Ectopic pregnancy.pptx obstetricians and gyn

Obstetricians and gyn

1. ECTOPIC PREGNANCY By: Tumwebaze Celia Supervisor: Doctor Mark

2. OUTLINE INTRODUCTION RISK FACTORS FORMS OF ECTOPIC PREGNANCY SITES OF IMPLANTATION CLINICAL PRESENTATION DIAGNOSIS INVESTIGATIONS DIFFERENTIAL DIAGNOSIS MANAGEMENT COMPLICATIONS PROGNOSIS REFERENCES

3. INTRODUCTION DEFINITION An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial lining of the uterine cavity. Following fertilization and fallopian tube transit, the blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation elsewhere is considered ectopic.

4. RISK FACTORS History of Previous ectopic pregnancy History of PID History of tubal ligation Contraception failure Previous ectopic pregnancy Assisted reproductive Technologies Previous induced abortion Tubal endometriosis Smoking

5. SITES OF IMPLANTATION

6. TUBAL PREGNANCY Sites of Ectopic Pregnancy Tubal Ectopic Pregnancies – ~95% Ampulla – 70% (most common) Isthmus – 12% Fimbrial end – 11% Interstitial – 2% Nontubal Ectopic Pregnancies – ~5% Implant in ovary, peritoneal cavity, cervix, or previous cesarean scar. Heterotopic Pregnancy ; Rare occurrence of simultaneous intrauterine and ectopic implantation in a multifetal pregnancy.

7. Pathogenesis and potential outcomes Because the fallopian tube lacks a submucosal layer, a fertilized ovum quickly implants into the muscularis as trophoblast invades. This can lead to tubal rupture, tubal abortion, or pregnancy failure with spontaneous resolution. Ruptured tubal pregnancies occur when the growing conceptus tears the tube, leading to persistent, potentially life-threatening hemorrhage.

8. In tubal abortion , the pregnancy is expelled through the distal end; bleeding may stop or continue if products remain, with blood pooling in the rectouterine pouch. If the fimbrial end is blocked, a hematosalpinx can form. Rarely, the fetus may reimplant on the peritoneum as an abdominal pregnancy. Spontaneous failure involves death and resorption of the ectopic pregnancy, often detected early with sensitive β-hCG tests.

9. FORMS OF ECTOPIC PREGNANCY Acute ectopic pregnancy ; There is high serum beta HCG level at presentation that correlates with depth of trophoblastic invasion in tubal wall. This leads to severe ischemic changes and tubal wall rupture. Chronic ectopic pregnancy ; Here there is silent minor ruptures or abortions of an ectopic pregnancy instead of single episode of bleeding, incites an inflammatory response often leading to formation of a pelvic mass. Its abnormal trophoblasts die early. Hence negative or lower, static serum beta HCG levels.

10. Clinical Manifestations The classic triad is amenorrhea that is followed by abdominal pain and vaginal bleeding . With tubal rupture, lower abdominal and pelvic pain is usually severe and frequently described as sharp, stabbing, or tearing. In addition to bleeding, women with ectopic tubal pregnancy may pass a decidual cast. This is the entire sloughed endometrium that takes the form of the endometrium.

11. Tubal pregnancy diagnosis 1. Beta Human chorionic Gonadotrophin hCG is produced by trophoblast cells after implantation. Modern tests detect the β-subunit, which is pregnancy-specific. A urine test can pick up hCG at 20–25 mIU/mL, while a serum test detects as low as ≤5 mIU/mL (so it picks it up earlier). If positive, pregnancy is confirmed — but you don’t yet know where the pregnancy is located.

12. The initial β-hCG level sets expectations for anticipated TVS finding. With values above a discriminatory threshold, a normal IUP is expected to be seen within the uterus. Some institutions set their discriminatory threshold at ≥1500 mIU/mL, whereas others use ≥2000 mIU/mL. Connolly and associates (2013) suggested an even higher threshold. They noted that with live IUPs, a gestational sac was seen 99 percent of the time in those with a discriminatory level >3510 mIU/mL.

