ECTOPIC PREGNANCYECTOPIC PREGNANCY

ASSOCIATE PROFESSOR IOLANDA BLIDARU, MD, PhD

18/04/23 20:25 Ectopic Pregnancy 2

ECTOPIC PREGNANCY

DEFINITION

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

ectopic / extrauterine

heterotopic

18/04/23 20:25 Ectopic Pregnancy 3

INCIDENCE >1 in 100 pregnancies.

• The incidence of ectopic pregnancy has been rising:– USA - 5 fold– UK - 2 fold– France - 15/1000 pregnancies– India - 1/100 deliveries

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

18/04/23 20:25 Ectopic Pregnancy 4

18/04/23 20:25 Ectopic Pregnancy 5

ETIOLOGY

• Any factor that causes delayed transport of the fertilised ovum through the Fallopian tube (tubal ectopic pregnancy).

• These factors may be:

1. congenital or acquired;

2. mechanical or functional

18/04/23 20:25 Ectopic Pregnancy 6

ETIOLOGY

• CONGENITAL - tubal hypoplasia, tortuosity, congenital diverticuli, accessory ostia, partial stenosis

• ACQUIRED – Inflammatory: PID, septic abortion, puerperal sepsis,

medical termination → intraluminal / peritubal adhesions– Surgical: tubal reconstructive surgery, recanalisation of

tubes – Tumoral: broad ligament myoma, ovarian tumour– Miscellaneous causes: IUD, endometriosis, ART,

hormonal perturbations → tubal disfunctions– Previous ectopic pregnancy

18/04/23 20:25 Ectopic Pregnancy 7

SITES OF ECTOPIC PREGNANCY

1)Fimbrial 2)Ampullary 3)Isthmic 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%)

18/04/23 20:25 Ectopic Pregnancy 8

PATHOLOGIC ANATOMY

• minimal reaction against trophoblast invasion

• local hemorrhage → hematoma

• The uterus - some of the changes associated with normal early pregnancy, (softening of the cervix and isthmus, increase in size).

• the Arias-Stella reaction in the endometrium – in pregnancy both endocervical gland hyperplasia and hypersecretory appearance

18/04/23 20:25 Ectopic Pregnancy 9

EVOLUTION

Tubal pregnancy • tubal abortion in ampullary pregnancy • tubal rupture in isthmic pregnancy, interstitial

(cornual) pregnancy• hematosalpinx• pelvic hematoceleAbdominal/ovarian pregnancy (primary/secondary)Broad ligament pregnancyCervical pregnancy• spontaneous regresion

Ruptured tubal (ampullary) early pregnancy

18/04/23 20:25 Ectopic Pregnancy 10

18/04/23 20:25 Ectopic Pregnancy 11

CLINICAL PRESENTATION

• Ectopic pregnancy remains almost asymptomatic until it ruptures.

• In contemporary practice, syptoms and signs of ectopic pregnancy are often subtle or even absent.

• In recent years, in spite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.

•

18/04/23 20:25 Ectopic Pregnancy 12

DIAGNOSIS

• SYMPTOMS1. Amenorrhea – abnormal menstruation

2. Abdominal pain – absent / different sites; pain in the neck or shoulder (diaphragmatic irritation); tenderness on bimanual ex. + motion of the cervix

3. Syncope, vaso-vagal response (bradycardia, hypotension)

4. Vaginal bleeding – scanty, dark brown, intermitent / continuous

5. Pelvic mass - lateral or posterior to the uterus, +/- uterine displacement; painful; bulging of Douglas pouch

18/04/23 20:25 Ectopic Pregnancy 13

EARLY MULTI-MODAL DIAGNOSIS

• Vaginal ultrasound scanning (+ colour Doppler) • Serum beta HCG level • Serum progesterone levels < 5ng/mL• Uterine curettage• Culdocentesis• Hemogram • Laparoscopy / laparotomy

A combination of these methods may have to be employed, but only to hemdynamically stable women; those with presumed rupture must undergo surgical therapy.

18/04/23 20:25 Ectopic Pregnancy 14

METHODS OF EARLY DIAGNOSIS

Multi-modality diagnosis results

1. TV – US - Demonstration of the gestational sac with or without an alive embryo outside the uterus .

- Ruptured ectopic with fluid in the cul-de-sac and an empty uterus.

2. Culdocentesis - in emergent situations to confirm diagnosis, highly specific if performed and interpreted correctly → presence of free-flowing, NON-clotting blood

18/04/23 20:25 Ectopic Pregnancy 15

18/04/23 20:25 Ectopic Pregnancy 16

18/04/23 20:25 Ectopic Pregnancy 17

DIFFERENTIAL DIAGNOSIS

• Threatened or incomplete abortion

• Salpingo-ooforitis

• Appendicitis

• Twisted ovarian cyst

• Rupture of a corpus luteum / follicular cyst

• Other abdominal conditions

18/04/23 20:25 Ectopic Pregnancy 18

MANAGEMENT

• Depends on the stage of the disease and the condition of the patient at diagnosis.

1. COMPLICATED ECTOPIC PREGNANCY

2. NON-COMPLICATED ECTOPIC PREGNANCY

18/04/23 20:25 Ectopic Pregnancy 19

MANAGEMENT OF COMPLICATED ECTOPIC PREGNANCY

TREATMENT – ALWAYS SURGICAL

• Salpingectomy of the offending tube

• Posterior colpotomy - if pelvic haematocele is infected → to drain the pelvic abscess

• Salpingo-oophorectomy

18/04/23 20:25 Ectopic Pregnancy 20

MANAGEMENT OF NON-COMPLICATED = UNRUPTURED ECTOPIC PREGNANCY

• SURGICAL

• MEDICAL TREATMENT

• EXPECTANT MANAGEMENT

OPTIONS

18/04/23 20:25 Ectopic Pregnancy 21

SURGICAL TREATMENT OF UNRUPTURED ECTOPIC PREGNANCY

• Carried out by Laparoscopy / Laparotomy.

• The procedures are: – Salpingectomy / Cornual resection /

Excision

– Conservative surgery (in cases of Infertility & desire for pregnancy)

18/04/23 20:25 Ectopic Pregnancy 22

18/04/23 20:25 Ectopic Pregnancy 23

MEDICAL TREATMENT • Trophotoxic substance:

– Methtrexate - resolution of tubal / abdominal pregnancy by systemic administration

– Interferes with the DNA synthesis

• Ectopic pregnancy size should be < 3.5 cm.

• IV/IM/Oral, usually along with Folinic acid.

• Injection into the ectopic pregnancy sac or affected tube

CLINICAL FORMSDIAGNOSIS AND MANAGEMENT

• Tubal pregnancy

• Abdominal pregnancy - laparatomy

• Cervical pregnancy - hysterectomy

18/04/23 20:25 Ectopic Pregnancy 24