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23 Cards in this Set
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Define ectopic pregnancy |
Definition: EP occurs when the fertilized ovum implants on a site other than the endometrial lining of the normal uterine cavity.EP is preferred terminology to extra-uterine pregnancy because pregnancy can be on the uterus (i.e cervix) and still be ectopic |
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Incidence of ectopic pregnancy |
Incidence - UK 1-3% - Nigeria 4.1 – 5.6% |
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Reasons for increased incidence |
Incidence on the increase due to - •improved diagnostic techniques •increased number of pelvic infections in reproductive age •Use of ovulation induction agents •Assisted reproductive techniques (ART) |
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Sites of ectopic pregnancy |
Sites – 1. Commonest – fallopian tube 97%: •55% in the ampulla •25% in the isthmus •17% in the fimbria 2) 0.6% in the cervix 3) Abdominal cavity 0.3% |
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Etiology of ectopic pregnancy |
Aetiology: III understood - probably delay in transit of the fertilized ovum through the fallopian which should be accomplished in 5-7 days, resulting in shedding of the zona pellucida and implantation. |
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Risk factors for ectopic pregnancy |
•History of previous ectopic pregnancy •Tubal surgery including sterilization •Use of IUCD •Genital tract infection (Chlamydia and Gonorrhoea) •In utero exposure to diethylstilbestrol •History of infertility •Cigarette smoking •Early age of intercourse/multiple partners •Assisted Reprodutive techniques |
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Clinical presentation of ectopic pregnancy |
1. Acute 2. Silent and subacute 1. •Acute pain (abdominal or pelvic, localized or generalized, unilateral or bilateral, shoulder tip when ruptured with an intraperitoneal haemorrhage •Amenorrhoea (absent in 40% of cases; only irregularity or intermenstrual spotting noted) •Vaginal bleeding followed by passage of decidual cast•Dizziness and fainting attacks2. Silent and subacute:•Presents diagnostic problems-Index of suspicion should be high •Some ill-defined vaginal bleeding •Fainting attacks even before haemorrhage •Referred pain to the shoulder may be present •Bimanual exam reveals localized tenderness in the lateral and posterior fornix. Signs: •Tenderness – generalized or localized abdominal tenderness in more than half of the cases. •Increase in size of the uterus •Adnexal mass •Changes in haemodynamic status- high pulse rate, low BP •Skipworth’s sign: Patient sits up avoiding the recumbent position that may elicit pains from diaphragmatic irritation |
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Differential diagnosis for ectopic pregnancy |
•Normal pregnancy •Torsion or rupture of ovarian lesions •Appendicitis •In any woman of reproductive age presenting with abdominal pains -/± amenorrhoea, consider EP until ruled out |
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Investigations for ectopic pregnancy |
1. Packed cell volume: may be low or high. Consider EP in any woman with unexplained anaemia. 2. Ultrasonography: Diagnostic test of choice. Combined with B – HCG. EP is suspected if B-HCG level is more than 6,500nIU/L and intrauterine gestational sac (GS) is not seen on transabdominal scan or ≥1500 IU/L and gestational sac is not seen via TVS. This is the so called D (laparoscopy) Discriminatory zone. 3. Beta hCG: The doubling time is important. Increases by 53% every 48 hours, peaking at 100,000 IU/L in normal pregnancy. Subnormal increases makes further investigations (laparoscopy) expedient. 4. Laparoscopy: Used when diagnosis is difficult with the advent of U/S, it’s use is on the decline. 5. Laparotomy: Can be carried out when the index of suspicion is high. 6. Serum progesterone: Sensitivity is low at 15%. 85% of patients with EP will have normal progesterone levels. Can detect pregnancy failure and those at risk of EP. 7. Diagnostic uterine Curettage: To detect chorionic villi. Not commonly used. Could terminate a desired pregnancy. Indicated when Beta hCG is falling or elevated levels and U/S does not reveal gestational sac. 8. MRI: Useful in rare cervical and C/S scar ectopic; when conservative is adopted to avoid life threatening haemorrhage. Other investigations not commonly used:9. Culdocentesis – through the pouch of Douglas- false positive rate is 26% 10. Paracentesis: abdominis – in both, presence of non clotting blood is obtained. Dry tap does not exclude EP. 11. Examination under anaesthesia: Not advocated since EP may not be palpable. |
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Treatment of ectopic pregnancy |
•Is an emergency •Set up an intravenous infusion with a wide bore cannular for blood transfusion. •If veins are collapsed, do venous cut down. •With maximum speed, requiring little anaesthesia-Make an abdominal incision and clamp the bleeding point L •Lawson Tait performed the first successful operation for ectopic pregnancy •Non availability of blood is not an indication to postpone surgery. Auto transfusion can be done with blood collected from peritoneal cavity. |
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Types of operative procedures |
1. Salpingectomy: When patient has completed her family or tubal findings inappropriate for conservative management.-Examine the other tube before surgery-No need for oophorectomy except when haemostasis is difficult.
