Pain in Early Pregnancy Ectopic Pregnancy

ECTOPIC PREGNANCY

Case study 1: A 22-year-old woman, para 0, was admitted with mild vaginal bleeding after 7 weeks of amenorrhoea. She had had a positive home pregnancy test. Ultrasound scan showed an empty uterus, with an adnexal mass around 2 cm. quantitative β-hCG was 2000 iu/ml. At laparoscopy ectopic pregnancy was confirmed in the ampulary part of the right tube. Linear salpengotomy was performed. The patient was discharged home the following day in good condition.

Case study 2: A 22-year-old woman, para 0, was admitted with vaginal bleeding after 8 weeks of amenorrhoea. She had had a positive home pregnancy test, and described passing some tissue per vaginum. Ultrasound scan showed an empty uterus, although urinary B-hCG was still positive. A presumptive diagnosis of incomplete abortion was made, and evacuation of the uterus carries out uneventfully. She was discharged the following day Was readmitted that night with lower abdominal pain; a ruptured ampullary ectopic was found at laparotomy. Histology of curettage “ decidua with Arias-Stella type reaction, no chorionic villi seen”.

Case study 3: An 33-year old woman para 4, was brought into E.R. collapsed with lower abdominal pain. On admission she was shocked with blood pr. Of 60/40, a pulse of 120 bpm and tender rigid abdomen. Vaginal exam. Revealed a slight red loss, bulky uterus and marked cervical excitation with a tender mass in the right fornix. At laparotomy, 3000 ml of fresh blood was removed from the peritoneal cavity and a ruptured right tubal ectopic pregnancy was found. The patient was in irreversible D.I.C. with Hb =0 .5 gm/dl and eventually died

Incidence: Increasing due to P.I.D./ infertility 1-2% of all births Definition: “ Any pregnancy occurring outside the uterus” Incidence: Increasing due to P.I.D./ infertility 1-2% of all births 9% after IVF-ET Site of implantation:

Abdomen (< 2%) Ampulla (>85%) Isthmus (8%) Cornual (< 2%) SITES OF ECTOPIC PREGNANCY Abdomen (< 2%) Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Cervix (< 2%) 1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal

Risk Factors: Any factor that leads, directly or indirectly, to a reduction in tubal motility increases the risk for tubal pregnancy History of infertility Pelvic inflammatory disease Pelvic operations { tubal … appendix }failed tubal sterilization Previous tubal pregnancy Assisted conception { particularly IVF if tubes are patent and damaged } Failed contraceptive methods Presence of an intra uterine device.

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

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: Dysmenorrhea Dysfunctional uterine bleed UTI Diverticulitis Mesenteric lymphadenitis

Symptoms & Signs: Ectopic Pregnancy In a woman of child bearing age with pelvi-abdominal pain and/ or vaginal bleeding …… ALWAYS….think Ectopic Pregnancy

DIAGNOSIS In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate. This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease. This has resulted in early diagnosis and effective treatment. Now the rate of tubal rupture is as low as 20%.

METHODS OF EARLY DIAGNOSIS Immunoassay utilising monoclonal antibodies to beta HCG Ultrasound scanning – Abdominal & Vaginal including Colour Doppler Laparoscopy Serum progesterone estimation not helpful A combination of these methods may have to be employed.

Diagnostic modalities Pregnancy test. Urinary B-hCG… sensitive, detects 25-50 ml I.U/ml.. Positive before missing the next period Serum B-hCG…… Mainly used for quantitative rather than qualitative purposes In 85% normal pregnancy B-hCG doubles every 2-3 days In 85% ectopic pregnancy B-hCG 65% Increase every 2-3 days 2. Pelvic ultrasound scan Abdominal. Sac at 5 wks F.H. at 7 wks.. Needs full bladder Transvaginal. A wk earlier than abdo… empty bladder

METHODS OF EARLY DIAGNOSIS At 4-5 weeks- TVS can visualise a gestational sac as early as 4-5 weeks from LMP. During this time the lowest serum beta HCG is 2000 IU/Lt. When beta HCG level is greater than this and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected. In such a situation, when the value of beta HCG does not double in 48 hours ectopic pregnancy will be confirmed.

