Ectopic pregnancy extrauterine pregnancy extrauterine pregnancy

Objectives: Students will be able to: Students will be able to: –Define ectopic pregnancy. –List risk factors. –List differntial diagnosis of abdominal pain and vaginal bleeding in early pregnancy. –Evaluate case and confirm diagnosis and justify treatment option.

Ectopic pregnancy:  It is an implantation of fertilized ovum on any site other than the endometrium of uterus.  Ectopic pregnancy remains an important cause of maternal mortality worldwide.

Sites of ectopic:  Fallopian tube is the most common site ( 98%), the ampulla (80%) is the most common site of implantation.  Uterus.  Ovary.  Cervix.  Broad ligaments.  Else where in peritoneal cavity.

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

Incidence : It's incidence directly related to the prevalence of salpingitis and it is about 1% of all pregnancy.

Causes:  Any mechanical or functional factors that prevent or interfere with passage of fertilized ovum into uterine cavity and delay it and include the following:  Pelvic inflammatory disease(PID): (Chlamydia, gonococcal, tuberculous).  Tubal surgery: (tubal sterilization, reversal of tubal sterilization).  Congenital abnormalities of fallopian tube: (diverticula, accessory ostia, hypoplasia, Diethyl stillbesterol (DES) exposure in utero).  Peritubal adhesion: secondary to infection or surgery (appendicectomy).

Causes:  Gross pelvic pathology (endometrosis).  Uterine fibroid at utero-tubal junction.  Intra uterine device (IUD) in situ (in uterus), 3-4% of pregnancy if occur, is ectopic.  Progesterone only pills.  Assisted reproductive technique (ART) increase risk of hetrotopic pregnancy(as IVF).

Risk factors for ectopic pregnancy:  History of previous ectopic pregnancy.(the risk of recurrent ectopic pregnancy is 12–18%. The future risk increases further with every successive occurrence).  Intrauterine device (IUD) or sterilization failure.  Pelvic inflammatory disease.  Chlamydia infection.

Risk factors for ectopic pregnancy:  Early age of intercourse and multiple partners.  History of infertility.  Previous pelvic surgery.  Increased maternal age.(35 years and more risk to have ectopic).  Cigarette smoking.  Strenuous physical exercise.  In utero diethylstilbestrol (DES) exposure.

Pathological anatomy: In normal intrauterine pregnancy :  The ovum is fertilized in the Fallopian tube and then it is transported into the uterus where there is thick deciduas (between trophoblast and uterine muscle) in which fertilized ovum can be embeded.

In ectopic pregnancy :  in tube, there is only a very thin layer of connective tissue separating the epithelium from muscle so it is easy for the trophoblast to erode into muscle of tube (as there is no decidual formation) and no resistance to invading trophoblast and some of vessels which meet the trophoblast opened and haemorhage occur around embryo and embryo die.

 Uterus respond to hormonal changes and its enlarged and then endometrium undergoes decidual changes.  Histologic Characteristics: Chorionic villi, usually found in the lumen, are pathognomic findings of tubal pregnancy. Gross or microscopic evidence of an embryo is seen in two thirds of cases.

In normal intrauterine pregnancy:

In ectopic pregnancy:

The natural progression of tubal pregnancy (Course and outcome) Tubal pregnancy may terminate in number of ways :  Tubal abortion: Part or all of the products of ectopic are expelled from the tube into peritoneal cavity and collect in rectovaginal pouch.  2.Tubal rupture: Product of conception invade and expand the tube and cause rupture of tube. If it occur in first few weeks, the pregnancy is situated in isthmic portion of tube. Later rupture occur in interstial ectopic pregnancy.

The natural progression of tubal pregnancy (Course and outcome )  3.Tubal mole: Dead embryo surrounded by clot retained in tube which may be absorbed later on.  4.Secondary abdominal pregnancy (rare): Embryo is expelled from tube and acquires a secondary attachment in peritoneal cavity and embryo continuo to grow.

Clinical presentation:  The clinical presentation of ectopic pregnancy is very variable.  It is largely determined by the location of pregnancy within the tube.

