Abortion and ectopic pregnancy

DR YIHUN A
 Ectopic pregnancy

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 2) Ectopic pregnancy
• Defn: Blastocyst implants out of end. Of Ux.
• Incidence-1.6/100 pregnancies
• Significant increase in the past 20yrs cos’:
1-increased incidence of PID
2-increased diagnosis(previously undetected)
3-tubal factor infertility, including restoration of
tubal patency or documented tubal pathology
has increased
   4-delayed childbearing is more prevalent and has
been accompanied by an increased use of assisted
reproductive technologies, which carry increased
risk of ectopic pregnancy.
  
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 5-Intrauterine device (IUD) and tubal
sterilization rates have increased and
failures predispose to ectopic pregnancy
o After ectopic7-13X increase in subsequent
ectopic
Subsequent pregnancy
50-80%---Intrauterine
??10-25%---Ectopic,(7-15% )

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Sites:
• Fallopian tube-------95%
• Abdominal cavity---3-4%
• Ovarian----------------1%
• CX-----------------------<1%
Fallopian tube:
Ampulla------80%
Isthmus-------~12%
Fimbrial-------6%
Interstitial----2%
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Implantation
11/30/2021 sites for ectopic pregnancy following natural cycles and ART. 6
Mortality
• Ectopic pregnancy remains the leading cause
of early pregnancy-related death and accounts
for 9-10% of all pregnancy related deaths.
• Racial disparities affect ectopic pregnancy-
related deaths.
• A nonwhite woman had an overall risk of
death 3.4 times higher than a white woman.
• Inadequate access to gynecologic and prenatal
care may partially explain this trend.

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Tubal Rupture
• Rupture can lead to severe hemorrhage with
resulting morbidity and mortality
• Over the past two decades, the rate of rupture
with ectopic pregnancy ranged from 20 to 35
percent
• Three risk factors that increase the likelihood of
tubal rupture include ovulation induction,
serum -hCG level exceeding 10,000 IU/L when
ectopic pregnancy is first suspected, and a
history of never having used contraception
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 Risk
Factor
Factors for Ectopic Pregnancy
Odds Ratio (95% CI)

Prior ectopic pregnancy 12.5 (7.5, 20.9)

Prior tubal surgery 4.0 (2.6, 6.1)

Smoking >20 cigarettes per day 3.5 (1.4, 8.6)

Prior STD with confirmed PID by laparoscopy 3.4 (2.4, 5.0)

and/or positive test for Chlamydia
trachomatis

Three or more prior spontaneous miscarriages 3.0 (1.3, 6.9)

Age 40 years 2.9 (1.4, 6.1)

Prior medical or surgical abortion 2.8 (1.1, 7.2)

Infertility >1 year 2.6 (1.6, 4.2)

Lifelong sexual partners >5 1.6 (1.2, 2.1)

Previous IUD use

11/30/2021 1.3 (1.0, 1.8) 9
Pathophysiology
• Environment in the tubes different for trophoblastic invasion
-Resistance decreased
-Muscular mass lower
-high blood pressure
-hCG---low
• Because of these factorstermination of tubal pregnancy
common early by:
-abortion
-spontaneous regression
-or tubal rupture depending on gestational age
and location of implantation
o If embryo dies early spontaneous regression

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o If spontaneous regression fails to occur,
-ampullary and fimbrial preg. will end

up in abortion
-Isthmic and interstitial –tubal
rupture

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Diagnosis
• S/S:
I. Before rupture
1. Abdominal pain—close to 100% of the cases
tubal stretching & contraction
2. Delayed menses or ammenorrhea(75-90%)
3. Abnormal vaginal bleeding(50-80%) secondary to uterine
decidual shedding as a result of decreased hormones.
4. Absence of common signs of pregnancy(75%)
5. Abdominal tenderness(75%)
6. Palpable pelvic mass(30-50%)
II. During rupture
-Exacerbation of the pain

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III. After rupture
1. Faintness/Dizziness
-bleeding causes it
2. Generalized, unilateral or deep lower
quadrant acute pain
-blood irritating the peritoneum
3. Referred shoulder pain
-diaphragmatic irritation of
haemoperitoneum
4. Signs of shock
5. Afebrile state
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Investigations
A. Serum progestron
>25ng/ml—normal
<5ng/ml---abortion or ectopic
5-25%----not conclusive
B. Serial Serum hCG
Ectopic or abortion
-slow rise
-plateau at 6wks & then declines gradually
Normal intrauterine preg
-rapid rise
-plateau at 10wks & then decrease sharply
C. Ultrasound
Pseudogestational sac without fetus found in
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uterus &/or cystic mass found on tubes 14
D. Culdocentesis
-nonclotted blood
E. Laparoscopy—an endoscope is inserted through a small
abdominal incision to visualize the peritoneal cavity.
F. Curretage(Histology)
-Hyperplasia of endometrium glands that
are hypersecretory may be found with
out chronic villi.
Rx:
1. Before rupture
a. Non surgical
-cytotoxic drugs---Methotrexate