2. Partial Salpingectomy – part of the tube is removed.
3. Salpingostomy – Linear incision is made at the anti-mesenteric border and allowed to heal by secondary intention.
4. Salpingotomy: Similar incision is made as above but sutured with fine non – absorbable suture.
5. Oophorectomy: Removal of the ovary. |
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Conservative management |
Conservative management•Rate is increasing due to early diagnosis •Indicated when tube is unruptured •Contralateral tube is diseased •Tubal diameter < 3-4cm.•Options include aspiration of the affected segment, milking of the tube or linear Salpingostomy Complications of conservative management •Bleeding post operatively •Persistent trophoblast requiring further treatment •Risks of further ectopic pregnancy |
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Laparoscopy |
LaparoscopyIndicated in•Stable patient haemodynamically •Experienced surgeon •Ampullary ectopic •Conceptus 3cm or less •Unruptured ectopic Procedures that can be carried out laparoscopically•Linear Salpingostomy •Segmental resection of the tube-Salpingectomy Advantage -Decreased hospitalization -Decreased post operative recovery time -Crude pregnancy rate similar to laparotomy -Promotes improved healing due to reduced adhesion formation Disadvantage -May leave persistent trophoblastic tissue |
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Expectant management |
-In many cases, ectopic pregnancy undergoes tubal abortion and / or resorption -Spontaneous resolution occurs in 80% of cases and pregnancy rates similar as in conservative surgery. Indications -Beta hCG less than 1000IU/L or 10 iu/ml -Declining hCG level -Diameter of EP less than 3cm -No fetal heart beat -Patient agreed with follow up requirements -No evidence of blood in pouch of Douglas(POD) -Less than 100mls of fluid in the POD Follow up -Twice weekly serial HCG showing decline by 50% in one week. -TVS showing reduction in size over one week-Thereafter weekly HCG and TVS until hCG level less than 20iu/l -Counsel patient on the importance of follow up and staying within easy access to hospital. |
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Medical management |
Medical management: (Non surgical) -Indications similar as in expectant management -Non-laparoscopically diagnosed ectopic pregnancy -Persistent trophoblastic production of HCG following conservative surgery. Agents used: -Prostalglandin F2 alpha -Methotrexate (commonly used) -Hyperosmolar glucose -Mifepristone (RU486) |
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Methotrexate action, route of administration, dose, side effects, preparation before treatment, success rate |
•Folic acid antagonist, inhibits dihydrofolate reductase thus inhibiting synthesis of purines and thymidylic acid required for DNA synthesis •Actively dividing tissues such as trophoblast are sensitive. Route of Administration I.M, oral and direct tubal injection I.M is the preferred route. Dose 1mg/kg + citrovorum factor (0.1mg/1kg) rescue for two to four consecutive courses - or 40mg/m2 -or single 15 mg intra-gestational injection. Side effects -mouth ulcerations, nausea, elevated liver enzymes. -decreased bone marrow production of blood cells and platelets Preparations before treatment -Check serum creatinine-SGOT -Complete blood count with platelets during treatment Success rate – 80% |
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Advantages and disadvantages of use of medical management |
Advantages -Convenience, decreased cost and hospitalization -Deceased patient morbidity Disadvantages -Surgical intervention may still be necessary |
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General prognosis for EP |
General prognosis for EPRemember 30:30:30:10 -30% have difficulty in conception -30% have births -30% abortion -10% recurrent ectopic |
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Criteria for diagnosis of ovarian pregnancy & aetiology |
(Speigelberg criteria) 1. Location in ovarian fossa 2. Attachment of the ovarian ligament to the pregnancy sac 3. Intact ipsilateral tube 4. Ovarian tissue demonstrated in pregnancy sac on histology
Aetiology – Re-implantation of ruptured tubal ectopic |
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Management of ovarian pregnancy |
Management
-Laparoscopy: with effort made to preserve ovarian tissue -Oophorectomy or Salpingo-oophorectomy may be done to achieve haemostasis -In advanced cases, delivery of fetus with umbilical cord cut close to the placenta. -Placenta is left intact as removal may provoke bleeding. -Placenta undergoes autolysis as patient is covered with broad spectrum antibiotics-Methotrexate may be given to aid autolysis. |
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Heterotropic pregnancy |
Coexistence of an ectopic gestation with an intrauterine pregnancy |
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What is the discriminatory zone |
It is the level of ß-HCG concentration above which a gestational sac can be consistently visualized in the uterine cavity |
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Abdominal pregnancy |
Rare Follows re-implantation of a ruptured tubal ectopic pregnancy Treatment: delivery of the fetus with the cord cut as low to its insertion as possible. Placenta is left to prevent hemorrhage; can undergo autolysis or methotrexate should be given. Cover with broad spectrum antibiotics. Give Rhesus anti-D immunoglobulin to all rhesus negative women |
