Ectopic pregnancy

Define ectopic pregnancy

Ectopic pregnancy is one in which the fertilised ovum becomes implanted in any other site other than the uterine cavity.

It is the consequence of abnormal implantation of blastocyst.

Frequency of ectopic pregnancy

2% in USA.

3-4% worldwide.

Risk of subsequent ectopic pregnancy in a mother who had ectopic pregnancy before

7-13 fold increases

Site of ectopic pregnancy

Fallopian tube 95-98%

Uterine Cornu 2-2.5%

Ovary, cervix, abdominal cavity <1%

More common on the right side.

Parts of fallopian tube with their length and diameter

Intramural/interstitial part- length: 1.25cm diameter: 1mm

Isthmus- length:2.5cm diameter: 2.5mm

Ampulla- length: 5cm diameter:1 cm

Infundibulum- length: 1.25cm diameter: 6mm

Normal ovum implants in which positions in fallopian tube?

5 main positions.

1. Fimbriated opening- primary implantation at this is unusual

2. Ampulla- most common and least dangerous

3. Isthmus- less common but more dangerous

4. Interstitial- rare

5. Diverticulum of fallopian tube

Risk factor

1. Pelvic inflammatory disease(PUD)

2. Smoking

3. Use of intrauterine contraceptive device

4. Assisted reproductive technology pregnancy

5. Tubal damage(surgical occlusion or cilia damage)

6. Tubal surgery

7. Prior ectopic pregnancy(10fold)

8. Woman of age 35-33years

9. Non white

10. Endometriosis

11. Salpingitis isthmia nodosa

12. Developmental error of tube

13. Over development of ovum & external migration

Aetiology of ectopic pregnancy

1. Most common-Acute salpingitis

2. PID

3. IUCD- progesterone device→altered motility of tube→abnormal implantation

4. Smoking

5. Surgical obstruction → Tubal damage

6. Assisted reproductive techniques

7. Tubal surgery → following surgery of blocked tubes and reversal of sterilization

8. Salpingitis isthmia nodosa

9. Prior ectopic pregnancy

10. Developmental error of tube

11. Overdevelopment of ovary and external migration

Clinical feature of ectopic pregnancy

S/S:

1. S/S of pregnancy

2. Abdominal pain(dull,cramps,colicky)

3. Evidence of hemodynamically instability (hypotension, collapse, signs of shock)

4. Vaginal bleeding

5. Adnexal mass(with or without tenderness)

6. Peritoneal irritation

7. Absence of gestational sac with Beta HCG of more than 2500mIU/ml

Clinical picture of chronic ectopic pregnancy

Pain and syncope most constant symptoms

P/V bleeding

Shoulder tip pain/ epigastric pain

Signs-

1. Tenderness and muscle guarding over the lower abdomen specially on the affected side

2. Some degree of intestinal distention is a common sign

3. Cullen’s sign- bruising around umbilicus

4. Irregular tender enlargement of adnexa on the affected site & ill defined semisolid swelling in the pouch of Douglas indicate pelvic hematoma

5. Atrial palsation of forbid on the affected site

6. Tenderness of pelvis is a constant sign.

Rupture ectopic pregnancy

1. Short period of amenorrhea

2. Sharp lanciating pain in one iliac fossa of epigastrium followed by collapse marked by pallor, lower BP, subnormal temperature, weak pulse

