ectopic pregnancy rs
TRANSCRIPT
ECTOPIC PREGNANCY
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
INTRODUCTION
• CASE DESCRIBED IN EGYPTIAN HEIRLOGRAPHICS
• DEFINITIVE SURGERY FIRST SUCCESSFULLY DONE
BY LAWSON TAIT IN 1883 AD - SALPINGECTOMY
• ANY FACTOR INTERFERING WITH NORMAL
FERTILISATION & NIDATION CAN CAUSE ECTOPIC
• INCIDENCE 1: 150-300 PREGNANCIES
• HIGHEST INCIDENCE REPORTED 1:28 WEST INDIES
(STD)
• ICMR 1990 INCIDENCE 3.2per1000 PREGNANCIES
Ectopic Pregnancy
The Rising Incidence
1per300 PREG-1970
1per70/200 PREG-1990
slide
Trend of Ectopic Pregnancy Incidence in
the US
0
20
40
60
80
100
1970 1975 1980 1985 1990
Ecto
pic
s
Ectopic Pregnancy
Potentially Lethal• Leading cause of maternal death
• Accounted for 15% of all maternal deaths in the US in 1988 (1)
• Risk of deaths five times higher in teenagers (2)
(1) National Centre for Health Statistics. 1990; 38(13): 23
(2) Goldner T E et al. MMWR Morb Mortal. 1993; 42(SS-6): 73
DEFINITION
• Ectopic pregnancy is defined as implantation and
development of zygote at a site other than normal
implantation site
Then
what is the normal implantation site?
• Uterine cavity but does not include the angles of the
cavity and cervical canal.
SITES & INCIDENCE
HETEROTROPIC 1:10000
UTERINE (3%)
CERVICAL (0.2 %)
ANGULAR
CORNUAL
DIVERTICULA
RUDIMENTARY
HORN
TUBAL (96%)
AMPULLARY (80%)
ISTHMUS (12%)
FIMBRIAL (5%)
INTERSTITIAL (2%)
OVARIAN (0.2%)
ABDOMINAL (1.4%)
INTRALIGAMENTARY
POST-HYSTERECTOMY
PROLAPSED TUBE
CERVICAL STUMP
VESICO-VAGINAL/RECTAL
SPACE
Bilateral tubal
AETIOLOGICAL FACTORS• TUBAL
• ANATOMICAL FACTORS ABNORMAL TUBAL DEVELOPMENT / ATRESIA / ACESSORY OSTIA / DIVERTICULA / ABNORMAL LENGTH / KINKING
• PHYSIOLOGICAL FACTORS TUBAL SPASM / IMPAIRED PERISTALSIS / IMPAIRED CILIARY MOTION CILIARY DESTRUCTION / BLOCKAGE MUCUS PLUG SYNECHIAE FORMATION POCKETS & PARTIAL OBSTRUCTION
• INFECTIONS ENDOSALPINGITIS (tubercular, non tubercular) / EXOSALPINGITIS
• ENDOMETRIOSIS
• PRIOR SURGERY TUBECTOMY,TUBOPLASTY,PELVIC SURGERY
• BROAD LIGAMENT FIBROID , peritubal adhesions, large ovarian/paraovarian tumours causing stretching of tube
• DES EXPOSURE
AETIOLOGICAL FACTORS
OVARIAN FACTORS
FERTILISATION OF UNRUPTURED OVA
TRANSMIGRATION OF OVA
LATE OVULATION
OVUM ENLARGEMENT DRUGS
AETIOLOGICAL FACTORS
ZYGOTE ABNORMALITIES
ABNORMAL SPERM MOTILITY
ABNORMAL SPERMATOZOA MORPHOLOGY BODY /
TAIL
CHROMOSOMAL ABNORMALITIES
AETIOLOGICAL FACTORS
EXOGENOUS
INTRAUTERINE CONTRACEPTIVE DEVICE
6-8 FOLD INCREASE AS IT PREVENTS
INTRAUTERINE IMPLANTATION EFFECTIVELY
Cu-T : 3-4 times ; PROGESTASERT : 9-10 times
PROGESTERONE ONLY PILL / INJ DEPOT-PROVERA
REDUCED TUBAL PERISTALSIS, TUBAL
DECIDUALISATION
EMERGENCY CONTRACEPTION FAILURE, TUBAL
DECIDUALISATION
AETIOLOGICAL FACTORS
MISCELLANEOUS
ASSISTED REPRODUCTIVE TECHNIQUES 9.5%
INCIDENCE OF ECTOPICS
• SIFT
• ZIFT
• GIFT
• IVF-ET
ELONGATED CERVIX
PATHOLOGY
• INVASIVENESS OF TROPHOBLAST INTO THIN ANATOMICAL STRUCTURE (MUSCULAR LAYER) LACK OF RESISTANCE LEADS TO RUPTURE & HAEMORRHAGE
RECURRENT BLEEDING LAMINATIONS TUBAL MOLE
TUBAL ABORTION PELVIC HAEMATOCELE,EXPULSION OF RPOC
ABSORPTION
TUBAL EROSION/PENETRATION/ PERFORATION PERITUBAL HAEMATOMA BROAD LIGAMENT/SECONDARY ABDOMINAL PREGNANCY
TUBAL RUPTURE BROAD LIGAMENT HAEMATOMA/PELVIC HAEMATOCELE
CONTINUATION OF PREGNANCY
OVARIAN PREGNANCY
• EXTRAOVULAR / INTRAOVULAR
• SPEIGELBERG’S CRITERIA
TUBES SHOULD BE INTACT ABSOLUTELY.
