ECTOPIC PREGNANCY

DEFINITION

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

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INCIDENCE >1 in 100 pregnancies. 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

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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

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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.

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AETIOLOGY CONGENITAL - Tubal Hypoplasia ,

Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis

ACQUIRED - Inflammatory: PID, Septic Abortion, Puerperal

Sepsis, MTP (lntraluminal adhesion) Surgical: Tubal reconstructive surgery,

Recanalisation of tubes Neoplastic: Broad ligament myoma, Ovarian

tumour Miscellaneous Causes: IUCD , Endometriosis,

ART (IVF & & GIFT), Previous ectopic

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SITES OF ECTOPIC PREGNANCY

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%)

CLINICAL PRESENTATION Ectopic Pregnancy remains asymptotic until it

ruptures when it can present in two variations - Acute &. Chronic

SYMPTOMS- Amenorrhea Abdominal Pain Syncope Vaginal Bleeding Pelvic Mass

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DIAGNOSIS

“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

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DIAGNOSIS In recent years, inspite of an increase in the

incidence of ectopic pregnancy there has been a fall in the case fatality rate.

This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease.

This has resulted in early diagnosis and effective treatment.

Now the rate of tubal rupture is as low as 20%.

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METHODS OF EARLY DIAGNOSIS Immunoassay utilising monoclonal antibodies to beta HCG

Ultrasound scanning – Abdominal & Vaginal including Colour Doppler

Laparoscopy Serum progesterone estimation not

helpful

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A combination of these methods may have to be employed.

METHODS OF EARLY DIAGNOSIS

TVS can visualise a gestational sac as early as 4-5 weeks from LMP.

During this time the lowest serum beta HCG is 2000 IU/Lt.

When beta HCG level is greater than this and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected.

In such a situation, when the value of beta HCG does not double in 48 hours ectopic pregnancy will be confirmed.

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At 4-5 weeks-

METHODS OF EARLY DIAGNOSISThe USG features of ectopic pregnancy after 5

weeks can be any of the following-

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1. Demonstration of the gestational sac with or without a live embryo (Begel’s sign) - The GS appears as an intact well defined tubal ring by 6 weeks when it measures 5 mm in diameter. Afterwards it can be seen as a complete sonolucent sac with the yolk sac and the embryonic pole with or without heart activity inside.

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METHODS OF EARLY DIAGNOSIS

2. Poorly defined tubal ring possibly containing echogenic structure and POD typically containing fluid or blood.

3. Ruptured ectopic with fluid in the POD and an empty uterus.

4. In Colour Doppler, the vascular colour in a characteristic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow

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The USG features of ectopic pregnancy after 5 weeks can be any of the following-

MANAGEMENT Depends on the stage of the disease

and the condition of the patient at diagnosis.

Options- Surgery – Laparoscopy / Laparotomy Medical – Administration of drugs at the

site / systemically Expectant – Observation

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Hospitalisation Resuscitation -

Treatment of shock Lie flat with the leg end raised Analgesics Blood transfusion

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

Culdocentesis: - Most Helpful in Emergent Situations to

Confirm Diagnosis Highly Specific if performed and

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

Negative Tap Inconclusive Remains Controversial

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

Laparotomy should be done at the earliest.

Salpingectomy is the definitive treatment.

No benefit from removing Ovary along with the tube

If blood is not available, auto-transfusion can be done.

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MANAGEMENT OF CHRONIC ECTOPIC PREGNANCYINVESTIGATIONS-

Laboratory/Chemical test – Serial quantitative beta HCG level by RIA Serum progesterone level (<5 mg/ml in

ectopic pregnancy) Low levels of Trophoblastic proteins such

as SPI and PAPP-, Placental protein 14 & 12 USG- usually haematocele is found Laparoscopy

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MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY

TREATMENT – ALWAYS SURGICAL Salpingectomy of the offending tube

If pelvic haematocele is infected, posterior. colpotomy is to be done to drain the pelvic abscess

Salpingo-oophorectomy

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MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY

SURGICAL- SURGICALLY ADMINISTERED MEDICAL

(SAM) TREATMENT MEDICAL TREATMENT EXPECTANT MANAGEMENT

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OPTIONS: -

SURGICAL TREATMENT OF ECTOPIC PREGNANCY

Carried out either by Laparoscopy / Laparotomy.

The procedures are: - Salpingectomy / Cornual resection /

Excision Conservative surgery (in cases of Infertility

& desire for pregnancy) Linear salpingostomy Linear salpingotomy Segmental resection and anastomosis Milking of the tube

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SURGICAL TREATMENT OF ECTOPIC PREGNANCY

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LAPAROTOMY?

VS.

LAPAROSCOPY?

SALPINGECTOMY?

VS

SALPINGOSTOMY / SALPINGOTOMY?

