under hospital observation, patient sometimes can be managed expectantly if ꞵ hcG titer are low < 200 mIU / ml or decreasing and the risk of rupture is low.

37. MEDICAL MANAGEMENT METHOTREXATE Methotrexate a folinic acid antagonist has been shown to destroy proliferating trophoblast and may be effective in the medical management of small, unruptured ectopic pregnancies in asymptomatic women. CRITERIA FOR PATIENT SELECTION FOR MEDICAL MANAGEMENT No intrauterine gestational sac or fluid collection is detected by transvaginal ultrasonography the ꞵ hcG level is greater than 2000 mIU /ml, the ꞵ hcG level is rising and an ectopic pregnancy mass of 4.0cm or less without cardiac activity or 3.5 cm or less with cardiac acting is visualized. ꞵ hcG level is persistent after salphingotomy

38. METHOTREXATE DOSAGE Single dose of methotrexate 50mg/ m3/IU is given and patient is followed up by measuring ꞵ hcG level at day 4 & 7. If fall in ꞵ hcG level is > 15 % methotrexate injection is repeated weekly until ꞵ hcG level is <15 mIU /ML. But if difference is less than 15 % methotrexate injection is repeated and started as new day 1. If on 7 th day fetal cardiac activity is present, methotrexate dose is repeated and started as new day 1. If ꞵ hcG levels are not decreased or fetal cardiac activity persists after 3 dose of methotrexate surgical treatment should be done.

39. Cont., Variable dose Methotrexate 1 mg/kg IM is given on day 1, 3, 5, 7 until ꞵ hcG decreases >15% in 48 hours or 4 dose methotrexate are given. After that weekly ꞵ hcG is estimated until value is less than 5.0 mIU /ml Leukovorin 0.1 mg/kg / IM is given on day 2,4,6,8.

40. Exclusion criteria for methotrexate therapy Noncompliant patient Women who completed child bearing Peptic ulcer disease Immunodeficiency Pulmonary disease Liver disease Renal disease Blood dyscrasias Hemodynamic instability Free fluid in the cul-de-sac with pelvic pain Sensitivity to methotrexate.

41. INDICATION FOR SURGICAL INTERVENTION Persistent and worsening pain in conjuction with a hemoperitonum on ultrasound and or hemodynamic instability mandates immediate surgical intervention. RISK OF METHOTREXATE TREATMENT Actinomycin D is a more potent chemotherapeutic agent. It has been used successfully in treating a limited number of ectopic pregnancies, especially in advanced gestation. Potassium chloride, kcl injection into the fetal heart in advanced ectopic pregnancy. Mifepristone it is an antiprogestin used for pregnancy terminations. Anti – D immunoglobin should be administered by Rh- ve sensitized mothers

42. SURGICAL TREATMENT SALPHINGOSTOMY In unruptured ectopic pregnancy a small longitudinal incision is made on the antimesenteric border directly over the site of ectopic pregnancy. After removing the products, the incision line is kept open to be healed later on by secondary intention. Haemostasis is achieved by electrocautery or laser. SEGMENTAL RESECTION This is of choice in isthmic pregnancy. End to end anastomosis can be done immediately or at a later date after appropriate counselling of the patient.

43. Surgical treatment cont., PLUCKING OUT With fimbrial pregnancy, product of conception are often visible at the most distal end of the tube, which may be plucked out. SALPINGECTOMY Is done when whole of the tube damaged. Tubal resection can be performed through laparoscopy or via laparotomy, for ruptured as well unruptured ectopic pregnancies.

44. RH NEGATIVE MOTHER In Rh negative women not yet sensitized to Rh antigen, anti- D gamma globulin – 50ug (<12weeks) or 300ug (>12weeks) intramuscularly is administered soon following operation to prevent isoimmunization.

45. Prevention of recurrence of tubal pregnancy Precautions during primary surgery Removal of blood clots as far as practicable Squeezing out of blood from the contralateral tube Removal of ipsilateral ovary. b) Bilateral salphingectomy in ectopic pregnancy following tubal sterilisation.

46. ABDOMINAL PREGNANCY PRIMARY Criteria laid down by studiford to diagnose primary abdominal pregnancy are: Both the tubes and ovaries are normal without evidence of recent pregnancy. Absence of utero – peritoneal fistula Presence of a pregnancy related exclusively to the peritoneal surface and young enough to eliminate the possibility of secondary implantation following primary nidation I the tube.

47. Cont., SECONDARY Abdominal pregnancy is almost always secondary, the primary sites being tube, ovary or even the uterus. SIGNS Uterine contour is not well defined even by massaging the abdominal wall, as the Braxton – Hicks contraction is absent in abdominal pregnancy. Fetal parts are felt easily and persistent abnormal attitude ad position of the fetus on repeated examination is quite common.

