Ectopic Pregnancy

Ectopic PregnancyAasem Zeidan Abu-ShtayaNormally,

Normally, Fertilization occurs in the lateral third of the fallopian tube.On average it takes the spermatozoa 1 hr to reach the ovum.5-6 days post fertilization, the fertilized egg travels back to the uterus for IMPLANTATION to occur INSIDE the uterine cavity.DefinitionAn ectopic pregnancy is one that implants outside the uterine cavity (not the uterus) in a place other than the endometrium Where outside the uterine cavity?

Then..Implantation occurs in the fallopian tube in up to 98% of cases2nd comes the abdominal implantation, where the placenta could attach to the bowel. With an incidence of ~ 1%3d: ovarian ~0.2%4th : cervical ~0.2%Incidence The incidence of ectopic pregnancies has increased dramatically during hthe past 10 years and now occurs in more than 1:100 pregnancies.This is thought to be secondary to the increase of:STIsAssisted fertilityPIDsWhy does it happen?several risk factors predispose patients to extrauterine implantation.Many affect the fallopian tubes leading to either:Tubal scarringDecreased peristaltic motility of the tube.Risk factors for ectopic pregnancyTable 2-1, Blueprints Obs&Gyne 5th edition, page 15History of STI or PIDPrior ectopic pregnancyPrevious tubal surgeryPrior pelvic or abdominal surgeries leading to adhesionsEndometriosis Current use of exogenous hormones including progesterone and estrogenIVF and assisted reproductionCongenital abnormalities of the fallopian tubesUse of IUD for birth controlHowever..in as many as one third to one half of ectopic pregnancies, no risk factors can be identified.Through the R.FsPIDs can lead to intra or peritubal adhesions decreasing the ability of the fertilized ovum to reach the uterine cavity.STIs can directly destroy the cilia of the fallopian tube epithelium.Any tubal surgery like Tubal reanastamosis, tubal ligation, tubal adhesions can cause impairement of cilial movement.Methods of contraceptions as IUCD prevent the implantation into the endometrial tissue.Progesterone only pills cause EP because they lead to relaxation of the muscle layer of the tube...

Any inflammatory process within the uterus or the pelvis in general could theoretically lead to the occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia.CLINICAL MANIFESTATIONSClinical manifestations typically appear six to eight weeks after the last normal menstrual period, but can occur later, especially if the pregnancy is not in the fallopian tube. Normal pregnancy discomforts (eg, breast tenderness, frequent urination, nausea) are often present.DiagnosisHistoryPhysical examinationLab testsU/sHistoryThe 3 classical symptoms of ectopic pregnancy are:AmenohreaAbdominal painVaginal bleedingHistory In any lady presenting with those symptoms during her first trimester, EP should be excluded. you should also think of:Normal intrauterine pregnancySpontaneous abortionSalpingitisappendicitis

Physical ExaminationUsually associated with minimal findings but may reveal:Tender adnexal massA uterus that is small for gestational ageCervical bleeding.

Patients with RUPTURED EP may be hypotensive, unresponsive, or show signs of peritoneal irritations sec. to haemoperitoneum.(-hCG)EXTREMELY importantLab method of a choice for confirming EP

In normal intrauterine pregnancy (-hCG) is secreted by the trophoblastic tissue in a predictable manner. The absolute value doubles approximately every 2.5-3 days.HoweverIn EP the levels are low for gestational age.e.g. (-hCG) of 500 IU/ml at day one repeated 3 days later and revealed a value of 2000 IU/ml decreases the likelihood of EP

Progesterone levelsGood specificity and sensitivity for normal intrauterine pregnancy.Not reliableIf its low, its a marker of abnormal pregnancyCannot differentiate b/w EP and abortionU/SMight show normal IUP, hence we are most probably dealing with an abortion.might show an adnexal massFetal heart activity in the adenxia could be monitoredBleeding in doglus pouch

Diagnostic method of a choice is:LAPROSCOPYWhat were afraid of ?!Theres always a small risk for heterotropic pregnancy, a multiple gestation with at least one IUP and one EP.This is a particular concern in the setting of IVF when more than one embryo was utilizedThose patients are labelled as rule-out ectopic.Should be followed with B-hCG levels every 48 hours and undergo a transvaginal U/sManagement (1) Mrs. Amireh, a 28 y/o lady presents to the ER with unilateral lower abdominal pain. Fresh vaginal bleeding of 1 day duration. Her LMP was 10 weeks ago.The Pt. is concious, oriented and looks well.Upon P/E her pulse was 85, Bp: 130/ 85 Temp. 36.8Urine pregnancy test was performed and was positive.The rotating dr. decided to perform an abdominal U/S that revealed a mass measuring 3 cm in the right fallopian tube and fluid collection in the pouch of doglus . No IUPWe take into consideration:1. Patient stability (immediate surgical interferance if unstable)2. desire of future fertilitySite of E/P State of EP (ruptured or intact)Our very first priority is to stabilize the patient and look for signs of distress.Our patient looks fine, stable and oriented.Hence, can be treated either:Medically SurgicallyMedical Tx:The drug of a choice used at most institution is MTXIts appropriate for who have small E/P less than 4 cm and for those patients who are reliable for follow up.The drug is given as one shot IM 50gmPatient should be followed with serial b-hCG.B-hCG levels will rise the first few days after MTX, but will start decreasing after 4-7 days.If such a fall is not achieved or if the levels plateau, a 2nd dose should be given.If it stays high MUST go for surgery

