Lecture Supplement #50, Ectopic Pregnancy

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					Lecture Supplement #50, Ectopic Pregnancy


•   Ectopic Pregnancy = implantation outside the uterine cavity
    • Overview
       • In addition to the problem of fetal loss, ectopic pregnancy represents a leading
          cause of maternal mortality and morbidity.
       • Early diagnosis (before tubal rupture) may be lifesaving and may preserve
          future fertility. A high degree of suspicion is necessary for timely
          diagnosis.
       • The consequences of an unrecognized ectopic pregnancy may include
          irreparable tubal damage, and subsequent infertility as well as life-threatening
          hemorrhage, and the attendant concerns of transfusion and emergency
          surgery.
       • Incidence increasing due mainly to increased incidence of PID which is being
          medically treated as opposed to surgically as in the past, and tubal surgery
       • Mortality, however, is decreasing 2° to earlier diagnosis and intervention
       • Although implantation may occur on many sites, 95% are tubal, and of these,
          80% - 95% are ampullary
    • The "risk factors" for ectopic pregnancy
       • History of salpingitis
       • History of prior ectopic
       • Age
       • Black /Hispanic
       • IUCD
       • Tubal surgery
       • GIFT/ZIFT (see Lecture Supplement #32)
       • Diethylstilbesterol (DES) exposure
       • Infertility
    • Possible outcomes (pathogenesis)
       • Tubal rupture
       • Tubal abortion
       • Spontaneous regression
       • Mummification (lithopedeon)
       • Abdominal/intraligamentary implantation
    • Reaction of the uterine mucosa
       • Mucosa responds with decidual change regardless of the site of the pregnancy
       • Arias-Stella Reaction = neoplastic appearing endometrial glandular changes,
          usually focal. While suggestive of ectopic pregnancy, may also be found in
          normal pregnancy
       • With death of the embryo, or falling hormone levels from whatever cause, the
          uterine mucosa is cast off
       • Such a cast may be misdiagnosed as an incomplete abortion unless
          histological evaluation is performed and demonstrates the absence of
          chorionic villi
    • Clinical presentations
       • Classic is abdominal pain, amenorrhea, and vaginal bleeding (but only 15% of
          patients present with all three)


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Lecture Supplement #50, Ectopic Pregnancy


       • Early ectopics are asymptomatic
       • Shoulder pain
       • Urge to defecate
       • Syncope
       • Vaginal bleeding
       • Cervical motion tenderness/adnexal tenderness
       • Adnexal mass in 1/3 of cases, but absence does not R/O the diagnosis
       • Slight uterine enlargement simulating early intrauterine pregnancy
   •   Diagnostic procedures
       • Ectopic pregnancy is best R/O using both transvaginal ultrasonography
          and βhCG testing; a patient with no evidence of intrauterine gestation,
          and a βhCG value exceeding 2500 mIU/ml, or a value that plateaus,
          should be presumed to have an ectopic pregnancy until proved otherwise.
       • Pregnancy test
          • Discriminatory zone = that level of the β subunit of hCG above which a
             pregnancy (yolk sac) will be ultrasonographically visualized in utero.
          • Serial quantitative beta hCG levels (should double q 72 hrs in normal
             pregnancy)
       • Serum progesterone
          • Not commonly used
          • Values over 15 ng/ml R/O ectopic
          • Values below 5.0 ng/ml indicate non-viability
          • Unless serum progesterone determinations can be obtained from the
             laboratory with 24 hours, the test will have limited usefulness
       • Complete blood count (CBC)
                                                     o
          • Low Hgb/Hct can document anemia 2 to cryptic blood loss
          • WBC above 20,000 makes infection (PID) a more likely diagnosis than
             ectopic pregnancy
       • Culdocentesis
          • 10 ml of non-clotting blood with Hct above 15% is (+) for
             hemoperitoneum, but . .
          • Negative culdocentesis does not R/O unruptured ectopic pregnancy
          • Although beta subunit for hCG and ultrasound is better (see handout for
             algorithm) these may not be available in every hospital setting
       • Ultrasonography
          • 1800 mIU/ml is discriminatory zone for transvaginal ultrasound
          • 6000 mIU/ml is discriminatory zone for transabdominal ultrasound
          • The actual ectopic gestational sac can often be visualized on transvaginal
             ultrasound
          • With ultrasound, diagnosis of ectopic is usually made by ruling out an
             intra-uterine pregnancy when the level of the β subunit of hCG is above
             the discriminatory zone.
       • Curettage of the uterus
          • Can R/O ectopic by demonstration of chorionic villi


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Lecture Supplement #50, Ectopic Pregnancy


          •   Only of use where non-viability can be confirmed or pregnancy is not
              desired
       • Laparoscopy = most accurate (with laparotomy) but can miss 2-3% of early
          cases
   •   Differential diagnosis = suspect ALL sexually active, reproductive age females
       with pain, bleeding, and/or amenorrhea
       • Complications of intrauterine pregnancy, i.e., threatened, missed, inevitable,
          or incomplete abortion (see Lecture Supplement #49)
       • Non-pregnancy related gynecological conditions
          • Acute and chronic salpingitis
          • Rupture or torsion of an ovarian cyst
       • Non-gynecological conditions, i.e., appendicitis
   •   Management = (see handout for algorithm)
   •   Treatment options
       • Evolved from salpingo-oophorectomy (pre 1960's), microsurgery (1960's),
          linear salpingostomy, segmental resection, fimbrial expression (1970's), to
          endoscopic surgery and non-surgical management (1980's)
       • Salpingo-oophorectomy is essentially obsolete
       • Salpingectomy
          • Ruptured ectopic and/or hemodynamic instability
          • Patients wishing to avoid future pregnancy
          • Although salpingectomy offers almost a 100% cure, surgical treatment
              evolved to not only prevent death, but to allow rapid recovery, preserve
              fertility, and reduce cost.
       • Laparoscopic linear salpingostomy or salpingotomy (salpingotomy = closed
          by suture; salpingostomy= left open to heal by secondary intention)
          • Conservative treatment of choice for ampullary ectopic pregnancy
          • Successful in 95% of cases
          • Tube opened with scalpel, cautery, or laser
          • Conceptus expressed, hemostasis with cautery or laser
       • Fimbrial expression
          • Used for ampullary ectopic pregnancy already aborting thru fimbria
          • Otherwise, too traumatic with high incidence of recurrence or persistent
              ectopic
       • Segmental resection
          • Best suited to isthmic ectopic pregnancy
          • Anastamosis may be delayed
       • Non-surgical management (Methotrexate)
          • Systemic methotrexate is administered in one of two ways: as a single
              dose protocol or a multiple dose protocol
          • See text for protocol, p. 209
          • Induces tubal abortion avoiding tubal surgery
          • Advocates feel that future fertility is enhanced as compared to
              salpingostomy.



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