Ectopic Pregnancy

Semyatov S.

Associate professor

Dep. Obtetrics&Gynaecology of PFUR

Definition

Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.

Incidence

1 in 100 ( from 1:25 to 1:250) normal pregnancies

1:28 in West Indies 4,5-16,8:1000 in Russia Mortality - 0,4% in Russia The Secondary Infertility - 40% after

operation

Incidence Recent evidence indicates that the

incidence of ectopic pregnancy has been rising in many countries.– USA-5 fold– UK-2 fold– France 15/1000 pregnancies– India-1in100 deliveries

Recurrence rate - 15% after 1st, 25% after 2 ectopics

Overview

Incidence Increasing (Ќ 1:66 Pregnancies) Mortality Decreasing With Better Detection Surgical and Medical Treatment Available Recurrence Rate ~ 15%

History Ectopic pregnancy was first described in 963 Ad by

Albucasis. 1884 -- Robert Lawson Tait of Birmingham prformed

the first successful Salpingectomy operation 1953 -- Stromme – Conservative surgery of

Salpingostomy 1973 -- Shapiro & Adller – Laparoscopic

Salpingectomy 1991 -- Young et al – Laparoscopic Salpingotomy

Aetiology Any factor that causes delayed

transport of the fertilised ovum through the.

Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy.

These factors may be Congenital or Acquired.

Aetiology

CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis

Aetiology Previous Ectopic Pregnancy PID Congenital Defects in Fallopian Tubes

(Assesory ostia, Partial stenosis, Hypoplasia, Infantilism)

Migration of the Ova Externa Pelvic Abnormalities (Fundul Fibroma,

adenomiosis of Fallopian Tubes) Tubal Reconstrustive Surgery

Aetiology Tubectomy Operation Infertility IUD (~4% pregnancies with IUD in Situ

are Ectopic, Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy)

IVF Induction Ovulation with Gonadotropins Extraneous Factors (Appendicitis,

Endometriosis) Kartegener’s Syndrome (zebra)

Sites Ampulla (78-95%) Isthmus (8-12%) Interstitial portion (2%) - very rare form Cornua (< 2%) or in accessory horn Ovary (0,5-3%, 20-30% in IUD users) Abdomen (< 2%): Primary - very rare.

Secondary. Cervix (< 2%) Combined Uterine Pregnancy and Ectopic

Gestation - 1-3% in IVF, 1:4 000 - 1: 30 000

Sites

1 - Fimbrial 2 - Ampullary 3 - Isthemic

4 - Interstitial 5) Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament 10) Primary abdominal

Ampulla (>85%)Isthmus (8%)

Cornual (< 2%)

Ovary (< 2%)

Abdomen (< 2%)

Cervix (< 2%)

Symptoms

Amenorrhea ~ in 75% cases Abdominal Pain - in 95% cases.

Shoulder and Epigasrtric Pain Vaginal Bleeding Syncope Pelvic Mass

Endometrium

Under Hormonal Effect of the Ectopic Pregnancy it Hypertrophies and Converted into a Decidua

Clinical Course

Unruptured (Progressive) - without specific sings

Tubal Abortion - minimal sings Tubal Rupture (into the peritoneal

cavity or between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock

Evaluation and DiagnosisThe diagnosis of ectopic gestation often

presents great difficulty and it is usually missed because it is NOT suspected.

“Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it.” - Mc. Fadyen - 1981

Evaluation and DiagnosisWomen, during the childbearing

period of life complaining of pain in the lower abdomen associated with continuous vaginal bleeding should be suspected of ectopic gestation

Evaluation and Diagnosis History and Physical Exam Vaginal Examination CBC, T+S Serial Quantitative -hCG (BSU) Ultrasound TAS & TVS Progesterone Level? Culdocentesis Laparoscopy D&C HSG

Serial BSU’s-hCG* Levels Double Every 48 Hrs < 66% Rise / 48 Hrs Consistent With

Ectopic Pregnancy Single Determination Not Helpful Best If Done Within Same Laboratory Never Rules Out Ectopic Pregnancy* generally greater than > 6 500 miu/mL

Ultrasound

May or May Not Be Helpful Discriminatory Zone:

TVS: 1500-2000 mIU/ml (5th Week of Gestation)

TAS: 6500 mIU/ml +IUP: Generally Excludes Ectopic

Culdocentesis Highly Specific if Interpreted

Correctly: Presence of Free-Flowing, NON-Clotting Blood

Negative Tap Inconclusive May Obviate U/S Most Helpful in Emergent Situations

to Confirm Diagnosis, But Remains Controversial

Progesterone Levels

> 15 ng/ml a/w IUP < 15: SAb or Ectopic May Take Several Days for Result Clinical Use Not Yet Widespread

Differential diagnosis Appendicitis (Perforated) PID Rupture of Follicle or Corpus

Luteum Cyst Threatened Abortion Splenic Rupture Perforated Gastric or Duodenal Ulcer

Differential diagnosis Acute Pancreatities Myocardial Infarct Pyosalpinx Septic Abortion Pelvic Abcess Retroverted Gravid Uterus Twisted Ovarian Cyst Rupture of Chocolate cyst

Treatment Observation Laparoscopy Laparotomy MTX Hyperosmolar Glucose KCl RU-486 Prostaglandin F2 alfa

Observation

Many Tubal Pregnancies Abort Israeli Study: Majority of Untreated

Ectopics Resolve Not Yet Acceptable Standard of

Care in US

Laparotomy

Acute Ectopic Gestation Salpingoectomy Secondary Abdominal Pregnancy Interstial Pregnancy Cornual Pregnancy Cervical Pregnancy Auto-Transfusion

Laparoscopy Allows Diagnosis and Treatment Salpingostomy Salpingectomy (Total / Partial) Cornual Resection Minimally Invasive, Unlike

Laparotomy Few Contraindications: Unstable

Patient (Possibly)

MTX Toxic to Trophoblast Cells Minimal Side Effects May Preserve Fertility in Cases of

Cervical Pregnancy Requires Compliant Patient, Time Pain Not Uncommon BSU May Rise Initially 25-50 mg into Gestational Sac

MTX Tubal Patency is Restored in 82% cases Oral - 50-100 mg (toxicity on GIT) Intramusculary 1 mg/kg

NB. Laparoscopic Injection of MTX, Prostaglandin F2 alfa, RU 486 (anti-progesterone), Potassium Chloride into gestational sac is possible only if the sac measures less than 3 cm, and fetal heart is absent

Persistent Trophoblast

Most Often A/W Salpingostomy Laparoscopic ~ 3% Minilap <1% Most Easily Treated With MTX

Cervical Pregnancy

Incidence ~1:1 000 Profuse painless bleeding following a

short period of Amenorrhea PE: a patulous external os and

productsmof conception in the cevical canal, internal os is closed and the uterus is firm and normal in size

Cervical Pregnancy

US helps in the correct diagnisis Treatment: - Suction Evacuation and

Tamponade by inserting a distended Foley Catheter for 24 hours

- Hysterectomy - Hysteroscopic Resection

using Resectoscope - MTX

Outcomes

15% Repeat Ectopic Rate Ќ 2 Ectopics:

33% Pregnancy Rate

25% Ectopic No Benefit To Removing Ovary

Along With Tube

Summary Ectopic Pregnancy is a Common,

Treatable Problem Sensitive BSU Assays Allow Early

Detection Surgical and Medical Options Exist Ruptured Ectopics Should be

Unusual with Compliant Patients and Appropriate Medical Care