The debate goes on

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COMPARING LAPAROTOMY Vs LAPAROSCOPY

L’tomy L’scopyHospital cost More? Less?Post operative adhesions More LessRisk of future ectopic Same SameFuture fertility Same SameExperience of Surgeon Trained Special Instruments General Special

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SALPINGECTOMY VS

SALPINGOSTOMY / SALPINGOTOMY

All tubal pregnancies can be treated by partial or total Salpingectomy

Salpingostomy / Salpingotomy is only indicated when: 1. The patient desires to conserve her fertility2. Patient is haemodinmically stable3. Tubal pregnancy is accessible4. Unruptured and < 5Cm. In size5. Contralateral tube is absent or damaged

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The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment

Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.

SALPINGECTOMY VS

SALPINGOSTOMY / SALPINGOTOMY

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Fertility reducing factor Score• Antecedent one Ectopic pregnancy 2• Antecedent each further

Ectopic pregnancy 1• Antecedent Adhesiolysis 1• Antecedent Tubal micro surgery 2• Antecedent Salpingitis 1• Solitary tube 2• Homolateral Adhesions 1• Contralateral Adhesions 1

SALPINGECTOMY VS

SALPINGOSTOMY / SALPINGOTOMY

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• The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy.

• Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more.

SALPINGECTOMY VS

SALPINGOSTOMY / SALPINGOTOMY

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It is carried out by laparoscopic scissors and diathermy or Endo-loop.

After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch.

The excised tissue is removed by piece meal or in a tissue removal bag.

LAPAROSCOPIC SALPINGECTOMY

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To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal saline is injected into the mesosalpinx.

Then the tube is opened through an antimesenteric longitudinal incision over the tubal pregnancy by a

– Co2 laser (Paulson, 1992)– Argon laser (Keckstein et al; 1992) – Laparoscopic scissors and ablating the

bleeding points with bipolar diathermy. – Fine diathermy knife (Lundorff, 1992)

LAPAROSCOPIC SALPINGOTOMY

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The tubal pregnancy is then evacuated by suction irrigation.

Hemostasis of the trophpblastic bed is ensured.

The tubal incision is left open.

LAPAROSCOPIC SALPINGOTOMY

PERSISTENT ECTOPIC PREGNANCY (PEP)

This is a complication of salpingotomy / salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy.

Diagnosis is made because of a raised postoperative serum HCG

If untreated, can cause life threatening hemorrhage

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PERSISTENT ECTOPIC PREGNANCY (PEP)

TREATMENT is by- Reoperation and further evacuation

/ Salpingectomy Administration of IM / oral

Methtrexate in a single dose of 50 mg/m2 of body surface

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SAM TREATMENT Aim- trophoblastic destruction without

systemic side effects Technique- Injection of trophotoxic

substance into the ectopic pregnancy sac or into the affected tube by- Laparoscopy or Ultrasonographically guided

Transabdominal (Porreco, 1992) Transvaginal (Feichtingar, 1987)

With Falloposcopic control (Kiss, 1993)

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SAM TREATMENT Trophotoxic substances used-

Methtrexate (Pansky, 1989) Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486) PGF2 (Limblom, 1987) Hyper osmolar glucose solution Actinomycin D

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MEDICAL TREATMENT WITH METHOTREXATE

Resolution of tubal pregnancy by systemic administration of Methotrexate was first described by Tanaka et al (1982)

Mostly used for early resolution of placental tissue in abdominal pregnancy. Can be used for tubal pregnancy as well

Mechanism of action- Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the trophoblast.

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MEDICAL TREATMENT WITH METHOTREXATE

Ectopic pregnancy size should be < 3.5 cm.

Can be given IV/IM/Oral, usually along with Folinic acid

Recent concept is to give Methtrexate IM in a single dose of 50mg/m2 without Folinic acid. If serum HCG does not fall to 15% with in 4-7 days, then a second dose of Methtrexate is given and resolution confirmed by HCG estimation

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MEDICAL TREATMENT WITH METHOTREXATE

Advantages – Minimal Hospitalisation.Usually outdoor

treatment Quick recovery 90% success if cases are properly selected

Disadvantages- Side effects like GI & Skin Monitoring is essential- Total blood count,

LFT & serum HCG once weekly till it becomes negative

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EXPECTANT TREATMENT Tubal Pregnancies are known to Abort /

Resolve Befor the advent of salpingectomy in

1884, ectopic pregnancies were being treated expectantly with 70% mortality.

Today only selected cases are managed expectantly, screened and identified by high resolution ultrasound scanner and monitored by serial serum HCG assay

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EXPECTANT TREATMENT Identification criteria (Ylostalo et al ,

1993)- Diameter of ectopic pregnancy <4 Cm. No sign of intrauterine pregnancy No sign of rupture by TVS No sign of acute bleeding by TVS Falling level of serum HCG at 2 day intervals

If any deviation from the above criteria occurs, then emergency treatment is necessary.

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EXPECTANT TREATMENT Spontaneous resolution occurs in

72%,while 28% will need laparoscopic salpingostomy

In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant level.

The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2.

Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low.

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SUMMARY Incidence of ectopic pregnancy is rising while

maternal mortality from it is falling. Early diagnosis is the key to less invasive

treatment. The choice today is Laparoscopic treatment of

unruptured ectopic pregnancy. The trend is towards conservative treatment. Careful monitoring and proper counselling of

patients is mandatory. Ruptured ectopics should be unusual with

compliant patients and appropriate medical care.

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