Ectopic pregnancy.pptx

References from "Tintinalli's emergency mannual"

1. ECTOPIC P REGNANCY PRESENTOR : MANIKANDAN . V, MSc. EMERGENCY MEDICINE, AIMS, KOCHI. MODERATOR : Dr. DHANASEKARAN . B.S , PROFESSOR. EMERGENCY MEDICINE, AIMS, KOCHI.

2. Causes & Riskfactors Introduction AMPULLARY -> ENDOMETRIUM OF UTERUS Pathophysiology & Types Clinical manifestation Triad Diagnosis & Management surgical , medical CONTENT : Tubal pregnancy Anatomy & Normal implantation DAMAGE TO TUBAL MUCOSA Fallopian tube to Peritoneal cavitry

3. INTRODUCTION 01 Tubal pregnancy

4. Introduction Ectopic pregnancy occurs when a conceptus implants outside of the uterine cavity ; ruptured ectopic pregnancies ( life-threatening cause of vaginal bleeding)are a leading cause of maternal death in the first trimester of pregnancy. Ectopic pregnancies are often called tubal pregnancies because most are located in the fallopian tube.

5. ANATOMY & NORMAL IMPLANTATION 2 AMPULLARY -> ENDOMETRIUM OF UTERUS

6. ANATOMY :

7. NORMAL IMPLANTATION : Fertilization of the oocyte usually occurs in the ampullary segment of the fallopian tube . | In normal pregnancy, after fertilization, the zygote passes along the fallopian tube and implants into the endometrium of the uterus .

8. CAUSES & RISK FACTORS 3 DAMAGE TO TUBAL MUCOSA

9. CAUSES : INFECTION preventing transport of the ovum to the uterus. Tubal sx Elevated estradiol or progesterone levels which inhibit tubal migration. Defects in the ovum resulting in premature implantation The vast majority of ectopic pregnancies implant in the ampullary portion of the fallopian tube . The underlying cause is most often damage to the tubal mucosa from,

10. Pelvic inflammatory disease, history of sexually transmitted infections History of tubal surgery or tubal sterilization Conception with intrauterine device in place Maternal age 35–44 (age-related change in tubal function) Assisted reproduction techniques (cause unknown, as tube is bypassed in implantation) Previous ectopic pregnancy Cigarette smoking (may alter embryo tubal transport) Prior pharmacologically induced abortion RISK FACTORS :

11. PATHOPHYSIOLOGY & TYPES 4 FALLOPIAN TUBE TO PERITONEAL CAVITY

12. PATHOPHYSIOLOGY : Tubal implantation results in the penetration of the ovum into the muscular wall of the tube , and maternal blood seeps into tubal tissue. | Intermittent distention of the fallopian tube with blood can occur, with leakage of blood from the fimbriated end of the fallopian tube into the peritoneal cavity. | The aborting ectopic pregnancy and associated hematoma can be completely or partially extruded out of the end of the fallopian tube or through a rupture site in the tubal wall

13. TYPES

14. TYPES : Abdominal ectopic pregnancie s : (~1% of ectopic pregnancies) most commonly derive from early rupture or abortion of a tubal pregnancy , with subsequent reimplantation in the peritoneal cavity. 2. Cesarean scar pregnancy is rare but can cause massive maternal hemorrhage.

15. TYPES : 3. Cervical ectopic pregnancies ; occur in <1% of ectopic pregnancies. with predisposing factors similar to those associated with ectopic pregnancies (previous dilatation and curettage, previous cesarean delivery, in vitro fertilization, adhesions or fibrosis of the endometrium, prior instrumentation, infertility, previous ectopic pregnancy). Patients develop profuse vaginal bleeding . Bimanual exam reveals a soft, large cervix when compared to the uterus or an hourglass-shaped uterus, and diagnosis is confirmed with US.

