Ectopic Gestation & Other Gynaecological Emergencies

Dr A. E Edugbe, MBBS, FMCOG, FWACS

Bingham University/Bingham University Teaching Hospital

Outline

• Introduction/epidemiology
• Risk factors/aetiology
• Pathophysiology
• Types/classification
• Presentation
• Investigations
• Treatment modalities

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Introduction/epid.

• Ectopic pregnancy constitutes one of the leading causes of pregnancy-related maternal deaths and accounts for about 10% of maternal mortality

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• An ectopic pregnancy is any pregnancy implanted outside the endometrial cavity

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• Ectopic pregnancy was considered to be a rare but universally fatal condition in the mid 19 century

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• With the improvements in surgical techniques at the turn of the twentieth century, ectopic pregnancy became curable

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Introduction/epid.

• The incidence has quadrupled over the past three decades

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• The perceived increase in the incidence of ectopic pregnancy may be due to a number of factors.
• Increasing incidence of pelvic inflammatory disease (PID) in the community,
• Use of intrauterine contraceptive devices (IUCD)
• wider use of assisted reproductive technology (ART)
• Availability of potent antibiotics
• Improved sensitivity of diagnostic tests for ectopic pregnancy, in the past a significant number of ectopic pregnancies may have resolved spontaneously without being detected

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Risk factors/aetiology

• Previous pelvic inflammatory diseases/ isolated chlamydia infection
• Genital tuberculosis
• Endometriosis in the pelvis causing distortion of the fallopian tube
• Previous ectopic pregnancy
• Pelvic adhesions
• Congenital elongation, accessory ostia, diverticula
• Transmigration
• Previous tubal surgery, tubectomy
• IVF programme
• IUCD, progesterone containing IUCD
• Progestogen-only pills (POP)
• Cigarette smoking

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Pathophysiology

• Any abnormality in tubal morphology or function may lead to ectopic pregnancy.

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• In normal pregnancy the egg is fertilized in the Fallopian tube, and then it is transported into the uterus.

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• It is believed that the most important cause of ectopic pregnancy is damage to the tubal mucosa, which could obstruct the embryo transport due to scarring.

Pathophysiology

• In these women the cause of ectopic pregnancy may be a dysfunction in the tubal smooth muscle activity

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• In general, oestrogens stimulate tubal myoelectrial activity while progesterone has an inhibitory effect

Classification

Extrauterine

• Tubal (90–95%)
• Ovarian (1%)
• Abdominal (1–2%)—rare now

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Uterine but ectopic location in the uterus

• Interstitial/cornua (2%)
• Rudimentary horn of a bicornuate uterus
• Cervical (0.5%)
• Caesarean scar
• Heterotopic pregnancy

Classification

Ectopic time table

• Isthmic pregnancies tend to rupture earliest, at 6 to 8 weeks' gestation, because of the small diameter of this portion of the tube.

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• Ampullary pregnancies rupture later, generally at 8–12 weeks.

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• Interstitial pregnancies are the last to rupture, usually at 12–16 weeks, as the myometrium allows more room to grow than the tubal wall.

Clinical presentation

• This depends on gestational age, location, whether ruptured/ unruptured and haemodynamic stability of the patient

asymptomatic (usually incidental finding)

• Generally

symptomatic

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Clinical symptoms/signs

• Amenorrhoea: about 75% patients present with a history of amenorrhoea of less than 6 weeks duration
• Pain: abdominal pain, generally severe, is a consistent feature of ectopic pregnancy in 95% cases
• Vaginal Bleeding: vaginal bleeding is almost always small but persistent and consists either of dark altered and fluid blood or of dark coagulated blood
• Acute Ectopic Pregnancy: a patient with acute intraperitoneal haemorrhage presents with pallor and two other signs of internal haemorrhage, viz., restlessness and air hunger. The patient is cold, the skin is clammy, the temperature subnormal and the pulse thready with marked tachycardia. Blood pressure will be low

Other examination findings

Diagnostic Investigations

• Pregnancy test

• Serum b-hCG level; repeat every 2 days

• Ultrasound (TVS)

• MRI

• Culdocentesis

• Laparoscopy

• Hematocrit
• The hematocrit will vary depending on the patient population and the degree, if any, of intra-abdominal bleeding