13. 2. Trans vaginal Sonography TVS Findings: IUP seen → diagnosis confirmed. No IUP seen → classified as PUL. Most PULs: Early IUP, failing IUP, recent abortion, or ectopic pregnancy. Next Step: Serial β-hCG every 48 hrs to monitor pregnancy progression. Expected Rise: Normal IUP → 35–53% increase in 48 hrs; same applies for multifetal pregnancies.

14. INTERSTITIAL PREGNANCY It is the rarest variety of tubal pregnancy. Because of the thick and vascular musculature of the uterine wall with greater distensibility, the fetus grows dissecting the muscle fibers for a longer period (12-14 weeks) before termination occurs. The usual termination is rupture. It is associated with massive intraperitoneal hemorrhage due to its combined vascularization by the uterine and ovarian arteries. On rare occasion, abortion occurs through the uterine cavity. The diagnosis before rupture is very difficult. β- hCG , high-resolution sonography and laparoscopy can lead to early diagnosis. However, the diagnosis is revealed on laparotomy following termination as rupture. Hysterectomy is commonly done.

15. Ruptured interstitial pregnancy—subtotal hysterectomy done

16. INVESTIGATIONS Blood examination should be done as a routine for: Hemoglobin. ABO and Rh grouping. Total white cell count and differential count. Erythrocyte sedimentation rate (ESR). There may be varying degrees of leukocytosis and raised ESR. Estimation of β - hCG : A single estimation of β - hCG level either in the serum or in urine confirms pregnancy but cannot determine its location . The suspicious findings are: Lower concentration of β- hCG compared to normal intrauterine pregnancy Doubling time in plasma fails to occur in 2 days.

17. Culdocentesis is simple and safe. Where sensitive TVS or laparoscopy is not readily available, culdocentesis is still a diagnostic alternative. Unfortunately negative culdocentesis does not rule out an ectopic pregnancy neither a positive result is very specific. Through an 18-gauge lumbar puncture needle fitted with a syringe, the posterior fornix is punctured to gain access to the pouch of Douglas. Aspiration of nonclotting blood with hematocrit greater than 15% signifies ruptured ectopic pregnancy.

18. Sonography: Transvaginal sonography (TVS) is more informative. The diagnostic features are : Absence of intrauterine pregnancy with a positive pregnancy test. Fluid (echogenic) in the pouch of Douglas. Adnexal mass clearly separated from the ovary. Rarely cardiac motion may be seen in an unruptured tubal ectopic pregnancy. Color Doppler Sonography: (TV-CDS)— can identify the placental shape (ring-of-fire pattern) and enhanced blood flow pattern outside the uterine cavity.

19. 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. However, laparoscopy runs the risk of false-positive or false-negative diagnosis in 2–5% of cases.

20. 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. Laparotomy offers benefit when in doubt. The old axiom, “ open and see ” holds good especially when the patient is hemodynamically unstable. One should not be ashamed of having a negative abdominal exploration , rather to be disgraced for the mistake in diagnosis with the eventual fatality.

21. Dilatation and curettage —Identification of decidua without villi structure is very much suggestive.

22. DIFFERENTIAL DIAGNOSIS Normal Pregnancy Threatened Abortion Incomplete Abortion Molar Pregnancy Acute Appendicitis Ruptured/Torsion Ovarian Cyst Salpingitis Fibroid Perforated Peptic Ulcer Twisted Ovarian Tumor Peritonitis Pelvic Abscess

23. MANAGEMENT OF ECTOPIC PREGNANCY RUPTURED Acute ectopic: The principle in the management of acute ectopic is resuscitation and laparotomy and not resuscitation followed by laparotomy . Antishock treatment : Antishock measures are to be taken energetically with simultaneous preparation for urgent laparotomy . Ringer’s solution (crystalloid) is started, if necessary with venesection. Arrangement is made for blood transfusion. Even if blood is not available , laparotomy is to be done desperately . When the blood is available, it is better to be transfused after the clamps are placed to occlude the bleeding vessels on laparotomy, as it is of little help to transfuse when the vessels are open. After drawing the blood samples for grouping and cross matching, volume replacement with colloids ( hemaccel ) is to be done.

