JESSENIUS FACULTY OF MEDICINE in MARTIN COMENIUS UNIVERSITY, BRATISLAVA, SLOVAK REPUBLIC

Ectopic pregnancy
Obstetrics & Gynecology Clinic
JLF UK Martin

Definition


  

An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there The most common site of occurrence is within a fallopian tube, however, ectopic pregnancies can occur in the ovary, the abdomen and in the lower portion of the uterus (the cervix) Put very simply, an ectopic pregnancy means "an out-of-place pregnancy Ectopic Pregnancy is a common, life threatening condition affecting one in 100 pregnancies As the pregnancy grows it causes pain and bleeding. If it is not treated quickly enough it can rupture and cause abdominal bleeding, which can lead to maternal cardiovascular collapse and death

History

Ectopic pregnancies were initially described in the 10th century (Albucasis in 963 A.D.) and for a long time were universally fatal events for the mother Initial treatments (in the old days) were desperate primitive attempts designed to destroy the growing pregnancy without sacrificing the mother's life. These included
 

 

starvation (hoping that the fetus would starve before the mother) bleeding (intentional exsanguination of the mother in the hope that the fetus would die and the mother could be spared) administration of strychnine (to preferentially destroy the fetus) administration of electricity into the growing gestational sac

History (cont)

First serious surgery attempts in the 19th century (Lawton Tait in 1884) - resulted in a high maternal mortality rate (greater than 60%) Development in the management of ectopic pregnancies have led to remarkable success from firstly aim "saving the mother's life" to recently "saving the woman's fertility"

Ectopic Pregnancy

 

Ectopics happen in about 0.25-1% of all pregnancies The mortality rate is about 1 per 1000 ectopics (10% of all maternal deaths) Ectopic pregnancy rate increased almost 4 fold (from 4.5 per 1000 pregnancies to 16.8 per 1000 pregnancies since 1970) Fatality rate from ectopic pregnancies dropped almost 90% (from 35.5 per 1000 ectopics to 3.8 per 1000 ectopics) Most ectopic pregnancies occur in women aged 25-34 years Over 75% of ectopics are diagnosed before 12th week of gestation

 

Ectopic Pregnancy

The decrease in maternal morbidity is due to:

     

early detection of pregnancy (hCG assays) aseptic (sterile) technique antibiotics anesthetic agents availability of blood and transfusions surgical techniques (salpingectomy & salpingostomy)

Classification

   

Tubal pregnancy (96-98%) ampullary (mid) portion of the fallopian tube (80-90%) isthmic (area closer to uterus) portion of the fallopian tube (5-10%) fimbrial (distal end away from uterus) portion of the fallopian tube (5%) cornual (within the uterine muscle) portion of the fallopian tube (1-2%) Abdominal (1-2%) primary/secondary (tubo-abdominal/abdomino-ovarian) Ovarian (0.5-1%) Cervical (less than 0.5%) Heterotopic (combination of ectopic + intrauterine pregnancy)

Uncommon Ectopics
  

Intraligamentous pregnancy (in broad ligament) Pregnancy in a uterine diverticulum or sacculation Angular pregnancy (inside the uterotubal attachment) Pregnancy in a rudimentary horn of uterus Intraural pregnancy (in myometrium) Vaginal pregnancy Multiple tubal pregnancy

   

Histology & Anatomy



The fallopian tubes (oviducts) are small, hollow muscular tubes each about ten cm long Inside the tube is delicate mucous membrane that forms the fimbriae In the epithelial lining of the tubes half the cells are mucus-secreting and half have cilia- tiny hair like projections which beat gently to propel these secretions towards the uterus The muscular wall of each tube becomes thicker towards the uterus, and has a natural peristaltic action which assists the movement

Embryology & Physiology

Risk Factors for Ectopic Pregnancy



Pelvic inflammatory disease (PID) or Salpingitis 6 -10 times higher risk. Mainly invasion of gonorrhea or chlamydia from the cervix up to the uterus and tubes and infection in these tissues causes an intense inflammatory response and scar tissue adhesions in the tube and may damage the cilia of the fallopian tube Endometriosis History of IUD use Progesterone only contraceptive pill (mini pill) tubal motility Pregnancy after tubal ligation or coagulation Previous tubal surgery Ovulation induction or ovarian stimulation alters

