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Ectopic Pregnancy

Prof. K.Punithalakshmi

Principal

JIETCON

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Objectives

At the end of the session, the students will be able to

  • Define Ectopic pregnancy
  • List the sites of Ectopic pregnancy
  • Enumerate the Risk factors of Ectopic Pregnancy
  • Describe the pathophysiology of EP
  • Explain the clinical features, diagnosis, treatment and complications of EP

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Definition

  • An ectopic pregnancy occurs when the conceptus implants either outside the uterus (Fallopian tube, ovary or abdominal cavity) or in an abnormal position within the uterus (cornua, cervix).

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Blastocyst implanted in the fallopian tube

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Sites of Ectopic Pregnancy

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Risk factors of ectopic pregnancy

History of PID

History of tubal ligation

Contraception failure

Previous ectopic pregnancy

Tubal reconstructive surgery

History of infertility

Previous induced abortion

Tubal endometriosis

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Risk factors

The risk of ectopic pregnancy increases with:

  • 1.maternal age,
  • 2.number of sexual partners,
  • 3.the use of an intrauterine device,
  • 4.after proven pelvic inflammatory disease (gonorrhoea, Chlamydia) and
  • 5.after pelvic surgery.

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Mortality rate

  • Mortality from ectopic pregnancy remains high.
  • Representing 13 per cent of all maternal deaths
  • The fatality rate of ectopic pregnancy is about four times that of childbirth.

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Pathophysiology

Effective transport of embryos 🡪 Fallopian Tube 🡪regulated complex interaction 🡪 tubal epithelium, tubal fluid and tubal contents.

This interaction 🡪generates 🡪mechanical free 🡪 composed 🡪 tubal peristalsis,ciliary motion fluid 🡪 drive 🡪 embryos 🡪 cavity.

Any mechanical and functional factors 🡪 prevent or interfere 🡪 passage 🡪 fertilized egg 🡪 uterine cavity 🡪 cause 🡪 ectopic pregnancy.

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Functional Factors are

1. Progesteron oral pill.

2. Intra uterine device.

3. Luteal phase defects

4.Cigarette smoking

5.Vaginal douching

Mechanical Factors are

  1. Pelvic Inflammatory Disease (Infection)
  2. Tubal Surgery, Previous Pelvic surgery ( Reconstructive/ Sterilization)
  3. Chromosomal abnormalities

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  • As the ectopic grows, the outerlayer of the fallopian tubes stretches. It leads to tubal rupture and bleeding.

Fate of Tubal Pregnancy

  1. Tubal mole
  2. Tubal abortion
  3. Tubal rupture

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Clinical Features

General symptoms:

1- Short period of amenorrhoea: usually does not exceed 8-10 weeks. This may be lacking if the ectopic pregnancy is disturbed before the next menstruation. This may occur particularly with ectopic pregnancy in the interstitial portion of the tube.

2- Pain: is present in almost every case and precedes vaginal bleeding. It may be:

a. Aching due to tubal distension.

b. Colicky in tubal abortion.

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c. Stabbing in tubal rupture.

d. Shoulder pain if blood accumulates under the diaphragm.( rare)

e. Bladder and rectal irritability in pelvic haematocele.

3- Vaginal bleeding: Due to shedding of the decidua. It is usually slight and follows the pain.

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General signs:

General examination:

  • Breast signs of pregnancy.

Abdominal examination:

  • Lower abdominal tenderness and rigidity especially on one side may be present.

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Vaginal examination:

  • Bluish vagina and bluish soft cervix.
  • Uterus is slightly enlarged and soft.
  • Marked pain in one iliac fossa on moving the conception from side to side.
  • Ill defined tender mass may be detected in one adnexa in which arterial pulsation may be felt.

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�Investigations of Ectopic Pregnancy�

(1) Serum b-hCG:

  • Urine pregnancy tests are positive. Detection of b-hCG in the serum by ELISA or radioimmunoassay are more sensitive and can detect very early pregnancy about 10 days after fertilization i.e. before the missed period.
  • If the test is negative, normal and abnormal pregnancy including ectopic are excluded.
  • If the test is positive, ultrasonography is indicated.

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Doubling time:

  • In normal pregnancy, the b -hCG level is doubling every 48 hours during the first 42 days of gestation.
  • Ectopic pregnancy usually shows less than 66% increase in b -hCG level within 48 hours.
  • As well as in abortions there is also slow doubling time.

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(2) Ultrasonography:

In general, a positive b-hCG test with empty uterus by sonar indicates ectopic pregnancy. This is true if the ß-hCG is at or above the threshold level in which an intrauterine gestational sac can be detected. This is called discriminatory zone.

Discriminatory hCG zones:

Diagnosis of ectopic pregnancy is made if there is:

An empty uterine cavity by abdominal sonography with b-hCG value above 6000 mIU/ml.

An empty uterine cavity by vaginal sonography with b-hCG value above 2000 mIU/ml.

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(3) Progesterone:

Serum progesterone level is lower in ectopic than normal pregnancy and usually less than 15ng/ml.

(4) Culdocentesis:

  • If non-clotting blood is aspirated from the Douglas pouch through a wide pored needle, intra-peritoneal haemorrhage is diagnosed.
  • Fluid containing fragments of old clots, or bloody fluid that does not clot, is compatible with the diagnosis of hemoperitoneum resulting from an ectopic pregnancy

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(5) Curettage:

  • If microscopic examination of the products of curettage reveals decidua and chorionic villi, the condition is abortion of intrauterine pregnancy.
  • If it reveals decidua only or Arias Stella reaction in the endometrium as well (cellular atypism, mitotic activity and glandular proliferation), ectopic pregnancy is diagnosed. The drawback is that in complete abortion also decidua only is curetted.