16. CLINICAL MANIFESTATION 5 TRIAD

17. CLINICAL PRESENTATION : When the site of oocyte implantation is a fallopian tube, most cases are diagnosed before rupture on the basis of three classic findings: ABDOMINAL PAIN. DELAYED MENSES. ABNORMAL VAGINAL BLEEDING. (1) Abdominal pain: If the tube is unruptured - the pain begins as a dull, lower quadrant pain on one side. As the tube stretches - the pain changes to a colicky pain, then a sharp, stabbing pain with tube rupture - to a sudden,excruciating pain that is felt throughout the lower abdomen. Referred shoulder pain is possible as the abdomen fills with blood.)

18. CONT... (2) Delayed menses : Most women report having a period that is delayed 1 to 2 weeks , a period that is lighter than usual, or an irregular perio d. (3) Abnormal vaginal bleeding (spotting): that occurs about 6 to 8 weeks after the last normal menstrual period. Up to 80% of women experience mild to moderate dark red or brown intermittent vaginal bleeding In ectopic pregnancy, bleeding usually occurs after the onset of pain.

19. DIAGNOSIS & MANAGEMENT 6 MEDICAL & SURGICAL

20. HISTORY : Ask about previous pregnancies, pregnancy problems, and miscarriages. Discuss previous medical and surgical history, and ask about substance abuse and smoking. Ask about sexual activity and contraception. Identify risk factors for ectopic pregnancy or spontaneous abortion, Determine current medications, including over-the-counter drugs. Pregnancy in a patient with prior tubal surgery for sterilization is assumed to be an ectopic pregnancy until proven otherwise. Patients are at particularly high risk if they have undergone laparoscopic partial salpingectomy or electrodestruction tubal ligation at a young age (age <28 years), especially 5 to 15 years after the procedure

21. DIAGNOSIS : The definitive diagnosis of ectopic pregnancy is made by US, by direct visualization by laparoscopy, or at surgery. No single or combination of laboratory tests has a sufficient negative or positive predictive value to completely exclude ectopic pregnancy or to definitively establish the diagnosis. 1. SERUM β -HCG : Differences in the dynamics of β-hCG production in normal and pathologic pregnancy are useful in the diagnosis of ectopic pregnancy. Early in normal pregnancy, β-hCG levels rise rapidly until 9 to 10 weeks of pregnancy and then plateau .

22. cont... Absolute levels of β-hCG tend to be lower in pathologic pregnancies than in IUPs . Doubling time refers to the time needed for β-hCG concentration in the serum to double. Absolute levels of β-hCG are lower and doubling times longer in ectopic pregnancy and other abnormal pregnancies. This and many other observations have led to the widely used rule of thumb , stating that the serum concentration of β-hCG approximately doubles every 2 days early in a normal pregnancy and that longer doubling times indicate pathologic pregnancy

23. cont.. PROGESTERONE : Progesterone is a steroid hormone secreted by the ovaries, adrenal glands, and placenta during pregnancy . During the first 8 to 10 weeks of pregnancy , ovarian production of progesterone predominates , and serum levels remain relatively constant. After the 10th week of pregnancy , placental production increases and serum levels rise . Absolute levels of progesterone are lower in pathologic pregnancies and fall when a pregnancy fails. An empty uterus or nonspecific fluid collection on US associated with progesterone ≤5.0 nanograms/m L is highly predictive of abnormal IUP or ectopic pregnancy

24. OTHER INVESTIGATION : secretory endometrial protein Estradiol - Decreaed level compared to normal IUP The pregnancy-associated proteins A to D, routine laboratory tests such as, Amylase - Elevated in the case of ruptured ectopic case creatine kinase ( non spicific) - Significantly increase in state in EP erythrocyte sedimentation rate - Significantly increase in state in EP

25. USG : Advances in sonographic imaging and the use of transvaginal US scanning allow earlier detection of an IUP or an ectopic pregnancy. These advances have contributed to increasing use of real-time, bedside US in the ED . ED US has the further advantage of allowing a potentially unstable patient to remain under continuous observation in the ED.