     

Risk Factors for Ectopic Pregnancy

   

In vitro fertilization IVF Advancing age

2-5% of pregnancies are conected with

Previous ectopic about 10-20% of women attempting pregnancy after one ectopic will have another Salpingitis Isthmica Nodosa uncommon diverticulae in the proximal (isthmic) portion of the tube that enhance tubal implantation of the early developing embryo Pelvic adhesions, pelvic tumors Atrophic endometrium Septate uterus Zygote abnormalities (chromosomal abnormatity, neural tube defects, abnormal spermatozoa)

   

Symptoms
        

One-sided pain in abdomen (can be persistent and severe, but may not be on the same side as an ectopic pregnancy) Shoulder-tip pain (due to internal bleeding irritating the diaphragm when woman breathe in and out) Bladder or bowel problems (woman feels pain when she has her bowels open tenesmus, or when she passes water) Collapse (feeling of light-headed or faint, paleness, increasing pulse rate, sickness, diarrhoea and falling blood pressure) Pregnancy test (from urine may be positive but not always hCG blood tests to confirm) Amenorrhoea (missed or late period) Abnormal vaginal bleeding Symptoms of pregnancy Fever (unusual, occuring in 2% of pacients)

Ectopics Manifestation

Emergency presentation - Suddenly, without warning a woman is very unwell, collapses and is taken to hospital in fase of haematoperitoneum and hemorrhage shock Subacute presentation - The most common presentation is with a missed period, positive pregnancy test, some abdominal pain, and irregular vaginal bleeding Rrisk pregnancy group - After previous ectopic, tubal surgery or assisted conception ( IVF) detection rate is high women are primary observed

Diagnosis

      

Early diagnosis of an ectopic pregnancy is critically important There is no uniformly accepted diagnostic protocol History Physical examination (pain, adnexal mass, enlarged uterus) Transvaginal or transabdominal ultrasound Quantitative hormone tests (HCG, -hCG, progesterone) Occasionally culdocentesis (thin needle is inserted at the top of the vagina, between the uterus and the rectum, to check for blood in CD) Sometimes dilatation and curettage (exclude intrauterine

USG Diagnosis

   

Pseudogestational sac in uterus (is seen in 10-20% of ectopics) Decidual transformed endometrium (thick & hyperechogenic) No presence of developing fetus in uterus Adnexal mass or Tubal ring (gestational sac, yolk sac or fetal pole) Occasionaly hemosalpinx (tubes fill with blood) Enlargement of uterus (not appropriate for date) Fluid in Cul De- Sac

  

Hormone Tests Diagnosis

  

Obviously first of all is a pregnancy test (urinary RIA, ELISA test) HCG more than 200 mIU/mL Blod serum quantitative levels of -hCG testing
- Common used is ELISA method - Remember: monitor the progress In a normal pregnancy level of -hCG should double every 48 hours, in ectopic is ratio lower

- An

increase in serum -hCG less than 66% over two days is predictive of ectopic pregnancy

- Results reported in mIU/ml (milliInternational units per milliliter) - To establish the diagnosis correlate lab results with the clinical picture
- -hCG - -hCG

peaks in 10 weeks after last menstrual period assay is negative (when less than 5 mIU/mL) )

Other Pregnancy Related Hormones



Progesterone concentration of greater >25 ng/mL is highly correlated (greater than 95%) with a normal intrauterine pregnancy concentration of less <15 ng/mL is highly correlated (almost 100%) with an abnormal and nonviable pregnancy Early pregnancy factor (EPF) Pregnancy specific beta-1 glycoprotein (SP1) Placental protein 5 (PP 5) Serum creatine kinase (CK)

   

Differential Diagnosis

          

Abortion (complete,incomplete, inevitable, missed) Threatened appendicitis Acute dysmenorrhea Placenta previa Shock (hemorrhagic, hypovolemic) Ruptured corpus luteum cyst Adnexal torsion Cornual myoma or abscess Ovarian tumor Endometrioma Cervical cancer