24. Laparotomy : Indications of laparotomy are— Patient hemodynamically unstable. Laparoscopy contraindicated. Evidence of rupture. The principle in laparotomy is “ quick in quick out ”. Salpingectomy is the definitive surgery. The excised tube should be sent for histological examination. CHRONIC ECTOPIC: All cases of chronic or suspected ectopic are to be admitted as an emergency. The patient is kept under observation, investigations are done and the patient is put up for laparotomy at the earliest convenient time. Usually a pelvic hematocele is found. Blood clots are removed. The affected tube is identified and salpingectomy is commonly done as described previously.

25. Note the placement of the Salpingectomy clamps

26. UNRUPTURED: This can be managed using an expectant, medical or a surgical approach, depending on clinical presentation. Laparoscopic view of an unruptured tubal ectopic pregnancy (Rt). Hugely dilated ampulla is seen (arrow)

27. EXPECTANT MANAGEMENT Expectant management: Where only observation is done hoping spontaneous resolution. Indications are: Initial serum hCG level less than 1,000 IU/L and the subsequent levels are falling. Gestation sac size less than 4 cm. No fetal heart beat on TVS. No evidence of bleeding or rupture on TVS.

28. CONSERVATIVE MANAGEMENT Conservative management may be either medical or surgical . Otherwise salpingectomy is done. The drugs commonly used for salpingocentesis are: methotrexate, potassium chloride, prostaglandin (PGF2 α), hyperosmolar glucose or actinomycin. The patient must be — Hemodynamically stable. Serum hCG level should be less than 3,000 IU/L. Tubal diameter should be less than 4 cm without any fetal cardiac activity. There should be no intra-abdominal hemorrhage. For systemic therapy, a single dose of methotrexate (MTX) 50 mg/M2 is given intramuscularly.

29. METHOTREXATE It is a folic acid antagonist, inhibits DNA synthesis in trophoblastic cells. It can be administered as a single IM injection or a multiple fixed dose regimen. The dose is calculated based on body surface area of 50mg/m2 or 1mg/kg.

30. Conservative Surgery: The procedure can be done either laparoscopically or by microsurgical laparotomy . Indications: (a) Cases not fulfilling the criteria of medical therapy. (b) Cases where b- hCG levels are not decreasing despite medical therapy. (c) persistent fetal cardiac activity. Linear salpingostomy Linear salpingotomy Segmental resection Fimbrial expression

31. Laparoscopic linear salpingostomy for unruptured tubal pregnancy— (A) Linear incision on the antimesenteric border (B) Gestation sac is removed (C) Incision margins left unsutured . Above: Schematic and Below: operation.

32. Salpingectomy is done when Whole of the affected tube is damaged, Contralateral tube is normal or Future fertility is not desired.

33. OTHER TREATMENTS Blood transfusion Pain relievers Antibiotics. In Rh-negative women not yet sensitized to Rh antigen, Anti globulin D 50 µg (if gestation < 12 weeks) or 300 µg (if > 12 weeks) intramuscularly is administered soon following operation to prevent isoimmunization. Post op, start appropriate family planning method (IUD excluded)

34. COMPLICATIONS Rupture with internal haemorrhage Anaemia Shock Peritonitis Secondary infertility

35. PROGNOSIS Immediate prognosis so far as maternal mortality is concerned has been markedly reduced (0.05%) due to early diagnosis, adequate blood replacement and surgery even in desperately ill patient. An ectopic mother has got every chance of a viable birth in 1 in 3 and a chance of recurrence of ectopic in 1 in 10. Patient is asked to report after she misses her period to confirm and to locate the new pregnancy.

36. ABDOMINAL PREGNANCY This can be either Primary or Secondary. Primary implantation is rare and occurs when fertilized ovum implants on peritoneum. Its Diagnostic Criteria( Studiford ) is; Both the tubes and ovaries are normal without evidence of recent injury Absence of uteroperitoneal fistula Presence of a pregnancy related exclusively to the peritoneal surface and young enough to eliminate the possibility of secondary implantation

37. Abdominal pregnancy is almost always secondary. The primary sites being tube, ovary or the uterus. The conceptus escapes out through the rent in the uterine scar.