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b. Surgical
-various types
-choice depends on:
-site
-cause
-extent of tissue involvement
-wish of future fertility
Types:
-Salpingostomy—secondary intention healing
---fimbrial & ampullary
-Salpingotomy—incision closed with sutures
-segmental resection & end to end anastomosis
.pregnancy---proximal isthmus
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II. After rupture
-resuscitate patient
blood transfusion may be needed
-Salpingectomy commonest
-Salpingoophrectomyif gross distortion
of both tubes and ovaries.
Complication
Maternal—death(10% of all maternal
death), anemia, shock.
Other types of Ectopic pregnancy
1. Abdominal pregnancy
-usually result of tubal abortionsecondary
abd.pregnancy.
-Primary abd.pregnancy is rare.
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• 5-25% reach to fetal viability
-usually fetus deformed b/c of oligohydraminous
.Joint deformity
.neck webbing
.facial asymetry
.hypoplastic limbs
Rx:
-Surgery-as soon as Dxbecause of increased risk of
maternal complication
-Don’t remove placenta unless attached to:-
a. Uterus & ovary—b/c these organs can be
removed if there is heavy bleeding
b. Blood vessel that supplies the placenta
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can be ligated.
• Complications of leaving placenta behind:-
infection
abscess
adhesion
intestinal obstruction
paralytic ileus
pre-eclampsia (post partum)
wound dehiscence
2. Cervical ectopic pregnancy
-surgery—last alternative b/c risk of uncontrolled h’ge
& injury to urinary tract
-choice—methotrexate.
If contraindicated  surgery
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 ABORTION

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• Defn: terminologies:
• Abortion is the process of termination or
expulsion of pregnancy before 28th completed
weeks of gestation or <1000gm weight.
• Definition differs from countries to countries
base on technology of neonatal care.
• WHO defines abortion < 20 weeks or wt <500g
• Can be spontaneous (miscarriage) or induced
abortions.
• Can be safe or unsafe abortion

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• Unsafe abortion- characterized by lack or
inadequate skill of provider, hazardous
technique, & unsanitary facility or both.
• Recurrent abortion in its broadest definition is
defined as 2 to 3 or more consecutive
pregnancy losses before 28 weeks of gestation.
• Therapeutic abortion- abortion done for the
purpose of saving the life of the mother.
• Septic abortion- any type of abortion
complicated by pelvic infection
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Incidence:
• 15% of all pregnancies  spontaneous abortion
• Another 15% of all pregnancies  unsafe
abortion
• World wide13% of maternal deaths– due to
complication of abortion
• For every maternal death due to unsafe abortion
—>10-15 women suffer from morbidity
• Ethiopia—>25-50% maternal losses-secondary to
abortion & its complication.

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 Contii…
• In some developing countries also contributes to
50% maternal deaths.
• Effective FP-services reduce rate of induced
abortion but not to zero level b/s of some
reasons:
i) lack of access to FP
ii) no method is 100% effective/method
failure.
iii) high rate of violence(home/war time)
iv) Changing circumstance(divorce, crisis)
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 Clinical stages of abortion:
1)Threatened abortion: slight to moderate vaginal
bleeding, with or without uterine contractions,
without dilatation of the cervix, and without
expulsion of the products of conception, uterine size
is equal to date.
2)Inevitable abortion: slight to moderate bleeding,
with dilatation of the cervix, without expulsion of the
products of conception, Uterine size is less than or
equal to date.
• The gestational tissue can often be felt or visualized
through the internal cervical os.
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3)Complete abortion is the expulsion of all of the
products of conception, the uterus is small and well
contracted with a closed cervix, scant vaginal
bleeding, and only mild cramping.
4)Incomplete abortion: an abortion with retained
products of conception after expulsion of some.
The cervical os is open, gestational tissue may be
observed in the vagina/cervix, and the uterine size is
smaller than expected for gestational age, but not
well contracted.