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B-hCG

• b-hCG is detected in the serum 9 days (5–10 mIU/mL) and in the urine 13 days after ovulation, around the time of implantation and before the missed period. The level doubles every 2 days in a normal pregnancy. Therefore, in case of doubt and if the condition of the woman remains stable, serial study and doubling time study are useful. If the level does not rise or rises by less than 66% from the previous reading, ectopic pregnancy or missed abortion should be suspected
• If the hCG level is over 6500 mIU/L, the ultrasound invariably reveals a uterine pregnancy in 95% cases. At 6 weeks, 85% of ectopic pregnancies reveal a low level of b-hCG or a slow rise subsequently.
• Ratio of hCG at 48 h/HCG at 0 h: Ratio of less than 2 is more or less diagnostic of an ectopic pregnancy. In ectopic pregnancy, the doubling rate of b-hCG is slow with less than 66% increase over 48 h
• Rapid bedside qualitative hCG test with a sensitivity of 25–50 mIU/L should be used, if available, in an acute emergency case (takes 1 h)
• Progesterone level less than 20 ng/mL also suggests abnormal pregnancy but this hormone test has a limited value and takes time (24 h). It is not done in a routine work-up. It has a sensitivity of only 80%

�Culdocentesis or Aspiration of Pouch �

• Culdocentesis or aspiration of pouch of Douglas is helpful if free blood can be aspirated. A positive finding of microclots in the blood justifies laparotomy; a negative result obligates further investigations

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• Ultrasound: In an ectopic pregnancy, the uterus appears empty and a mass can be located in one of the lateral fornices. The gestational sac is however identified only in 5 to 15% cases in early ectopic pregnancy. b-hCG in the urine and serum, empty uterus, adnexal mass and free fluid in the peritoneal cavity is pathognomonic of an ectopic pregnancy

USS Contd.

• The ultrasonic findings alone may resemble that of PID and endometriosis. The advantage of transvaginal sonography is the early detection of a uterine pregnancy at fifth week of gestation when the serum b-hCG reaches 1000 mIU/L. In a normal uterine pregnancy, the gestational sac with a yolk sac is slightly asymmetrically placed attached to one wall of the uterus

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• In an ectopic pregnancy, a pseudosac or an empty sac without yolk is formed by decidual thickening and therefore is central in location

Laparoscopy

• When an ectopic pregnancy is suspected, but the diagnosis cannot be confirmed because of equivocal findings of hormonal tests and ultrasound, one should proceed with laparoscopic visualization of the pelvis

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• It is important to note that the laparoscopist should be competent to perform therapeutic procedure if so required in the same sitting

Cornual ectopic

Cudocentesis

Magnetic resonance imaging

• Magnetic resonance imaging is a useful adjunct to ultrasound in cases where an unusual ectopic location is suspected

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• An accurate diagnosis of cervical, cesarean scar, or interstitial pregnancy.

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Treatment

• Initially, surgery (laparotomy) was the only lifesaving management of an ectopic pregnancy

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• Then followed conservative fertility-retaining procedures and laparoscopically performed conservative surgeries

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• With the possibility of diagnosing a very early, unruptured pregnancy by routine ultrasonic screening, more cases are now treated with medical treatment with equally good outcome, without added surgical morbidities

Treatment modalities

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expectant

• Conservative mgt:

medical

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Conservative

• Surgical mgt:

Radical

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Conservative mgt.

• Expectant Treatment: comprising follow-up with hCG levels and ultrasound scanning is only possible if the gestational sac is less than 2 cm and hCG level is not high (,2000 mIU/mL) and haemoperitoneum is 50mL Most resolve without any surgery or medical treatment
• Medical treatment
• methotrexate
• Mifepristone
• Prostaglandins (PG F2a)
• 20% KCl solution
• Glucose solution—all injected into the gestation sac under ultrasound/laparoscopic control
• Actinomycin D

Indications for medical mgt.

• The women should be haemodynamically stable
• Ectopic pregnancy should be unruptured
• Serum b-hCG level should not exceed 6500– 10,000 mIU/mL
• The size of the gestation sac should not exceed 3–5 cm in its longest diameter
• Fetal cardiac activity should be absent
• The patient should be willing to come for follow-up
• There should be no contra-indication to MTX (liver disease, anaemia)
• The patient should be desirous of future fertility
• Hb%, WCC and liver function should be normal

Surgical mgt.

• This could be via laparatomy or laparoscopic routes

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• Conservative: salpingostomy, salpingotomy, fimbrial expression

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• Radical: salpingectomy, fimbriectomy

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Conclusion

• Improvements in non - invasive diagnosis of ectopic pregnancy have led to substantial changes in the management of this common condition.

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• Despite these major improvements, there is no room for complacency as the mortality rates of ectopic pregnancy have remained stubbornly constant for the last two decades.

Other gynaecological emergencies

• Ovarian cyst accidents (rupture, torsion, infection)
• Abortions (incomplete, septic)
• Pelvic abscess
• pyosalpinx
• Acute pelvic inflammatory disease
• Bartholin gland abscess
• Coital laceration