38. The prerequisites 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 living ovum and the placenta should occur through the rent. Placenta gets attached to the neighboring structures and new vascular connection should be re-established. Intestine, omentum and adjacent structures get adherent to the secondary sac.

39. OVARIAN PREGNANCY Diagnostic Criteria( Spiegelberg's ) for ovarian pregnancy includes; Tube on the affected side must be intact The gestation sac must be in the position of the ovary The gestation 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 extrafollicular. In either types, rupture is an inevitable phenomenon and salpingo -oophorectomy is the definite surgery . Ovarian resection could be done when the diagnosis is made early.

40. CORNUAL PREGNANCY Pregnancy occurring in rudimentary horn of a bicornuate uterus is called cornual pregnancy . The horn does not usually communicate with the uterine cavity. The impregnation is presumed to occur by a spermatozoa which passes through the normal half of the uterus and tube. It then fertilizes an ovum either in the peritoneal cavity or in the tube connected to the rudimentary horn by transperitoneal migration Termination by rupture is inevitable between 12 and 20 weeks with massive intraperitoneal hemorrhage .

41. The condition is commonly diagnosed as fibroid or ovarian tumor with pregnancy. Position of the round ligament which is attached to the sac and the long pedicle by which it is attached to the uterus are the diagnostic points. Surgery includes removal of the rudimentary horn. If the pedicle is short and the attachment is wide, hysterectomy may have to be done.

42. Cornual pregnancy

43. CERVICAL PREGNANCY This is a rare (1 in 16,000 pregnancies) variant of ectopic pregnancy when the implantation occurs in the cervical canal at or below the internal os . Erosion of the walls by the trophoblasts occurs resulting in thinning and distension of the canal. The condition is commonly confused with cervical abortion. In cervical pregnancy, the bleeding is painless and the uterine body lies above the distended cervix. The morbidity and mortality is high because of profuse hemorrhage.

44. Clinical diagnostic criteria (Rubin–1983) for cervical pregnancy are—(a) Soft, enlarged cervix equal to or larger than the fundus. (b) Uterine bleeding following amenorrhea, without cramping pain. (c) Products of conception entirely confined within and firmly attached to endocervix. (d) A closed internal cervical os and a partially opened external os Sonography reveals the pregnancy in the cervical canal and an empty uterine cavity. Hysterectomy is often required to stop bleeding

45. Cervical pregnancy—hysterectomy done (showing Rubin’s diagnostic criteria): (A) Globular cervix with partially opened external os (B) Uterus cut opened through the anterior wall to show the huge hemorrhagic mass occupying the cervical canal with empty uterine cavity (C) When the mass was dissected, the cervical wall showed macroscopic evidence of invasion of trophoblastic tissue (confirmed on histology)

46. CESEREAN SCAR PREGNANCY Implantation occurs within the scar of a prior cesarean delivery via a microscopic tract in myometrium. Can also be from prior uterine surgery like myomectomy ,curettage , manual removal of placenta. Criteria: An empty uterine cavity, an empty cervical canal, a gestational sac in the anterior part of the uterine isthmus, absence of healthy myometrium between the bladder and gestational sac. Management. MTX with or with out suction curettage, isthmic resection and double layer closure.

47. PERSISTENT ECTOPIC PREGNANCY A persistent ectopic pregnancy refers to the continuation of trophoblastic growth after a surgical intervention to remove an ectopic pregnancy(persistent trophoblast proliferation). It is due to incomplete removal of trophoblast. It is high after fimbrial expression and in cases where initial serum β- hCG level is greater than 3,000 IU/L. Prophylactic single dose MTX (1 mg/kg) IM is effective to resolve the problem.

48. HETEROTOPIC PREGNANCY Incidence is about 1 in 8,000 pregnancies at present. It is more common following ART procedures. Intrauterine pregnancy may be coexistent with tubal or rarely with cervical or ovarian pregnancy. Diagnosis is difficult. Absence of vaginal bleeding in the presence of signs and symptoms of an ectopic pregnancy is suspicious. Abnormally rising hCG level and ultrasonography may be helpful.

49. REFERENCE WILLIAMS OBSTETRICS , 25th EDITION DC DUTTA’S TEXTBOOK OF OBSTETRICS 8 TH EDITION