Ectopic Pregnancy

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					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
“ 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:

Ampulla (>85%)           Abdomen (< 2%)
            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%)

  Onset occurs ~7 weeks after LMP
  Abdominal pain
  Vaginal bleeding

   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:

In a woman of child bearing age with pelvi-
abdominal pain and/ or vaginal bleeding ……
   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
   This has resulted in early diagnosis and
    effective treatment.
   Now the rate of tubal rupture is as low as
   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
                   Diagnostic modalities
1. Pregnancy test.
   a) Urinary B-hCG… sensitive, detects 25-50 ml I.U/ml.. Positive
      before missing the next period
   b) 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
   a) Abdominal. Sac at 5 wks F.H. at 7 wks.. Needs full bladder
   b) Transvaginal. A wk earlier than abdo… empty bladder
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.
The USG features of ectopic pregnancy after 5
weeks can be any of the following-
 2. Poorly defined tubal ring possibly containing
    echogenic structure and POD typically
    containing fluid or blood.
 3. Ruptured ectopic with fluid in the POD and an
    empty uterus.
 4. 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
Depending on the presentation:
 Acute… with ruptured ectopic and intra-abdominal bleeding….
ABC,,, + surgical approach.
 Early stages, with intact ectopic:

 1. Expectant… decreasing B-hCG …. Tubal abortion
 2. Medical… Depending on size of ectopic and level of B-hCG…..
    Use methotrexate….. Not common approach
 3. Surgical
             Surgical Management
 Conservative,
   Open vs laparoscopic….. Linear salpengotomy vs
milking of the tube

 Radical,
  laparoscopic vs open ……. salpengectomy

 Fertility post ectopic surgery…
The debate goes on


                           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

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

• The rationale behind the scoring system
  is to decide the risk of recurrent ectopic
• Conservative surgery is indicated with a
  score of 1-4 only, while radical treatment
  is to be performed if the score is 5 or
        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
 Ectopic pregnancy is a life threatening condition & on the
 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