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SURGICAL

MANAGEMENT OF
ECTOPIC PREGNANCY
Ectopic Pregnancy
In normal pregnancy, the blastocyst (fertilized ovum) implants
in the endometrial lining of the uterine cavity

ECTOPIC: Implantation of the blastocyst outside the uterine


cavity
Risk Factors
High: Tubal corrective surgery, tubal sterilization,
previous ectopic, in utero DES exposure,
Intrauterine device, tubal pathology
Moderate: Infertility, previous genital infection, multiple
partners
Slight: Previous pelvic/abdominal surgery, smoking,
douching, intercourse prior to 18 years of age
Epidemiology
 2% of all pregnancies each year in the Unites States

 Increasing incidence due to:


 Increasing prevalence of STIs
 Early diagnosis
 Contraception that predisposes failures to be ectopic
 Use of tubal sterilization techniques
 Use of assisted reproductive techniques
 Tubal surgery (salpingotomy, tuboplasty)

Commonest cause of maternal mortality within the 1st trimester

 Overall incidence in non-white women is 1.4 times higher


than in Caucasian women
Female Pelvic Anatomy
Types of Ectopic
Pregnancy
Abdominal (0.1%)
implantation within the
peritoneal cavity (can occur
secondary to tubal
pregnancy)

Interstitial: gestation
implants in the interstitial
portion of the fallopian
Cervical tube.

Vaginal
Angular: A gestation that Broad ligament
extends beyond the interstitium
into the adjacent uterine cavity
Tubal Pregnancy
 Commonest site of ectopic pregnancy (99%)

 The ampulla is the most frequent location


of implantation (64%)
Symptoms:
 Onset occurs ~7 weeks after LMP
 Abdominal pain
 Vaginal bleeding
Signs:
 Abdominal tenderness (91%)
 1st trimester bleeding (79%)
Common associated findings:
 Adnexal tenderness (54%) , Amenorrhea
 Early pregnancy symptoms
 Cullen’s sign (Periumbilical bruising)
 Nausea, vomiting, diarrhea, dizziness
Other Signs:
 Tachycardia, Low grade fever
 Chadwick’s sign (cervix and vaginal cyanosis)
 Hegar’s sign (softened uterine isthmus)
 Hypoactive bowel sounds
 Cervical Motion Tenderness
 Enlarged uterus
 Tender pelvic or adnexal mass
 Cul-de-sac fullness
 Decidual cast (Passage of decidua in one piece)
Signs suggestive of ruptured ectopic pregnancy:
 Usually between 6 and 12 weeks gestation
 Severe abdominal tenderness with rebound, guarding
 Orthostatic hypotension
Differential Diagnosis
 Appendicitis
 Threatened Abortion
 Ruptured ovarian cyst
 PID
 Salpingitis
 Endometritis
 Nephrolithiasis
 Ovarian torsion
 Intrauterine pregnancy
Alternative diagnoses:
o Dysmenorrhea
o Dysfunctional uterine bleed
o UTI
o Diverticulitis
o Mesenteric lymphadenitis
Pathology of Ectopic Pregnancy

 Fertilized ovum borrows through the epithelium


 Zygote reaches the muscular wall
 Trophoblastic cells at zygote periphery proliferate, invade, and erode
adjacent muscularis
 Maternal blood vessels disrupted leading to hemorrhage
 Outcome: tubal abortion or rupture with hemorrhage
Case History
Presenting Complaint:
 23 year old female at 8 weeks gestation admitted
for observation following a 2 week history of
abnormal serum βhCG levels
 βhCG = 858U/L (normal= 7000-20000 U/L)

 Positive pregnancy test 20/12/05


 LMP 12/11/05
 EDD 19/08/06
 Para 0, gravida 5
Other significant details of the
history:
 Hx of p/c:
 βhCG levels closely monitored for 2/52
 No pain
 Intermittent bleeding PV for 1/52, no clots
 Past medical hx:
 5 previous miscarriages
 Chlamydia 2 yr. ago *risk factor
 Tx given, husband treated as well

 Retest was negative

 Medication: none
 NKDA
 Social hx:
 married
 Smoker (pack years unknown) *risk factor
 Other important facts that are not known:
 Sexual history ( coitrache, # of partners, etc.)
 Past menstrual hx
Examination
 General appearance: comfortable, no pallor
 Vitals signs: within normal limits
 BP 95/60mmHg
 CVS exam: heart sounds 1 and 2 present, no added sounds
or murmurs
 Resp exam: normal vesicular breath sounds
 Abdominal:
 Normal on inspection, no visible swellings, scars, etc.