Management

Once an ectopic is diagnosed, there are several different treatments It is not possible to take the pregnancy from the tube and put it into the womb In all cases, the pregnancy must be terminated Various forms of management The appropriate surgery follow up for the patient are serial blood tests of the pregnancy hormone (-HCG) Within a few weeks, the pregnancy hormone should not be measureable

  

Management (cont)
The options are as follows:
y

Expectant management - proportion of all ectopics will not progress to tubal rupture, but will regress spontaneously and be slowly absorbed Level of hCG must falling and a woman becomes clincally well. Situation needs daily hCG, TVS. If hCG increases or sonographic findings are suspicious active management Medical treatment (methotrexate,dyktinomycin, hyperosmolar glucose, potassium chloride, mifepristone) given by injection in form of systemic or local administration Laparoscopic surgery - (salpingotomy or salpingectomy). Open surgery (laparotomy) - involves a 5-8 cm incision at the top of the pubic hairline The affected tube is brought out and either salpingotomy or ectomy is performed

Criteria for Expectant Management

       

Decreasing hCG titers (less than 1500 mIU/mL ) Tubal location (rather than ovarian, abdominal, cervical) No evidence of rupture or significant bleeding Ectopic mass with size less than 4 cm Highly motivated patient with strong desire to avoid both surgery and medical management Hemodynamically stable healthy woman Absence of fetal heart tones

Methotrexate Treatment
  

Anti-metabolite drug Inexpensive, easy to obtain, well tolerated Mixture containing at least 85% of folic acid antagonist "4-amino10-methylfolic acid and 25% of Leucovorum calcium (folic acid agonist) The initial dose regimen MTX (1 mg/kg IM ) or single IM dose of 50 mg/square meter Leukovorum (0.1 mg/kg IM ) Dont exceed 4 doses 70-95% efficiency of cases treated Methotrexate management takes 4-6 weeks for complete resolution of the ectopic pregnancy

  

Complications of Methotrexate
 

Bone marrow suppression Acute and chronic hepatotoxicity transient elevations in serum liver transaminases Progressive pulmonary toxicity (pneumonitis and pulmonary fibrosis) Dermatologic effects (rashes, itch, folliculitis, photosensitivity, pigment changes, rarely alopecia) Renal impairment GI side effects (stomatitis, gastritis, diarrhoea)

 

Invasive Treatment

The standard aim of care is to control the bleeding and remove the ectopic pregnancy Prior to the late 1980's, this was accomplished by first making a large incision in the woman's abdomen and "looking" to find if there was a swollen fallopian tube containing the ectopic With the advent of advanced laparoscopic technique, the ectopic pregnancy can be identified with only a small incision below the umbilicus (navel) Microinvasive technique

Surgical Treatment Forms

Salpingotomy: Making an incision on the tube and removing the pregnancy Salpingectomy: Cutting the tube out Segmental resection: Cutting out the affected portion of the tube Fimbrial expression: "Milking" the pregnancy out the end of the tube Usually, if the tube is not ruptured laparoscopy

 

 

Cases of rupture with significant hemorrhage into the abdomen laparotomy

Complications

      

Hemorrhage and hypovolemic shock Infection Loss of reproductive organs following surgery Infertility, sterility Urinary and/or intestinal fistulas following complicated surgery Disseminated intravascular coagulation Persistent ectopic (complication of conservative surgical treatment, incomplete removal of trofoblastic tissue) Rh disease

Emotions Changes

Ectopic pregnancy can be a devastating experience (loss of baby, loss of part of fertility, recovery from surgery) Postsurgery depression Sudden end to pregnancy hormonal disarray

  

Distress and disruption of family life

Prognosis

The prognosis with an ectopic pregnancy is good for patients with an early diagnosis Good when fertility is preserved (as much as possible) Patients with a previous ectopic pregnancy should be educated regarding the potential increased risk for another ectopic pregnancy

The Future Pregnancy



If one of the tubes was removed, woman ovulate as before, but chances of conceiving will be reduced to about 50% Woman can still become pregnant and have a successful pregnancy with one intact tube Overall chances of a repeat ectopic are between 7 10% and depends on the type of surgery If infertility occurs, fertility treatment techniques can still help a woman achieve pregnancy (IVF)