48. IMAGING STUDIES Sonography X- ray examination Abnormally high position of the fetus with absence of outline of uterine shadow. Superimposition of gas shadow on the fetal skeleton. Lateral x –ray on standing position shows superimposition of fetal skeleton shadow with the maternal spinal shadow.

49. MANAGEMENT Urgent laparotomy irrespective of period of gestation. LAPAROTOMY To remove the entire sac- fetus , the placenta and the membranes. This may be achieved if the placenta is attached to a removable organ like uterus or broad ligament. If however, the placenta is attached to vital organs, it is better to take out the fetus and leave behind the placenta and the sac, after trying and cutting the cord flushed with its placental attachment. In such a situation, placental activity is to be monitored by quantitative serum hcG level and ultrasound. Complete absorption of the left behind placenta occurs through aseptic autolysis.

50. COMPLICATION Secondary haemorrhage Intestinal obstruction Infection

51. OVARIAN PREGNANCY SPIEGELBERG’S CRITERIA Tube on the affected side must be intact The gestation sac must be in the position of the ovary The gestational sac is connected to the uterus by the ovarian ligament The ovarian tissue must be found on its wall on histological examination. The embedding may occur intrafollicular or extra follicular In either types, rupture is an inevitable phenomenon and salphingo –oophorectomy is the definite surgery. Ovarian resection could be done when the diagnosis is made early.

52. CORNUAL PREGNANCY Pregnancy occurring in rudimentary horn of a bicornuate uterus, is called cornual pregnancy. Termination by rupture is inevitable between 12 – 20 weeks with massive intra peritoneal hemorrhage . It is treated either by hysterectomy excision of the horn, hysteroscopically guided suction curettage if the communication with cervix is patent, or by methotrexate depending upon the age of the woman and size of the gravid horn.

53. CERVICAL PREGNANCY When the implantation occurs in the cervical canal at or below the internal os . The bleeding is painless and the uterine body lies above the distended cervix. CLINICAL DIAGNOSTIC CRITERIA Soft, enlarged cervix equal to or larger than the fundus. Uterine bleeding following amenorrhoea without cramping pain. Products of conception entirely confined within and firmly attached to endocervix. A closed internal cervical os and a partially opened external os .

54. Cervical pregnancy Cont., CONFIRMATION Histological evidence of the presence of villi inside the cervical stroma. TREATMENT Hysterectomy is often required to stop bleeding Methotrexate therapy has been considered both systemic and direct local as an alternative or adjunct to hysterectomy Uterine artery embolization with gel foam can control haemorrhage.

55. CAESAREAN SCAR ECTOPIC PREGNANCY Ultrasound shows an empty uterus and cervix and the gestational sac attached low to the lower segment caesarean scar. Doppler imaging confirms the diagnosis. The patient presents with the clinical features of threatened abortion. The gestational sac is embedded in the myometrium. MRI is diagnostic. TREATMENT Methotrexate injection Surgery – suction curettage Hysterectomy is recommended in a multiparous woman.

56. TREATMENT OF ECTOPIC TUBAL PREGNANCY

57. Cont., Following medical management Follow up with hcG successful hcG rising or plateau or bleeding Laparotomy

58. SUMMARY So far we have discussed about the definition of ectopic pregnancy, pathophysiology, types, sites of implantation, tubal pregnancy, interstitial pregnancy, abdominal pregnancy, ovarian pregnancy, cornual pregnancy, cervical pregnancy, caesarean scar pregnancy and its managements.

59. CONCLUSION Ectopic pregnancy is still the leading cause of death in the first trimester of pregnancy. A high index of suspicion is required for an early diagnosis because signs and symptoms are not specific. Expectant management is suitable in a limited number of cases.

60. Theory application LYDIA E HALL’S CARE, CURE, CORE THEORY

61. JOURNAL APPLICATION Andola shruthi . Kumar R. Ramesh, Desai, Ratnamala m. S.A. Kruthika (2021) conducted a prospective study among 42 patients to “assess the risk factors and treatment modalities of ectopic pregnancy” for a period of one year over the patients who were diagnosed as ectopic pregnancy in the reproductive age group of 15 – 44 yrs were included. Among the 42, risk factors were found in 37 patients, of which most common were white discharge per vagina in 20 & tubectomy in 6, PID in 5 and no risk factors in 5 patients. Among the 42 patient, 37 underwent surgery as primary modality of treatment and 5 patient underwent medical management, 2 had complete resolution with medical management, 3 failed medical management. The author concluded as the incidence of ectopic pregnancy has been on the rise, screening of high risk cases, early diagnosis and early intervention are required to enhance maternal survival and conservation of reproductive capacity.

62. ASSINGNMENT A 25 yr old woman at 6 weeks of amenorrhoea, comes to the gynaec OPD with complaint if off and on lower abdominal pain. Her UPT was positive at home. Abdominal and per vaginal examination is unremarkable. USG shows an empty uterine cavity. Write an assignment on what is the next step in management for the woman?