METHODS OF EARLY DIAGNOSIS The USG features of ectopic pregnancy after 5 weeks can be any of the following- Poorly defined tubal ring possibly containing echogenic structure and POD typically containing fluid or blood. Ruptured ectopic with fluid in the POD and an empty uterus. In Colour Doppler, the vascular colour in a characteristic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow

Diagnostic modalities If early pregnancy problems…. Urine B-hCG + AScan Intra-uterine pregnancy …….GOOD No Intra-uterine gestation Seen…… serum B-hCG + TVS. with serum B-hCG of 1500-2000 ml I.U/ml Intra uterine gestation should be seen using TVS…… otherwise suspect Ectopic pregnancy 3. Diagnostic Laparoscopy. Early Pregnancy Assessment Clinic {EPAC}:

Diagnostic modalities Early Pregnancy Assessment Clinic {EPAC}: With Advance in diagnosis and improvement in patient awareness ectopic pregnancy is more and more being diagnosed in its early stages. So, to reduce the incidence of maternal mortality and serious morbidity this dedicated clinic is a must in regional hospitals. Patients with early pregnancy problems to report to Facilities to perform urine and serum P.T. onsite Facilities and expertise in performing TVS Access to operating theatre and blood bank .

MANAGEMENT Depending on the presentation: Acute… with ruptured ectopic and intra-abdominal bleeding…. ABC,,, + surgical approach. Early stages, with intact ectopic: Expectant… decreasing B-hCG …. Tubal abortion Medical… Depending on size of ectopic and level of B-hCG….. Use methotrexate….. Not common approach Surgical

Surgical Management Fertility post ectopic surgery… Conservative, Open vs laparoscopic….. Linear salpengotomy vs milking of the tube Radical, laparoscopic vs open ……. salpengectomy Fertility post ectopic surgery…

SURGICAL TREATMENT OF ECTOPIC PREGNANCY The debate goes on LAPAROTOMY? VS. LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY?

Hospital cost More? Less? Post operative adhesions More Less COMPARING LAPAROTOMY Vs LAPAROSCOPY L’tomy L’scopy Hospital cost More? Less? Post operative adhesions More Less Risk of future ectopic Same Same Future fertility Same Same Experience of Surgeon Trained Special Instruments General Special

SALPINGOSTOMY / SALPINGOTOMY SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY All tubal pregnancies can be treated by partial or total Salpingectomy Salpingostomy / Salpingotomy is only indicated when: The patient desires to conserve her fertility Patient is haemodinmically stable Tubal pregnancy is accessible Unruptured and < 5Cm. In size Contralateral tube is absent or damaged

SALPINGOSTOMY / SALPINGOTOMY SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.

SALPINGOSTOMY / SALPINGOTOMY SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY Fertility reducing factor Score Antecedent one Ectopic pregnancy 2 Antecedent each further Ectopic pregnancy 1 Antecedent Adhesiolysis 1 Antecedent Tubal micro surgery 2 Antecedent Salpingitis 1 Solitary tube 2 Homolateral Adhesions 1 Contralateral Adhesions 1

SALPINGOSTOMY / SALPINGOTOMY SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy. Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more.

Fertility post ectopic surgery… The overall subsequent conception rate in women with ectopic pregnancies is about 60% less than half of these pregnancies result in another ectopic or spontaneous abortion, so only about one third of women with ectopic pregnancies have subsequent live births . The subsequent fertility rate is significantly higher in parous women younger than 30 years. If the ectopic pregnancy is a women's first pregnancy, her subsequent conception rate is only about 35%. On the other hand, women with high parity (more than three pregnancies) who develop an ectopic pregnancy have a relatively high rate of conception (80%). The subsequent conception rate is lower in women who have a history of salpingitis and in those who have gross evidence of damage to the opposite oviduct as a result of previous salpingitis. Future fertility is significantly higher in women who have unruptured tubal pregnancies than in those who have ruptured ectopic pregnancies; hence, early diagnosis with serial hCG and ultrasound is desirable.

Repeat Ectopic Pregnancy The rate of repeat ectopic pregnancy after a single ectopic pregnancy ranges from 8% to 20%, with a mean of 15%. Only about one of three nulliparous women who have an ectopic pregnancy ever conceives again (35%), and about one third have another ectopic pregnancy (13%). After two ectopic pregnancies, infertility rates as high as 90% have been reported

REMEMBER Ectopic pregnancy is a life threatening condition & on the increase Not all cases present with a classical picture ALWAYS suspect ectopic pregnancy in a woman of a child-bearing age c/o pain and/or p.v. bleeding Early diagnosis and management is feasible {EPAC}, which should be available in referral centers Tailor your management on the patient presentation.+/_ F.up