 No pain on palpation

 Bowel sounds present


Initial Management
 Initial Investigations: Labs and Radiology
 Indications for procedure
 Contraindications for Surgery
 Patient Outcome Discussion
1. Procedure
2. Desired outcome

5. Potential Complications
1. Short Term Injury
2. Long term Injury

6. Pre-op Instructions
I. Rx/lifestyle/nutritional needs or changes
II. Psychological management
7. Legal issues
Initial Investigations
Monitor βhCG levels
 βhCG- hormone produced by the placenta (and fetal kidney)
 Detectable in plasma and urine following blastocyst implantation
 Blood levels rise rapidly, doubling every 2d and plateaus at 8-10
weeks gestation
 Serum βHCG levels correlate with the size and gestational age in
normal embryonic growth

 βHCG with inadequate increase may suggest ectopic


pregnancy
 Sensitivity: 36%
 Specificity: 65%

**βhCG level does not predict ruptured ectopic,


ruptured ectopic may occur at any βHCG level
Serum βhCG Levels
1000

900

800

700 LOW!!!!!
600
BhCG (U/L)

500

400

300

200

100

0
12/23/2005 12/25/2005 12/27/2005 12/30/2005 1/4/2006 1/6/2006 1/9/2006
DATE
Other Labs:
 Complete blood count
 Leukocytosis

 Urinalysis with microscopic exam

 Blood Type and Rhesus


 A negative
 Therefore, must give anti-D (RhoGAM) prior to
surgery
Imaging Studies
 US imaging confirms the clinical diagnosis of
suspected ectopic, location, and size

Findings suggestive of ectopic pregnancy:


Absence of gestational sac at βHCG 1800 IU/L
Free fluid present (71% likelihood of ectopic)
Echogenic mass at adnexa (85% likelihood)
Echogenic mass with free fluid (100% likelihood)

Transvaginal vs. Transabdominal


Transabdominal
Ultrasound
 Empty Uterus
(on admission)
 Free fluid
 Distended portion of left
Fallopian tube
 No evidence of rupture
 Adnexal mass:
1.7 x 1.6cm adjacent and
anterior to left ovary
 Cervical excitation
 Tenderness over left iliac
fossa on deep palpation
with the probe
Management Options
 Expectant Management Indications
 Minimal pain or bleeding in reliable patient
 bHCG less than 1000 IU/L and falling
 No signs of tubal rupture
 Adnexal mass <3 cm
 No embryonic heart beat
 Medical Management: Methotrexate (anti-metabolite)
 Stable vital signs with normal LFTs, CBC, platelets
 Unruptured ectopic pregnancy without cardiac activity
 Ectopic mass <4 cm
 βHCG <5000 IU/L
 Surgical Management Indications
 Failed or contraindicated non-surgical management
 Nondiagnostic Transvaginal US and βHCG >1500
 Hemoperitoneum
 Diagnosis unclear
 Advanced ectopic pregnancy
 Non-compliant patient
Surgical Options
1. Laparoscopy
 “Key hole” surgery
 Recommended approach

Advantages:
Less blood loss, decreased number of transfusions, less recovery time,
less post-op analgesia, cost effective
Contraindications:
Absolute: ruptured EP, haemodynamic instability, surgeon’s lack of
experience Relative: previous multiple pelvic surgeries, Unruptured
interstitial EP, morbid obesity
Surgical options (cont’d)
2. Laparotomy

 Surgical incision through


the abdominal wall
 Pfannensteil incision
 Mainly used for cases
involving haemodynamic
instability
Actual Management:
Day 1
 Admitted for observation following US diagnosis of left
tubal pregnancy
Day 2
 BhCG preformed (slightly increased)
 No change in symptoms

Day 3: 4pm Examination:


o soft abdomen
o mild lower abdominal and suprapubic pain on palpation
o Left iliac fossa pain on palpation
 Scheduled laparoscopic removal of ectopic pregnancy
 5pm: BP 110/80 mmHg, HR 84 bpm
↑ abdominal pain → OR within 30 min
Radical vs. Conservative
Surgery
Salpingostomy (Conservative)
 Small pregnancy (<2cm) located in distal fallopian
tube
 Maximizes preservation of affected tube
 Associated with a 5% risk or recurrence
 Risk of tubal scarring due to incision
Salpingotomy
 Same as above only incision is sutured closed