Asymptomatic: Asymptomatic: Discovered when patient attend antenatal clinic for booking and especially for high risk group. Discovered when patient attend antenatal clinic for booking and especially for high risk group. Clinical presentation: continued…

It is rare for ectopic pregnancy in tube to advance beyond 8 weeks without occurrence of symptoms. On the other hand one third of interstitial tubal ectopics develop in a similar way to healthy intrauterine pregnancies with evidence of a live embryo on ultrasound examination. These pregnancies tend to be clinically silent until sudden rupture occurs. Clinical presentation: continued…

Symptomatic: Symptomatic: Acute presentation (due to rupture ectopic and abortion). Acute presentation (due to rupture ectopic and abortion). Subacute presentation (due to non rupture ectopic). Subacute presentation (due to non rupture ectopic). Clinical presentation: continued…

Symptoms of ectopic pregnancy: 1.There is no pathognomonic symptoms of ectopic pregnancy but the classic triad consist of: 2.pain 3.nearly always precedes the bleeding. There is no pathognomonic pain that is diagnostic of ectopic pregnancy.

Symptoms of ectopic pregnancy: 1. Abdominal pain: nearly always precedes the, 2. vaginal bleeding. 3. Amenorrhoea.

Symptoms of ectopic pregnancy:  severe continuous acute sharp abdominal pain typically referred to shoulder due to diaphragmatic irritation intraperitoneal haemmorrhage occur in rupture ectopic and in tubal abortion.  Discomfort and dull aching lower abdominal pain mainly on affected side in rupture ectopic.

 Amenorrhoea: most commonly symptom arise after miss period. Occasionally symptoms arise before miss period. Sometimes 2-3 miss period in case of interstial ectopic or ectopic in rudemintary horn of uterus.

 Abnormal vaginal bleeding. the amount of bleeding varies a.Usually bleeding is scanty and dark brown in colour. b.in some women it can be quite heavy. c. About 10–20% of ectopic pregnancies present without bleeding  Passage of a decidual cast may sometimes lead to an erroneous diagnosis of miscarriage.

Examination: Rupture ectopic pregnancy:  1.With rupture ectopic pregnancy and intrabdominal hemorrhage, the patient develops tachycardia followed by hypotension (Shock state).  2.The abdomen is: Distended to some degree. Generalized tenderness and rigidity and rebound tenderness. Bowel sounds are decreased or absent.

3.Pelvic examination: Speculum examination has very little value in the detection of ectopic pregnancy. It may help to diagnose miscarriage by the visualization of the products of conception within the cervix or vagina. Dark brown blood seen from cervix. Soft cervix. Cervical excitation (tenderness in movement of cervix) is positive although cervical excitation is not a specific sign of an ectopic pregnancy. Uterus slightly enlarged. Tenderness in ectopic site. Rarely palpable adnexal mass. Most ectopic pregnancies are very small and they cannot be felt on palpation.

Unpurtured ectopic pregnancy:  1.Frequently, the findings before rupture and hemorrhage are nonspecific, and vital signs are normal.  2.The abdomen may be not tender or mildly tender, with or without rebound.

3.Pelvic examination:  must be performed in an area where facilities for resuscitation are available as examination may provoke rupture of tube.  Dark brown blood seen from cervix.  Soft cervix.  The uterus may be slightly enlarged, with findings similar to a normal pregnancy.  Cervical exitation (cervical motion tenderness) may or may not be present.  An adnexal mass may be palpable in up to 50% of cases, but the mass varies markedly in size, consistency, and tenderness. (remember the palpable mass may be the corpus luteum and not the ectopic pregnancy).

Differential diagnosis: Gynecological disorder: 1. abortion. 2. ruptured corpus luteum cyst. 3. acute pelvic inflammatory disease (PID). 4. adnexal torsion. 5. degenerating fibroid. Non gynecological disorder: Non gynecological disorder: 1. acute appendicitis. 2. pyelonephritis. 3. pancreatitis.