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• The amount of bleeding varies, but can be severe
enough to cause hypovolemic shock.
• Painful cramps/contractions are often present.
5)In missed abortion, the embryo or fetus dies, but the
products of conception are retained in utero. Little or
none bleeding. Cx closed. Uterine size is equal to or less
than date. Decreased pregnancy signs and symptoms.
6)Septic abortion is manifested by fever, malodorous
vaginal discharge, pelvic and abdominal pain, and
cervical motion tenderness.
 Peritonitis and sepsis may be seen.
 Trauma to the cervix or upper vagina may be recognized
if there has been a criminal abortion.
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Initial assessement
• Consider abortion– If at least two of the following are experienced in a
reproductive age:
-Vaginal bleeding
-Lower abd. Pain &/or cramp
-Hx of amenorrhea
• Complete clinical assessment is necessary in such patient:
History: ask about:-
LMP
Bleeding(duration, amount)
Cramping(duration, severity)
Abdominal or shoulder pain
Hx of interference
Symptoms of infection

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• Physical exam:
V/S
General health
General system exam
Abdominal exam(check)
bowel sounds
distension
tenderness-direct
-rebound
Remove any visible products from cx or vagina!

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• Note(speculum exam)
amount of bleeding
Cx dilatation
Foul smelling discharge
Cx- laceration
Bimanual exam:
-Size of Ux
-pelvic mass
-tenderness
-consistency of Ux
-Cx closed or dilated
-Cx motion tenderness
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Laboratory
• Hg/Hct, B/G & Rh
• Based on clinical assessment when indicated:-
• WBC, ESR
• U/A
• RFT, LFT
• PLT. Count
• Plain film of the abd.(erect)
• Pelvic U/S
• hCG-as indicated
• Cx culture
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Mx:
1)Threatened Abortion
• Bed rest, pelvic rest
• Avoid intercourse & douching
• Monitor progress-V/S,U/S evaluation, Vx bleeding
• If sign of infection—Evacuate Ux after antibiotics
coverage
2)Complete abortion
• Confirm completeness—U/S
• Administer Ergometrine-0.5mg im
3) Incomplete, Inevitable, Missed abortion
• Evacuation of the Ux
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Method of evacuation
a)Uterine Size <12wks
• MVA/EVA
• D&C
• E & C if Cx is open
b)Uterine size >_12weeks
• Prostaglandins(Mifepristone, Misoprostol)
• Oxytocin(High dose +high drips)
• E&C / D & C & D &E when appropriate

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Complicatios:
• Higher complications with unsafe Vs safe abortion
Short term
• Hypovolumic shock(h’ggic shock)
• Septic shock
• Uterine perforation
• Intra-abdominal injury
• Sepsis
• Heamatometra
• Cervical injury
• Death
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Long term
• Infertility—secondary to infection, hysterectomy & asherman syndrome
• Tubo-ovarian abscess, hydrosalpinx
• Chronic pelvic pain
• Dyspareunia
• Dysmenorrhea
Management of some complications
1) shock
s/s
• Anxious, restless, confused or unconscious
• Tachycardia, or weak pulse
• Tachypnea
• Low blood pressure or unrecordable
• Pallor skin, conj., palms, mouth
• Cold skin, clammyskin
• Oliguria
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Causes
• Severe blood loss
• Infection(sepsis)
Mx:
Universal measures
• Ensure airway is open
• Turn head & body to the side in case she vomites
• Keep her warm
• Elevate legs
• O2
• Fluids: Crystalloids
• Blood transfusion
Hgb< 5mg/100ml/Hct< 15%
• Medicines
If signs of infection- Broad spectrum antibiotics
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 Postabortal care(PAC)
• Consists of series of medical and related
interventions designed to manage the complications
of spontaneous and induced abortion, both safe and
unsafe.
• Aim of PAC:
-Reduce maternal morbidity and mortality
-improve women’s sexual and reproductive health
and lives

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• PAC consists of five elements:
1) Treatment-of unsafe and incomplete abortion and
abortion related complications that are potentially
life threatening.
2) Counseling-to identify and respond to women’s
emotional and physical health needs and other
concerns.
3) Contraceptive and family planning services-to help
women prevent unwanted pregnancy or practice
birth spacing

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4)Reproductive and other health services
- testing and treating of STI, including HIV/AIDS and
reproductive tract infection
-preconception care if women wants to become pregnant
-infertility screening and treatment
-screening and counseling for women who experienced
violence
-counseling for nutritional needs
-cancer screening-cervical
-ovarian
-endometrial

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5)Community and service provider partnership
-to prevent unwanted pregnancy and unsafe
abortion
-mobilize resources to help women receive
appropriate and timely care for abortion and
its complications.

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