Salpingectomy (Radical)
 Tubal resection

Segmental resection and anastomosis


Pre-Operative Work-Up
 Full blood count (Leukocytosis)
 Blood group serology
 Coagulation workup
 Vital signs → stable for surgery
 Review tests
 βhCG- ectopic still present
 US imaging- location, size
6. Medications:
 NKDA, GA (no allergy)
Patient Preparation
1. Pre-op nutrition- fasting (unless emergency)
2. Bowel prep- enema
3. Shave suprapubic hair
4. Patient information
 Risks and complications
 Risks of conversion to laparotomy
 Risks of salpingectomy
Surgical Complications

The patient MUST be made aware of these


risks when informed consent is obtained:

 Hemorrhage and hypovolemic shock


 Infection
 Loss of reproductive organs following surgery
 Infertility ***
 Urinary and/or intestinal fistulas following complicated
surgery
 Disseminated intravascular coagulation (rare)
Prognosis for Future Conception

 Conception rate post-ectopic: 77%

 Recurrent ectopic pregnancy risk:


 After 1st ectopic: 5-20% risk
 After 2nd ectopic: 32% risk
Operative Requirements
1) Equipment
Surgical Instrument (preference list)
• Patient Positioning
3) Procedure Overview
Objective: laparoscopic salpingectomy
Procedure
1. Opening
 Landmarks
 Trocar placement
 Localisation, Identification, Excision
 Wound Closure
Equipment

Video monitor
Laparoscopic Tools
1.Bipolar grasper
2.Atraumatic
grasper
3.Grasping forceps
4.Toothed forceps
5.Sharp-tipped
monopolar
device
6.5-10mm suction-
Patient Positioning

Low lithotomy
position
30 degree
Trendelenburg
Urinary catheter
NG tube (?)
Uterine cannulation
Trocar Placement for
Surgery

A)12mm optical trocar placed at umbilical level


B)and C) 5mm lateral operative trocars placed 3
fingerbreadths above the symphysis pubis
 Peritoneum is inflated with CO2
 Needle inserted at the umbilical level (primarily
used)
 OR at Palmer’s point (3cm below costal margin in
midclavicular line)
 Pressure should not exceed 14 mmHg- respiratory
Trendelenburg
postion:
 Caused the small intestine
loops and sigmoid to
move cephalically
 Exposes the pelvis
 Should not exceed 30
degrees Uterine Manipulation:

 Anteversion (exposure of
rectouterine pouch)
 Displaced to contralateral side of
ectopic
Exposure
1st Assistant:
• Holds laparoscope
• Pushes intestinal loops
cephalically using
grasping forceps

2nd Assistant:
• Anteverts uterus and
pushes it CL to the
ectopic pregnancy
Exploration
 To determine the precise location of the ectopic
pregnancy
 To evaluate the extent of Hemoperitoneum
 To determine the condition of the adnexa
 Visualize active bleeding
 Rule out any other associated pathology
 Examine contralateral tube to rule out
retrograde reflux and haematosalpinx
Anatomical Review

1. Medial tubal A.
2. Lateral tubal A.
3. Uterine A.
4. Ovarian A.
Laparoscopic Salpingectomy

Main Risk: devascularization of the ovary


 Operate close to the tube, away from ovarian
vessels and suspensory ligament
 Proximal tube division
 Isthmus is held upwards and outwards
 Isthmus is cauterized
 Take care not to cauterized the internal ovarian
A. and ovarian branch of the uterine A.
 Divide tube with scissors
1. Mesosalpinx
Division
 Divide the mesosalpinx
with scissors

 Cauterize and divide


the infundibulo-ovarian
ligaments and the
lateral tubal A.
1. Extraction of the tube
 Remove tube through an
extraction bag
 Verification of hemostasis
 Careful lavage
 Removal of equipment
 Suture/ Steri-strip Caution:
laparoscopic incisions  Endometriosis
 Utero-peritoneal
fistula
Post-operative Plan
 Remove urinary catheter and NG tube
 Observation and analgesia
 Remove IV on the evening of the procedure
 Food on evening of procedure
 Discharge following day
 Discuss use of contraceptives
 Pregnancy 2-3 months post-op (2-3 cycles)
 Information regarding the risk of ectopic
recurrence
Follow-Up:

 Smoking cessation

 Folic acid

 Early pregnancy clinic @ 6/52 gestation in


subsequent pregnancy

 Investigation regarding underlying


pathology due to past obstetrical hx
The End