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(6) Laparoscopy:

A good diagnostic aid particularly in disturbed ectopic.

(7) Complete blood picture:

- Haemoglobin and haematocrit ---- to assess anaemia.

- Leucocytic count ---- exclude infections as appendicitis and salpingitis.

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�Uncommon Sites of Ectopic Pregnancy�

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(I) Cornual angular pregnancy:

- It is implantation in the interstitial portion of the tube.

- It is uncommon but dangerous because when rupture occurs bleeding is severe and disruption is extensive that it needs hysterectomy.

- In some cases, the pregnancy is expelled into the uterus and rupture does not occur.

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(II) Pregnancy in a rudimentary horn:

- Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.

  • As such a horn is capable of some hypertrophy and distension, rupture usually does not occur before 16-20 weeks.

- Treatment: Excision of the horn. During operation, pregnancy in a rudimentary horn can be differentiated from interstitial cornual tubal pregnancy by finding the attachment of the round ligament.

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(III) Cervical pregnancy:

- Implantation in the substance of the cervix below the level of uterine vessels.

- May cause severe vaginal bleeding.

Treatment :

  • Evacuation and cervical packing with haemostatic agent as fibrin glue and gauze
  • If bleeding continues or extensive rupture occurs hysterectomy is needed.

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(IV) Ovarian pregnancy:

Aetiology:

  • Pelvic adhesions.
  • Favourable ovarian surface for implantation as in ovarian endometriosis.

Pathogenesis:

  • Fertilisation of the ovum inside the ovary or ,
  • Implantation of the fertilised ovum in the ovary.

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Spiegelberg criteria for diagnosis of ovarian pregnancy:

  • The gestational sac is located in the region of the ovary,
  • The ectopic pregnancy is attached to the uterus by the ovarian ligament,
  • Ovarian tissue in the wall of the gestational sac is proved histollogically,
  • The tube on the involved side is intact.

Treatment:

  • Laparotomy and inoculation of the ectopic pregnancy and reconstruction of the ovary if possible. Otherwise, removal of the affected ovary is indicated.

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(V) Abdominal (peritoneal) pregnancy:

Types:

  • Primary: implantation occurs in the peritoneal cavity from the start.(very rare)
  • Secondary: usually after tubal rupture or abortion.

Intraligamentous pregnancy: is a type of abdominal but extra peritoneal pregnancy. It develops between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the myometrium) pregnancy.

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Diagnosis:

(A) History:

Amenorrhoea followed by an attack of lower abdominal pain and slight vaginal bleeding which subsided spontaneously.

(B) Abdominal examination:

- Unusual transverse or oblique lie.

- Foetal parts are felt very superficial with no uterine muscle wall around.

(C) Vaginal examination:

- The uterus is soft, about 8 weeks and separate from the foetus.

- No presenting part in the pelvis.

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(D) Special investigations:

  • Plain X-ray : shows abnormal lie. In lateral view, the foetus overshadows the maternal spines.
  • Ultrasound : shows no uterine wall around the foetus.
  • Magnetic resonance imaging (MRI): has a particular importance in preoperative detection of placental anatomic relationships.

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Treatment:

  • The condition should be terminated surgically through laparotomy once diagnosed as the foetus is malformed in the majority of cases. In addition, there is risk of massive internal haemorrhage if separation of the placenta occurs.

Differential Diagnosis: Rupture uterus

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  • At least 2000 ml of cross-matched blood should be on hand before proceeding to laparotomy. The foetus is removed and if the placenta is attached to an excisable structure as omentum, it is removed with it. If the placenta is attached to an important structure leave it for autolysis which may extend to few months or years.

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  • Any attempt to separate placenta will evoke uncontrollable bleeding. In this case, methotrexate 12.5 mg IM daily for 5 days will destroy trophoblastic tissue and accelerates the involution of the placenta.

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Treatment for Ectopic Pregnancy�

Medical Management:

Methotrexate therapy

  • The folic acid antagonist, methotrexate, inhibits de novo synthesis of purines and pyrimidines, interfering with DNA synthesis and cell multiplication
  • Methotrexate directly impairs trophoblastic production of hCG with a secondary decrement of corpus luteum progestin secretion

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1- If the unruptured ectopic pregnancy measuring less than or equal to 4 cm by ultrasonography

2-Hemodynamically stable

3-B-HCG<10,000

4-Exist of FHR

Methotrexate treatment regimens include:

the multiple dose, single-dose, two-dose

protocol

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Side Effects

  • Bone marrow suppression, hepatotoxicity, stomatitis, pulmonary fibrosis, alopecia, and photosensitivity
  • Fortunately, the side effects reported with methotrexate used to treat ectopic pregnancy have mostly been minor.
  • D-negative women with an ectopic pregnancy who are not sensitized to D-antigen should be given anti-D immunoglobulin

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Surgical Treatment�

Ruptured Ectopic Pregnancy

  • laparotomy or laparoscopy with salpingectomy is the first choice for rupture

Stable Ectopic Pregnancy

  • If methotrexate is contraindicated, laparoscopic salpingostomy is the first surgical choice

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  • LAPAROSCOPY:
  • INDICATION:
  • MORE APPROPRIATE IN STABLE SITUATION.
  • SHORTER OPERATING TIME.
  • LESS BLOOD LOSS.
  • SHORTER STAY IN HOSPITAL
  • LESS NEED FOR ANALGESIA.�

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Complications of Ectopic Pregnancy

  • Massive bleeding, Anaemia
  • Pelvic abscess
  • Peritonitis
  • Sepsis
  • DIC
  • Pulmonary Embolism
  • Massive Rectal bleeding
  • Maternal mortality 4% to 29%
  • Fetal mortality ranges from 75% to 95%

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Thank you