Investigation: Investigation:  History and physical examination may or may not provide useful diagnostic information. The accuracy of the initial clinical evaluation is less than 50%. Additional tests are frequently required to differentiate early viable intrauterine pregnancy or suspected ectopic or abnormal intrauterine pregnancy.  Ectopic pregnancy must be suspected when pregnant patient present with abnormal bleeding and pelvic pain or in patient at risk of ectopic to prevent ruptured ectopic pregnancy which is life threatening to mother.

ultrasound examination detection of normal intrauterine pregnancy exclude diagnosis of ectopic pregnancy in most of cases. The spectrum of sonographic findings in ectopic pregnancy includes the following: Live embryo (fetal heart positive) in adnexa which is gold slandered to diagnose ectopic. it confirms ectopic. Enlarged and empty uterus &/or adnexal mass &/or fluid in pouch of Douglas.

ultrasound examination Negative pelvic ultrasound (20-30%) does not exclude ectopic pregnancy. So wait it and repeat ultrasound in 4 days time provided there are no clinical sign of intraperitoneal bleeding. Transvaginal scanning provides much clearer images of pelvic structures in comparison to transabdominal scanning and Intrauterine pregnancy can be diagnosed one week earlier with transvaginal than with transabdominal ultrasonography

2. Serum human chorionic gonadotropin (hCG): a. Serum B-hCG tests are positive in 100% of ectopic pregnancy. b. Serial estimation of B-hCG concentration. Serial serum hCG assay is particularly useful in the diagnosis of a symptomatic ectopic pregnancy. It can distinguish between intrauterine and ectopic pregnancy as the level of hCG doubles every 2 days in normal intrauterine pregnancy. Abnormally slow rise in serum hCG and prolonged hCG doubling time is an indicator of an abnormal pregnancy.

2. Serum human chorionic gonadotropin (hCG): c. B-hCG with ultrasound scanning (Discriminatory zone): With the use of transabdominal ultrasound, a normal pregnancy could be seen in most cases when serum hCG exceeded 6500 IU/l.With the transvaginal ultrasound this threshold can be lowered to 1000 IU/l.

progesterone level progesterone level serial measurement may be helpful.

Laparoscopy It allow for direct visualization of tubes and ovaries and should be considered in women with hCG above the discriminatory level and absence of intrauterine gestational sac on ultrasound and if diagnosis is in doubt. Laparoscopy is the gold standard for the diagnosis of ectopic pregnancy

culdocentesis Used in past to diagnose rupture ectopic and not useful for diagnose of early ectopic pregnancy. Not used nowadays as the results of culdocentesis do not always correlate with the status of the pregnancy.

uterine curttage not advised in routine investigation.

7.Surgery (laprotomy): For women who present in shock, immediate surgery is both diagnostic and therapeutic.

Treatment: Acute presentation (rupture ectopic) = surgery immediate resuscitation and intravenous fluid with blood transfusion as rapid as possible and as needed. under general anesthesia laprotomy or laproscopy done. simple salpingectomy to affected tube with conservation of ovaries.

Subacute/asymptomatic presentation (unruptured ectopic) Immediate treatment is essential and the aim to preserve tube and treat the condition before rupture of tube.

Types of treatment: medical treatment There is no role for medical management in the treatment of tubal pregnancy or suspected tubal pregnancy when a patient shows signs of hypovolaemic shock. It can be chosen for patient who has (all of following): size of ectopic pregnancy less than 4 cm. unruptured tube. Serum hCG level less than 1500 IU/lit. No evidence of embryonic cardiac activity (fetal heart negative by ultrasound.chose for patient has: size of ectopic pregnancy less than 4 cm. unruptured tube. Serum hCG level less than 1500 iu/lit. Non viable pregnancy (fetal heart negative) by ultrasound.

Women should be able to return easily for assessment at any time during follow-up. Drug used in medical treatment: methotrexate, prostaglandin( PGE2,PGF2α), potassium chloride, mifipristone.

Route of administration: systemic methotrexate, mifipristone. Local injection of drug into gestational sac by laproscopy, transvaginal, transcervical).

Follow up: The treatment need Follow up by Ultrasound combined with serial hCG which are essential at interval of 1-2 days.

Active management are needed (switch to surgical treatment) if : a. hCG level rise during follow up. b. suspicious clinical symptoms. c. sonographic finding develops.

