Ectopic pregnancy.pptx

educative

1. Ectopic pregnancy Ms. Nelly Nzingo

2. Ectopic Pregnancy

3. Objectives By the end of this session, the learner should be able to: Define the term ectopic pregnancy Identify various implantation sites Classify the risk factors for ectopic pregnancy as either congenital or acquired Describe the pathophysiology of ectopic pregnancy Identify the signs and symptoms and clinical presentation of ectopic pregnancy Discuss the management of ectopic pregnancy Identify complications of ectopic pregnancy

4. Definition An ectopic pregnancy is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. Usually ectopic pregnancies are not only viable but are also very dangerous for the mother as it used to be followed by a massive internal bleeding.

5. Risk factors Any factor that causes delayed transport of the fertilised ovum through the tube. Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired.

6. CONGENITAL FACTORS Tubal Hypoplasia Congenital diverticular Partial stenosis Intramural polyp

7. ACQUIRED FACTORS Increasing age >35 years PID Tubal ligation Contraception failure Previous ectopic pregnancy Tubal reconstructive surgery Seeking treatment procedures for Fertility (IVF )

8. Previous abortions Tubal endometriosis. Cigarette smoking Fibroids Trans peritoneal migration of ovum Multiple abortions History of STI like Chlamydia and Gonorrhea ACQUIRED FACTORS

9. Pathophysiology In normal pregnancy: the ovum during ovulation is carried by the ciliary action of the fimbria to t he ampulla where fertilization occurs. The zygote develops and remains in the fallopian tubes for 3-4 days as it continues dividing rapidly till it reaches the morula stage It becomes the embryo and begins to travel to the uterus where it penetrates the endometrium (implantation) around the 6 th day. Delay or obstruction of passage of the fertilized egg down the fallopian tube to the uterus may result in implantation elsewhere .

10. Pathophysiology Trophoblast develops in the fertilized ovum and invades the tubal wall Hcg is produced to maintain corpus luteum which in turn produces estrogen and progesterone. These change the endometrium into decidua, and the uterus enlarges up to the 8 th week. In the tube, the pregnancy cannot advance beyond week 10 because: Thin wall of the tube Tubal lumen is small in size Bleeding in the implantation site as the trophoblast invades

11. Pathophysiology The gestational sac is detached from the tubal wall causing its degeneration and a fall in Hcg levels and further decrease in estrogen and progesterone This leads to bleeding of the uterine decidua Fate of the tubal pregnancy: Tubal mole : the gestational; sac becomes surrounded by blood clots and is retained in the tube to become a chronic ectopic pregnancy Tubal abortion : there is expulsion of the gestational sac if implanted in the ampulla into the peritoneal cavity. Bleeding may be present or absent Tubal rupture : occurs if implantation was in the narrow isthmus and causes profuse bleeding (intraperitoneal bleeding)

12. Signs and symptoms Nausea and breast soreness like in a normal uterine pregnancy Sharp waves of pain in the abdomen, pelvis, shoulder and neck Severe pain that occurs in one side of the abdomen Light to heavy vaginal bleeding or spotting (vaginal bleeding or hematoperitoneum ) Dizziness or fainting due to the bleeding Pain while micturition and having a bowel movement

13. ACUTE ECTOPIC PREGNANCY

14. CHRONIC ECTOPIC PREGNANCY Patient would have recovered from previous attack of acute pain. Pt may present with amenorrhoea, dull aching lower abdominal pain, vaginal bleeding, dysuria, frequency of micturation or retention of urine and rectal tenesmus.

15. On examination : General examination: signs of early pregnancy Abdominal examination: lower abdominal tenderness and rigidity on one side Vaginal examination: bluish cervix that is soft, marked pain in one iliac fossa on moving the cervix from side to side NB: SPECULUM OR BIMANUAL EXAM SHOULD BE AVOIDED AS IT MAY INDUCE RUPTURE OF THE TUBE

16. INVESTIGATIONS  blood investigation.   Hcg . SPECIAL INVESTIGATIONS  Ultrasound culdocentsis  Laparoscopy  Laparotomy  Dilatation & Curettage  Magnetic Resonance Imaging

17.  HCG : It is produced by trophoblasts which can be detected in the serum of the mother in the first week after implantation. Its level doubles every 36-48 hours in a normal pregnancy starting fom 5 reaching up to 1500 IU/L. When hCG level < 1000 IU/L doubling time help to predict viable vs nonviable pregnancy. NB: the level of hCG doubles after every 3 days in a normal pregnancy but are reduced in an ectopic pregnancy .

18. Serum progesterone level Levels less than 5ng/ml are considered abnormal but for a normal developing pregnancy the levels are greater than 25ng/ml.

19. MANAGEMENT: MEDICAL MANAGEMENT: The administration of methotrexate intramuscularly may be a suitable treatment for ectopic pregnancy in certain circumstances. Methotrexate is an antimetabolite which inhibits DNA synthesis and stops cells from dividing . Administering a single 75mg IM ( in buttock or lateral thigh) injection of methotrexate is a suitable treatment for a small unruptured ectopic pregnancy in cases where beta hcg is<2000IU/ml .

20. Methotrexate Single-dose regimen: Day Management Day 0 - Serum hCG , FBC, U&E’s, LFT’s Day 1 - Administer intramuscular methotrexate 50 mg/m Day 4 - Serum hCG , FBC, U&E’s, LFT’s Day 7 - Serum hCG , FBC, U&E’s, LFT’s 2nd dose of Methotrexate if hCG increase, levels plateau or rise. Reassess the woman’s condition for further management. A second dose of Methotrexate may be given at 7 days if hCG levels fail to fall by more than 15% between day 4 and day 7 (14% of medically treated patients will require more than one dose of Methotrexate).

21. SUITABLE CRITERIA: normal renal and liver function serum hcg less than 3000iu/ml. minimal or mild symptoms only no evidence of haemoperitoneum ectopic mass less than 5cm diameter. no evidence of fetal activity.

22. Health education for patients on methotrexate Side effects of the methotrexate are minimal but may include nausea, vomiting and stomatitis. Maintain ample fluid intake. Avoid alcohol or folic acid containing vitamins during treatment. Avoid sexual intercourse until resolution of the ectopic pregnancy. Avoid exposure to sunlight. Avoid aspirin, NSAID’s

23. SURGERY: Laparotomy. Laparoscopy. INDICATION: Pt not suitable for medical management. Medical therapy has failed. Pt has a heterotopic pregnancy with a viable intrauterine pregnancy. Pt is hemodynamically unstable and needs immediate treatment. CONTRAINDICATION PT medically treatable. PT having other medical conditions that would make the risks associated surgery unacceptable,.

24. Follow up after conservative surgery With weekly Serum β HCG titre till it is negative. If titre increases methotrexate can be given.

25. Thank you