26. CONT.. An empty uterus with embryonic cardiac activity visualized outside the uterus is diagnostic of ectopic pregnancy. When performed by trained individuals, point-of-care ED US in the first trimester of pregnancy is accurate and can decrease ED length of stay, as long as a conclusive IUP is identified. It has previously been assumed that if an IUP exists, the diagnosis of ectopic pregnancy has been excluded. This assumption is based on the historical incidence of heterotopic pregnancy (combined IUP and ectopic pregnancy), reported to occur in 1 in 3,000 pregnancies

27. IMAGING : MRI has high sensitivity and specificity for the diagnosis of ectopic pregnancy, but cost, availability, and the time to perform the study make the use of MRI of only theoretical interest at the present time. Laparoscopy may be both diagnostic and therapeutic. Laparoscopy is primarily useful in patients with suspected ectopic pregnancy and a nondiagnostic US. It may provide an earlier diagnosis and a possible route for definitive treatment when compared with serial β-hCG measurements and US.

28. MEDICAL : SURGICAL : For unruptured ectopic pregnancy, the most frequently used surgical approach is laparoscopic salpingostomy MANAGEMENT : Administration of systemic methotrexate, comparable success rates to surgical therapies with unruptured ectopic pregnancies

29. MEDICAL MANAGEMENT : Methotrexate is the only drug currently recommended as a medical alternative to surgical treatment of ectopic pregnancy and is ideally used in patients with, Hemodynamic stability Minimal abdominal pain The ability to follow up reliably, and normal baseline liver and renal function tests.

30. ABSOLUTE : Intrauterine pregnancy Evidence of immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary disease Active peptic ulcer disease Clinically important hepatic or renal dysfunction Breastfeeding Hemodynamic instability RELATIVE : Embryonic cardiac activity detected by transvaginal US Human chorionic gonadotropin concentrations >5000 mIU/mL Ectopic pregnancy >4 cm in size as imaged by transvaginal US Refusal to accept blood transfusion Inability to reliably return for follow-up

31. MOA : Methotrexate is an antimetabolite chemotherapeutic agent | That binds to the enzyme dihydrofolate reductase , which is involved in the synthesis of purine nucleotides. | This interferes with deoxyribonucleic acid (DNA) synthesis and disrupts cell multiplication . DOSE : 50 mg/m2 IM in a single injection or as a divided dose injected into each buttock. Advise patients not to take vitamins with folic acid until complete resolution of the ectopic pregnancy. They should also refrain from alcohol consumption and intercourse for the same period.

32. PROTOCOL : Day 0 : Obtain β-HCG level, ultrasonography, and +/- dilatation and curettage. Day 1 : Obtain, β-HCG Liver function Blood urea nitrogen (BUN) Creatinine Evidence of hepatic or renal compromise is a contraindication to methotrexate therapy. Blood type, Rh status, and antibody screening are also performed, and all Rh-negative patients are given Rh immunoglobulin.

33. Day 4 : The patient returns for measurement of her β-HCG level. The level may be higher than the pretreatment level. The day-4 hCG level is the baseline level against which subsequent levels are measured. Day 7 : Draw β-HCG and AST levels and ,CBC. If the β-HCG level has dropped 15% or more since day 4, obtain weekly β-HCG levels until they have reached the negative level. WHEN - SECOND DOSE ? If the weekly levels plateau or increase If the β-HCG level has not dropped at least 15% from the day-4 level If no drop has occurred by day 14, surgical therapy is indicated. If the patient develops increasing abdominal pain after methotrexate therapy, repeat a transvaginal ultrasonographic scan to evaluate for possible rupture.

34. Abdominal pain after treatment followed by flatulence and then stomatitis. Lower abdominal pain lasting up to 12 hours is common 3 to 7 days after methotrexate treatment and is thought to be secondary to methotrexate-induced tubal abortion or tubal distention due to hematoma formation (“separation pain”). The pain is usually self-limited and may respond to NSAIDs. SURGICAL INTERVENTION INDICATION : Hemodynamic instability and/or falling hematocrit patients with moderate to severe pain, free fluid in the cul-de-sac Rebound tenterness.

35. REFERENCES : BOOK : NANCY CAROLINE’S “ EMERGENCY CARE IN THE STREET “ EDITION : EIGTH PG.NO : 1246 - 1248 2. TINTINALLIS EMERGENCY MEDICINE . EDITION : NINTH PG.NO : 615 - 620 WEB : MEDSCAPE

36. SHALOM