Tubal Pregnancy


Is a pregnancy that grows in the fallopian tube, not the uterus If the pregnancy continues and the tube ruptures, there may be lifethreatening intraabdominal bleeding Even with the modern practice of medicine, the rupture of the tubal ectopic pregnancy is still one of the leading causes of gynecological deaths

Tubal Pregnancy Findings

   

Acute tubal rupture (40% of tubal pregnancies) Chronic tubal rupture (60% of tubal pregnancies) Early unruptured tubal pregnancy Tubal abortion

Tubal Pregnancy at USG

Ultrasound showing uterus and tubal pregnancy 2D scan Uterus outlined in red Uterine lining in green Ectopic pregnancy yellow Fluid in uterus at blue circle is called a "pseudogestational sac"

   

Tubal Pregnancy at USG

   

Detailed view of ectopic (thick, brightly echogenic, ringlike structure outside the uterus) Tubal pregnancy circled in red 4.5 mm fetal pole (between cursors) in green Pregnancy yolk sac in blue

Tubal Pregnancy
  

A right tubal ectopic pregnancy seen at laparoscopy The swollen right tube containing the ectopic pregnancy is on the right at E The stump of the left tube is seen at L - this woman had a previous tubal ligation

Tubal Pregnancy
After laparoscopic resection of the tube, the tubal stump is seen at S

Close view of the same ectopic

Tubal Pregnancy
Same situation after rupture

Right tubal ectopic pregnancy in 11 th week of gestation

Tubal Pregnancy
DIAGNOSIS & TREATMENT OPERATIVE LAPAROSCOPIC SURGERY
 

Laparoscopist must try to remove the ectopic pregnancy, preserve the fallopian tube, and early send the patient home Diagnostic LSK picture below

Tubal Pregnancy


The first step of this technique involves making a linear slit into the fallopian tube over the ectopic with a monopolar needle tip.

Tubal Pregnancy


The second step involves teasing out the ectopic pregnancy intact, and then irrigating the incision to make sure it is free of any ectopic tissue

LAPAROSCOPIC SALPINGECTOMY FOR ECTOPIC PREGNANCY

CASE REPORT


Laparoscopic left salpingectomy after attempted salpingostomy for a left tubal ectopic pregnancy in a 32-year-old gravida 3 para 2 Because patient wished to retain her fertility, salpingostomy was initially attempted to save the tube, but hemorrhage and retained trophoblastic tissue dictated a partial salpingectomy (removal of part of the tube) The ectopic pregnacy is visualized in the ampullary region of the left fallopian tube

LSC salpingectomy (cont)

Salpingostomy on the antimesenteric border. Is perfomed to allow withdraw of the products of conception and preservation of the tube

After the tube is opened, a grasper is used to remove the products of conception

LSC salpingectomy (cont)

Bleeding occuring after removal of the products of conception Electrocoagulation is used to achieve hemostasis

Electrocoagulation has achieved hemostasis The tube was partially removed due to the retained trophoblastic tissue

LSC salpingectomy (cont)

The distal tube has been removed through the port

Successive electocoagulation of the mesosalpinx and subsequent sharp dissection allows partial salpingectomy

LSC salpingectomy (cont)



Once hemostasis is assured, the hemoperitoneum is evacuated A single follow up HCG should be examine for 2-3 weeks post operation

Ovarian Pregnancy

 

Ovary is the white structure in the middle Pregnancy is implanted on the far right side of the ovary at the "X Around the ovary are seen bleeding and clotted blood

Abdominal Pregnancy

     

Incidence of 1 in 8000 births Mostly secondary form of abdominal pregnancy Predominant symptom si pain with hemorrhage Genitourinary symptoms discomfort Immediate surgical removal of the fetus Retain attached placenta in site and start with MTX treatment High maternal & fetal mortality rate

Keep in Mind
Why is ectopic pregnancy so dangerous?

 

If the ectopic doesnt die, the thin wall of the tube will stretch and cause pain, discomfort in the lower abdomen There may be some vaginal bleeding at this time As the pregnancy grows, the tube may rupture, causing severe abdominal bleeding, pain, collapse death and if not recognized Even if woman has ectopic, first urine pregnancy testmay be negative !

End with Funny

Thanks for your attention !