SAC MUST BE CONNECTED BY OVARIAN
& MESO-OVARIAN LIGAMENT.
OVARIAN TISSUE MUST BE COVER SAC.
SAC MUST BE IN POSITION OCCUPIED BY
OVARY.
CERVICAL PREGNANCY
• MORE COMMON AFTER MTP
• PROFUSE BLEEDING MAY OCCUR IN ASSOCIATION
WITH PAINLESS ABORTION
• D.D. CA CX / ENDOCervical CA /DEGENERATING
FIBROID POLYP / INCOMPLETE ABORTION
• RX. D&C WITH LIGATION DESCENDING CERVICAL
ARTERY OR SHIRODKAR’S CERVICAL SUTURE ;
TAMPONADE USING FOLEY’S CATHETER OR
SENGSTAKEN BLACKMORE TUBE ; HYSTERECTOMY .
STUDDIFORD CRITERIA
PRIMARY ABDOMINAL PREGNANCY
• TUBES SHOULD BE NORMAL
• OVARY SHOULD BE NORMAL
• NO PRESENCE OF UTERO-TUBAL FISTULA
SECONDARY ABDOMINAL
PREGNANCY• History suggestive of Threatened Abortion/Ectopic pain , bleeding , fainting .
• Minor ailments of pregnancy severely exaggerated .
• Fetus felt very easily , also fetal movements .
• Abnormal position in abdomen .
• No Braxton Hick’s contractions .
• Uterus separate from fetus .
• X-ray abdomen AP & Lateral : Gas shadows & intestinal shadows overlie fetus shadows
Fetal skeleton overlies maternal spine
SECONDARY ABDOMINAL
PREGNANCY• INV : sounding uterus, HSG , USG , Doppler , Placentography
• Terminate pregnancy when diagnosis confirmed, as it is
associated with 50%foetal malformation rate.
• Keep 4-5 Units blood available at laparotomy.
• Wait only if issueless , elderly primigravida , BOH , POG =32
weeks . NO CONGENITAL ANAMOLIES DETECTED .
• Placenta should not be removed from adherent invaded
tissues . Only separated parts of placenta or part attached to
omentum, may be removed along with omentum , leave drain
, give METHOTREXATE .
• Patients usually have failure to lactate due to placental
hormones
CLINICAL SYMPTOMATOLOGY &
SIGNS• ABDOMINAL PAIN ILIAC FOSSAE 95% CASES
(Precedes Bleeding PV)
ill fitting pain/lancinating/pulsatile/colicky/ tenesmus
suprapubic–epigastric /shoulder tip
• AMENORRHOEA followed by BLEEDING PV 75% CASES
(Irregular around menses in 4-5%) Blood
Brownish-Violet with disintegrated granular endometrial tissue
• PREGNANCY SYMPTOMS i.e. NAUSEA/EMESIS
• PYREXIA MILD < 100.4*F
• 5 P’s :
PALLOR,PAIN,PROSTRATION,PULSE(TACHYCARDIA), PRE
SSURE(HYPOTENSION)
• LETHARGY / LISTLESS
Ectopic Pregnancy
The Masquerader & The Chameleon
• Varied presentations
• Features may change character even in the same
patient over time
• The ‘classic’ triad of pain, amenorrhea and
vaginal bleeding seen in less than half
• In a classic history, only 14% had ectopic
pregnancy
(1) Schwartz et al. Obstet Gynecol. 1980;56:197
CLINICAL SYMPTOMATOLOGY &
SIGNS• ACUTE PRESENTATION (1%)
PAIN ABDOMEN AMENORRHOEA followed by BLEEDING PV SHOCK FEATURES
• CHRONIC PRESENTATION
AMENORRHOEA
BLEEDING PV
PAIN ABDOMEN
DYSURIA / TENESMUS / DIARRHOEA (increase frequency of motion)
PALLOR
ICTERUS
ABDOMINAL TENDERNESS REBOUND/FIXED POINT
PV : ADNEXAL MASS
CLINICAL SYMPTOMATOLOGY &
SIGNS• Abdomen :
Inspection – Reduced movements,
Peri umbilical discolouration (Cullen’s Sign)
Palpation – Guarding, tenderness, Rebound
tenderness, Fixed point tenderness(Adler’s Sign)
• Per Vaginal :
Cervical Rocking test + 20% Cases ? fallacious tenderness
Pulsatile Fornix , Boginess in fornix
Uterus enlargement < 6 weeks
TENDER ADNEXAL MASS
CLINICAL SYMPTOMATOLOGY &
SIGNS
SYMPTOM ACUTE
Pain Abdomen +++
Bleeding PV +++
Syncope ++
Shoulder tip Pain ++
SIGNS
CVS Collapse +++
Abd Tender ++
PV Tender +
Fornix Mass -/+
CHRONIC
Silent / Less severe
+
-/+
-
-
-/+
+
++
Ectopic Pregnancy
A Diagnostic Dilemma
Net result of these vagaries of presentation of ectopic pregnancy is that accuracy of the initial clinical evaluation is less than 50%
Tuomivaara L et al. Arch Gynecol. 1986; 237: 135
Ectopic Pregnancy
How is the woman deceived?