3. Signs of shock & anemia.

4. Lower Abdominal tenderness

5. Dullness over flank

Outcome of ectopic pregnancy

1. Tubal abortion(expulsion of embryo by fallopian tube before rupture occurs)

2. Complete absorption

3. Complete abortion

4. Incomplete abortion

5. Tubal rupture

6. Tubal mole(gestational sac surrounded by blood clot & retained in the tube)

7. Chronic ectopic adnexal mass

8. Fetal survival to term

D/D of ectopic pregnancy

Obs disease- 1. Abortion of an early intrauterine pregnancy

2. Abortion followed by salpingitis

3. Early pregnancy with pelvic tumor

4. Retroverted gravid uterus(threatened abortion)

5. Septic abortion

Gynae disease-

1. Degenerating fibroid

2. Endometriosis

3. Ovulation

4. Rupture corpus luteum

5. Torsion of adnexal mass

6. Dysfunctional uterine bleeding

7. Acute or subacute salpingitis (including TB)

INV of ectopic pregnancy

1. Blood grouping and Rh typing

2. Beta HCG

3. Trans vaginal sonography(TVS):

   -presence of extra uterine ecogenic ring

   -hemosulpinx

   -adnexal mass- cystic or solid

   -presence of empty uterus or pseudo gestational sac

   -presence of free fluid or clotted blood In cul de sac

Mx & Rx of ectopic pregnancy

Emergency management- hospital admission, treatment of shock

Expectant management

Surgical management

Medical management

Expectant management of ectopic pregnancy

Criteria-

1. Serum HCG <1500IU/L

2. No fetal heart beat on TVS

3. No evidence of bleeding or rupture on TVS

4. Gestational sac<4cm

Contraindication-

1. Patient is hemodyanamically unstable

2. Presence of signs of impeding or on going rupture of ectopic mass

Medical Mx of ectopic pregnancy

1. Pt is hemodynamically stable & no pelvic pain

2. Ectopic pregnancy is <4cm & no fetal heart activity in TVS

3. No evidence of tubal rupture

4. Beta HCG is <3000IU/L with minimal symptoms

   Rx- methotrexate 5mg/m2 IM

Contraindications of medical Mx

1. Large ectopic size (>3.5cm)

2. Beta HCG >5000mIU/L

3. Presence of fluid

4. Presence of fetal heart activity

Surgical Mx

1. Candidate is not suitable for medical therapy

2. Failed medical therapy

3. Tubal Rupture

4. Presence of fetal activity

5. Heterotrophic pregnancy with viable intrauterine pregnancy

Indication for performing salpingectomy instead of salpingostomy/ indication of salpingectomy

1. Uncontrolled bleeding from the implantation site

2. Large tubal pregnancy (more than 5cm)

3. Woman not in her child bearing age anymore

4. Woman who may be treated with IVF in future

5. Severe damaged tube

6. Recurrent ectopic pregnancy in the same tube

Indication of laparotomy

1. Pt is hemodynamically unstable

2. Cervical, interstitial or abdominal ectopic pregnancy

3. Patient having large hematoma due to large ruptured ectopic pregnancy

4. Presence of 1500cc of hemoperitoneum

5. Pt having cardiac disease or COPD

Ovarian pregnancy

1. Fallopian tube must be intact at the affected site

2. Ovarian tissue must be at the sac wall

3. Fetal sac must occupy the position of ovary

4. Ovary must be connected to the uterus by ovarian ligaments

Rx- affected ovary has to be sacrificed

Cornual pregnancy

Implantation occurs at the cavity of the rudimentary horn of uterus.

Rx:affected horn together w the pregnancy being usually removed.

Cervical pregnancy

TVS:

1. Echo free uterine cavity or presence of false geostationary sac

2. Decidual transformation of the endometrium with dense echo structure.

3. Diffuse uterine wall structure

4. Hour glass uterine shape

5. Ballooned cervical Canal

6. Gestational sac in endocervix

7. Placental tissue in cervical canal

8. Closed internal os

Rx:

Abortion takes place sooner or later & when it does bleeding from the non retraction cervix can be so severe than it necessitates hysterectomy.

Abdominal pregnancy

1. Presence of normal tubes & ovaries with no evidence of recent or past pregnancy.

2. No evidence of uteroplacental fistula

3. The presence of pregnancy related exclusive to peritoneal surface & early enough to eliminate the possibility of 2ndary implantation after primary tubal nidation

Clinical feature of abdominal pregnancy

1. Intestinal distention, periodic abdominal pain, occasional slight uterine bleeding are common

2. The foetus usually takes up abnormal, attitude & position

3. The uterus may be felt as a tumor separate from the pregnancy sac & is mistaken for a leiyomyoma or cyst

4. The pregnancy mass on the other hand does not contract

Rx of abdominal pregnancy

Laparotomy

• dangerous operation skill is needed

• If placenta is implanted, then it is better to remove the placenta without disturbing its sac

• MTX has been used to manage the residual placenta but can accelerate tissue necrosis and infection.

Interstitial pregnancy

Comments type of ectopic, located outside the uterine cavity in the part of the fallopian tube which penetrates the muscular layer of the uterus.

Mx of interstitial pregnancy

Emergency laparotomy-ruptured ectopic

Surgical- cornual evacuation, cornustomy, cornual resection or cornual wedge resection.

Conservative Mx of interstitial pregnancy

1. MTX

2. Potassium chloride injection

3. Conservative laparoscopic surgery

4. Uterine artery embolisation

Intraligamentary pregnancy

Similar to secondary abdominal pregnancy in that it arises 2ndarily to tubal implantation

The tube rupturing extraperitoneally & discharging the foetus between the layers of broad ligament.