2. surgery: a. laproscopy b. laprotomy

Surgical approach can be by : a. laproscopy. b. laprotomy. The surgery of ectopic pregnancy were either conservative surgery (tubal conservation) or radical surgery (removal of the tube) and the choice between them should be made depending on the circumstances in each individual case. In general tubal conservation should be attempted if a woman desires further pregnancies and there is evidence of contralateral tubal damage.

conservative surgery. 1.Conservative surgery (removal of ectopic pregnancy and preserve affected tube) can be done by one of following: a. Salpingotomy (opening tube and left open to heal by secondary intention). It should be considered as the primary treatment when managing tubal pregnancy in the presence of contralateral tubal disease and the desire for future fertility. Women must be made aware of the risk of a further ectopic pregnancy. b. Fimbrial evacuation. c. Mid tubal resection with or with out re-anastmosis.

2.Radical surgery for ectopic is salpingectomy which is indicated in : 1. severely damaged tube. 2. women who complete her family. 3. uncontrolled bleeding from implantation site. 4. large tubal pregnancy (>5 cm). 5. recurrent ectopic pregnancy in same tube.

Persistent trophoblastic disease: viable trophoblastic tissue remains after medical treatment and/or conservative surgical treatment in about 5-10% and require further treatment either by methotrexate or surgery.

3.Expectant management (non- interventional ) methods: not common to use and not suitable for all patient as it needs follow up by ultrasound and hCG and may need active management at any time.

Remember: If the woman is Rh-negative and her husband is Rh-positive or unknown Rh, (250unite) anti-D immune globulin should be given intramuscularly to prevent anti-D isoimmunization.

Prognosis: Significant factors affect future fertility after treatment of ectopic pregnancy which are: 1.Condition of controlateral tube. 2.history of infertility. 3.Extent of surgery.

Intrauterine pregnancy rates following ectopic pregnancy range between 50 and 70%. Recurrent ectopic pregnancies occur in 6–16% of women with previous history of ectopics and these women should be offered early scans in all future pregnancies to detect recurrent ectopics before complications can occur. Pregnancy rates are similar in patients treated by either laparoscopy or laparotomy. In women with a damaged or absent controlateral tube, in vitro fertilization is likely to be required if salpingectomy is performed.

Non tubal pregnancy

Abdominal pregnancy: Rare condition and it is associated with high morbidity and mortality, with the risk for death 7 to 8 times greater than from tubal ectopic pregnancy and 90 times greater than from intrauterine pregnancy.

Symptoms and signs: 1.history suggest ectopic pregnancy in early pregnancy sometimes. 2.a symptomatic and suspected from examination. 3.persistant abnormal lie. 4.fetal parts are readily palpated. 5.enlarged uterus felt separate from fetus.

Investigations: 1.ultrasound show no clear outline of gestational sac and oligohydramnios and early intrauterine growth resriction (IUGR). In women with a clinical suspicion of abdominal pregnancy a transvaginal scan should be performed to assess the uterus and establish the continuity between the cervical canal, uterine cavity and gestational sac 2.X-ray of abdomen showed maternal intestinal gas superimposed on fetus. 3.oxytocin infusion which cause uterine contraction which felt separately from fetal part

course: 1.alive fetus reaches viability. 2. fetus die and thrombosis of vessel at placental site gradually occur and there will be either no symptome,or complications could arise.

Treatment Treatment of abdominal pregnancy is surgical by laprotomy as soon as viability is achieved because fetus will die once labour begin. The fetus should be removed, the cord cut short and the placenta should be left in situ. Any attempt to remove the placenta may result in massive uncontrollable haemorrhage. the residual placental tissue will absorb slowly over a period of many months, sometimes a few years.

Complications of abdominal pregnancy: 1.maternal complications: A. complication arising due to placenta in situ: infection. adhesion. obstruction. coagulopathy. B. complication arising due to fetal death in peritoneal cavity: Adhesion infection of sac and severe toxic effect

Fetus complications: Pressure deformity. Increase perinatal mortality to 75% or more.

Hetrotopic pregnancy: Is combined ectopic and intrauterine pregnancy. Treated by either: injection of hyperosmolar glucose in ectopic site. Surgical removal of ectopic.

Prognosis: 75% of intrauterine pregnancy reach term.

Types of treatment: Types of treatment: Medical treatment:Medical treatment: methotrexate (follow up). methotrexate (follow up). Surgical treatment:Surgical treatment: (laproscopy, laprotomy). (laproscopy, laprotomy).

Don’t miss this---- Ectopic pregnancy in women should be in mind in every emergency room. Ectopic pregnancy in women should be in mind in every emergency room.