Serum b-hCG levels after one MTX injectionManagement (2)Mrs. Badran, a 25 y/o lady, presented to the ER at 4 a.m with severe diffuse abdominal pain. She reports profuse vaginal bleeding. Her last LMP was 8 weeks agoUpon P/E her Pulse was 110, Bp. 100/70 temp 37 C. severe abdominal tenderness and guarding upon palpation.The pt is dioriented, drowsy and almost fell to the ground when entering the ER.Urine b-hCG was positive, U/s showed a ruptured left fallopian tube and severe bleeding within the peritoneumSurgical Tx:If a patient presents with a ruptured ectopic pregnancy and is unstable, the first priority is to stabilize with IV fluids, blood products, and pressors if necessary. The pt should be taken to the OR where exploratory laprotomy can be done to stop the bleeding and remove the ectopic pregnancyIf the pt is stable, the procedure of choice at most institutions is explotatory laproscopy that can be performed to evacuate the hemoperitoneum , coagulate any ongoing bleeding and resect the ectopic pregnancyResection can be either through:Salpingostomy: the EP is removed leaving the fallopian tube in place Salpingectomy: where the entire EP along with the tube are removed.

* Ovarian EP are normally treated surgically by oophorectomyThank you .. Miscarriage

Aasem Zeidan Abu-ShtayaDefinitionalso known as spontaneous abortion. refers to a pregnancy that ends spontaneously before the fetus has reached a viable gestational age. The World Health Organization defines it as expulsion or extraction of an embryo or fetus weighing 500 g or less from its mother. This typically corresponds to a gestational age of 20 to 22 weeks or less

IncidenceMost common gyanecological and obstetric disorderAbout 15-25% of all clinically recognized pregnancies.Underestimated because losses that occur 4 to 6 weeks gestational age are often confused with late mensesReal incidence could reach 30-35%Risk factorsAgePrevious spontaneous abortionSmokingAlcoholGravidityCocaineNSAIDsFeverCaffeineProlonged ovulation to implantation intervalProlonged time to pregnancyLow folate levelsMaternal weightAetiologyFirst trimester abortions60-80% are due to fetal chromosomal abnormalities. (m.c.c)Incidence of these abnormalities is increased with increasing maternal age.This could be because many abortions likely occur before implantation.Other causes:Infections : genital tract infections and systemic infections with pyrexiaMaternal anatomic defects: uterine anomalies, submucous fibroid, asherman syndrome etc..Endocrine and immunological factorsMultiple pregnancyCigarette smokingPsychological disorders

All together comprise the remaining 20-30%Second trimester abortionsBetween 13 to 26 weeks gestational ageLess common than first trimester abortionsHave multiple etiologies:

Genital tract infections and PROMMaternal uterine or cervical anatomic defectsMaternal systemic diseasesCervical incompetanceTRAUMAMultiple pregnancy.

TypesDefined by 1.any or all of the products of conception have passed2. whether the cervix is dilated or notTypes Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion Septic abortion Recurrent aborion

Threatened abortionAny vaginal bleeding before 20 weeks, without dilatation of the cervix or expulsion of any POC (i.e. a normal pregnancy with bleeding)

HxMild vaginal bleeding abdominal painP/ECervix is closedUterus size is correct for GAU/SShows the presence of fetal heart activityThreatened abortion- Management1. reassurance: if fetal heart activity is present, in more than 90% pregnancy will progress in a satisfactory way2. advice to decrease physical activity and avoid intercourse3. Give progesterone and hCG which are used in the first trimester to support pregnancy4. adequate dose of anti-D should be given to all Rh ve non-immunised patients, whose husbands are Rh +ve5. label as high risk patients because those patients are liable to late pregnancy complications such as APH and preterm labour.Inevitable abortionInevitable heavy vaginal bleeding and dilatation of the cervix WITHOUT expulsion of any POC