• Does not suspect pregnancy at all
• She thinks she is normally pregnant
• She thinks she is aborting a uterine pregnancy
Ectopic Pregnancy
Nothing Characteristic About It
• Pain extremely variable in intensity, location and character
• Amenorrhea may be absent in a fourth of women
• Adnexal mass in only upto 50% women
• Cervical motion tenderness may not be present
DIFFERENTIAL DIAGNOSIS
ALL ACUTE ABDOMEN EMERGENCIES
APPENDICITIS
DIVERTICULITIS
CHOLECYSTITIS
PERFORATED DUODENAL ULCER
PANCREATITIS
PYELO-NEPHRITIS
MESENTRIC CYST
COLITIS
THROMBOSIS MESENTRIC ARTERY
SPLENIC RUPTURE
HEPATIC RUPTURE
ANAEMIAS & VIRAL HEPATITIS IN CHRONIC ECTOPICS
DIFFERENTIAL DIAGNOSIS
• DYSMENORRHOEA WITH IRREGULAR PERIODS
• RETROVERTED GRAVID UTERUS
• ABORTION WITH SALPINGITIS
• THREATENED ABORTION
• RUPTURED / BLEEDING CORPUS LUTEUM CYST
• TORSION OF OVARIAN CYST / ADNEXAL MASS
• BLEEDING INTO ENDOMETRIOTIC CYST
• PREGNANCY WITH OVARIAN CYST / PEDUNCULATED
FIBROID
• RED DEGENERATION OF FIBROID
Ectopic Pregnancy
How to Diagnose It Then?
‘Be Ectopic Minded’
‘Keep a high index of suspicion’
‘Be paranoid about ectopic’ – after all, paranoia is but a heightened sense of awareness!
Have no regrets that it wasn’t ectopic – even if you find that after a laparoscopy or laparotomy!
INVESTIGATIONS• BASIC 1. Hb, TLC, DLC, BT, CT, PCV
2. Blood Group ABO/Rh
3. Urine RE/ME
4. LFT
• DISEASE 1. Urine Pregnancy Test
2. Beta hCG Assay
3. Ultrasonography Abdominal / TVS
Plain 53% 70%
Doppler 73% 93%
Gestational Sac absent in uterus
Thickened Endometrium
Adnexal Mass
POD Collection
Ring of Fire
4. Diagnostic Laproscopy
5. Culdocentesis / Paracentesis
6. D & C
MANAGEMENT
FACTORS DETERMINING MODALITIES
PATIENT ‘s CLINICAL STATUS
AGE
PARITY
FERTILITY FUNCTION
PRIOR SURGERY
MANAGEMENT
• WATCHFUL EXPECTANT
INDN : Asymptomatic, Reliable, Stable Patient.
USG Diagnosed Unruptured sac <2cm /Missed Abortion (No
FHM in Ectopic Gestation).
Low Beta hCG <5000IU/ml.
PROCEDURE : Monitor patient
Serum Beta hCG document falling titre.
TVS demise of Ectopic & reduction in size.
Shift to Medical Management if Criteria not fullfill.
MANAGEMENT• MEDICAL
INDN : Stable Patient . USG Gestation Sac < 3cms. No FHM.
Serum Beta hCG titre low preferably below 5000IU/ml.
PROCEDURE :
(a) Inject 20% KCl 0.5-1.0 ml near Fetal Cardiac Region.
(b) Inject Methotrexate 25 mg into Gestation Sac.
(c) Inject Methotrexate 50 mg/Sqm or 1mg/Kg IM.Dose apprx
50 mg per ampule.
30% Failure Rate, Require repeat doses.
MANAGEMENT
• ADVANCED OPERATIVE LAPROSCOPIC SURG
INDN : Stable Patient. Tubal Ectopic .
Gestation Sac <5cms. Preferably Unruptured.
PROCEDURE :
(a) Injection of Mrthotrexate into Gestational Sac via
laproscope.
(b) Linear Salpingotomy
(c) Linear Salpingostomy
(d) Partial / Complete Salpingectomy
(e) Segmental Resection & Anastomosis
MANAGEMENT• EXPLORATORY LAPROTOMY
INDN : Unstable Patient. Adnexal Mass
USG Gestation Sac > 5cms . Massive Haemoperitoneum.
Cornual / Angular Ectopic pregnancy . Abdominal Pregnancy .
PROCEDURE :
RESUSCITATE the Patient aggressively . Replace Blood .
Autotransfusion . Cell Saver . MAST Suit .
Partial / Complete Salpingectomy with or without
Oophorectomy.
