Ectopic pregnancy

Ectopic pregnancy

An ectopic pregnancy is the implantation of an embryo outside the uterus.

Tubal, ovarian, cervical, abdominal, histerotropic, c section scar

Porciones de la trompa

Sitio más común de embarazo ectópico

Trompa (90%)

Ectopic pregnancy can lead to …

Tubal rupture

Massive intra-abdominal hemorrhage > death

Tubal damage (reproductive outcome)

It is the leading pregnancy-related cause of death in the first trimester.

With reliable serum pregnancy tests and vaginal ultrasound, early detection and treatment can be posible.

Etiology

• Abnormality of fallopian tubes

• Loss of fimbrial, lumen and ciliated mucosa integrity

• Pelvic inflammatory disease

• Tubal surgery

• Infertility and assisted reproductive techniques

• Cigarette smoking

• Pregnancy with an Intrauterine Device IUD in place (DIU de cobre)

• Congenital defects of the tubes

¿Cuál es el sitio más común del embarazo ectópico?

Ampullar

95% of ectopic pregnancies occur in the:

Fallopian tubes

5% of ectopic pregnancies occur in the:

• Ovaries (3%)

• Peritoneal cavity (1%)

• Cervical

• C section scar

In the Fallopian tubes:

Ampulla (74%).

Isthmus (12%).

Fimbrial end of the tube (12%).

Interstitium (2%).

Signs and symptoms

Vaginal bleeding

Abdominal pain

Unilateral pelvic

Associated with shoulder pain

Dizziness

Fainting

Palpitations from hypotension due to intra-abdominal hemorrhage

Lower uterine hCG level that may not be detected in the urine test

Physical examination when there is tubal rupture:

Hypotension

Tachycardia

Abdominal distension due to hemoperitoneum

Signs of acute abdomen present with:

• Guarding

• Rebound tenderness

• Cervical motion tenderness

Physical examination in the absence of rupture:

• Physical exam can be normal

• Cannot diagnose rupture of ectopic pregnancy

• Diagnostic tests needed

• Presence of anexial mass

Diagnostic tests

Transvaginal ultrasound

• Rules out the presence of an intrauterine pregnancy

Human chorionic gonadotropin: discriminatory zone (2,000 mlU/mL)

Dilation and curettage

Serial hCG testing

Laparoscopy

Serum progesterone levels

Vaginal ultrasound

• 15-35% are not seen on ultrasound

• Suspicious signs

• Empty uterus, thick endometrium

• Presence of intrauterine pseudosac

• Sign of double halo in the tube

• Visualization of gestational sac outside the uterus with yolk vesicle 

Ectopic pregnancy

Ectopic pregnancy

Free fluid in pelvis: inflammatory process

HCG

• Serial determination of the beta fraction

• Produced by trophoblast cells

• Doubles value every 2 days

• Minor increase is suggestive of non-viable pregnancy (miscarriage or ectopic).

When ectopic pregnancy is suspected and inconclusive with US:

perform serial determination (pedir cada 2 días)

HCG B values > 1,000 - 2,000 mU, not visible on US:

High probability of ectopic embryo

Culdocentesis

Diagnostic technique for ectopic pregnancy

Identifying the presence of unclotted blood

Methotrexate

• Folic acid antagonist

• Inhibits de novo synthesis of purines and pyrimidines

• Interferes with DNA synthesis and cell multiplication.

• Trophoblast: tissue vulnerable to methotrexate.

Methotrexate exclusion criteria

• Previous severe renal or hepatic disease.

• Abnormality in hemogram (leukocytes < 2,000, platelets < 100,000, creatinine > 1.5)

• Treatment with NSAIDs or diuretics

Methotrexate inclusion criteria

• Hemodynamically stable

• No rupture of the ectopic pregnancy

• Maximum egg diameter not greater than 4 cm.

• Bhcg less than 5,000- 10,000 mU

• Presence of heartbeat makes it less successful.

Surgical treatment options

Salpingostomy

Salpingotomy: quitar y reparar embarazo ectópico

Salpingectomy: quitar la trompa

Cornual resection: embarazo intersticial

Oophorectomy: embarazo ovárico

Algoritmo

Methotrexate treatment doses

Surgical treatment

• Solves the problem definitively

• Previously considered gold standard

• Patients who do not meet the criteria for medical therapy

• Ruptured or suspected ruptured ectopic pregnancy.

Surgical approach

Salpingectomy

Tubal rupture and hypovolemic shock data

Linear salpingostomy

Clinically stable patients

Interstitial pregnancy

• Pregnancy implants within the tubal segment that lies within the muscular uterine wall.

• Usually rupture following 8-16 weeks of amenorrhea

• Because of the proximity of these pregnancies to the uterine and ovarian arteries hemorrhage can be severe and associated with higher mortality rates.

Interstitial pregnancy management

Cornual resection

Cornuostomy

Abdominal pregnancy

• Implantation in the peritoneal cavity of tubal, ovarian or intraligamentary pregnancy.

• Secondary to rupture of the salpingeum or miscarriage.

Abdominal pregnancy diagnosis

• Abdominal pain, nausea, vomiting

• Hemorrhage

• Fetal movements, reduced or absent.

• Increase in maternal serum protein fetus.

• US: Frequent but nonspecific oligohydramnios. Fetal head adjacent to maternal bladder.

Abdominal pregnancy approach if diagnosed after 24 weeks:

Expectant until the fetus is viable.

Abdominal pregnancy approach if diagnosed before 24 weeks:

Pregnancy interruption at the diagnosis time

Abdominal pregnancy

Abdominal pregnancy