HxVaginal bleedingP/EDilating cervixUterus may be in correct size for dateU/SFetal heart activity may or may not be present Incomplete abortionIncomplete heavy vagial bleeding and dilatation of the cervix WITH partial expulsion but not all the POC

HxVaginal bleeding with passage of POCP/EThe uterus is small for dateU/sRetained POC could be visualized Inevitable and Incomplete - ManagementHb, blood grouping, XM 2 units of bloodResucitation, large IV line, fluids and blood transfusion.Those types of abortions can be allowed to finish on their own, with expectant management Or:Can also be taken to completion by either D&C or adminstration of prostaglandins (misoprostol) to induce cervical dilatation and uterine contractionsComplete abortionComplete expulsion of all POC before 20 weeks gestation

Hx- Heavy vaginal bleeding which has been stopped.- Lower abdominal pain which follows the bleeding.P/ECervix is closedU/SShowed emty uterine cavityComplete -Management1. conservative management if the uterine cavity is emptyEvacuation and curettage in the presence of RPOCPost abortion managementMissed abortionDeath of the embryo or fetus before 20 weeks gestation with complete retention of all POCMostly diagnosed accidentaly during routine U/S in early pregnancy

Hx-episodes of mild vaginal bleeding.-regression of early symptoms of pregnancy-stoppage of fetal movementP/EUterus may be small for dateU/SEssential for diagnosis Performed twice at least 7 days apart showing no evidence of heart activityMissed - managementHb, blood grouping and XM 2 units of blood.Platelet count, to exclude risk of DICOptions for treatment:Conservative tx: if left alone, spontaneous expulsion will occur.Surgical evacuation of the uterus: by D&C, indicated in 1st trimester missed abortionMedical termination of pregnancy: by misoprostol (PGE1)Post abortion management.Septic abortionIt is an incomplete abortion which is complicated by infection of the uterine contents.Features:1. Includes features of incomplete abortion: severe vaginal bleeding with passage of part of the POC.2. Features of pelvic infection: pyrexia and tachycardia, general malaise, lower abdominal pain, pelvic tenderness and vaginal discharge.The commonest organisms areE.coli, strep & staphylococcus2. anaerobics: bacteroids.Septic abortionTypes:

Mild: the infection is confined to the decidua (80%)Moderate: the infection extends to the myometrium ( 15%)Severe: the infection extends to the pelvis (5%)Septic - Management1. investigations:Hb, blood grouping XM2 units of bloodCervical swab for culture and sensitivityCoagulation profile, serum electrolytes & blood culture if pyrexia is more than 38.52. antibiotics: IV cephalosporin + IV MDZ3. Surgical evacuation of uterus , usually 12 hrs after ABX therapy5. Post abortion management Post abortion management Support: from the husband, family and medical staffAnti D: to all Rh ve non immunised patients, whose husbands are Rh +ve.Explanation and counseling:Contraception: should start immediately after abortion if the patient chooses to wait because ovulation can occur 14 days after evacuation and so pregnancy can occur before the exoected next period

Could it happen again?As the commonest cause is the fetal chromosomal abnormality which is not a recurrent cause, so the chance of successful pregnancy next time is very high.When to try again?Best to wait 2 to 3 months before trying again. This allows patients to be physically and emotionally ready for pregnancyComplication of abortionHemorrhageComplications related to surgical evacuation i.e. E&C and D&CUterine perforation or ruptureCervical tear incompetanceExcessive dilatation incompetance Excessive curettage AdenomyosisInfection infertility + asherman syndrome.Rh iso immunization: if the anti-D is not given or if the dose is inadequatePsychological traumaRecurrent abortionA recurrent habitual aborter is a woman who has had 3 or more consecutive SABs.Types:Primary all pregnancies have ended in lossSecondary one pregnancy or more has proceeded to viability witll all others ending in loss.Incidence:Less than 1% of women of reproductive ageThe risk of a SAB after one prior SAB is 20-25%; after two consecutive SAB. 25-30%, and after 3 consecutive SAB is 30-35%CausesIn about 50% of cases its idiopathic and no cause can be identifiedKnown causes are:

Fetal chromosomal abnormalities and structural abnormalities.Endocrine disorders: DM, thyroid diseases, PCOS..Immunological disorders: anticardiolipin syndromeThrombophilia: protein C&S defeciency Uterine disorders: submucous fibroids, cervical incompetance, ashermans syndromeInfections: e.g. CMVRh isoimmunization Recurrent abortionDiagnosis

Hx-Previous abortion-medical hx: DM, thyroid, autoimmune diseases and thrombophiliaP/EGeneral: weight. Thyroid and hair distributionPelvic: cervix (length and dilatation) and uterine sizeInvestigationsInvestigationsFirst, a karyotype of both parents is obtained, as well as the karyotype of the POC of each SAB if possibleMaternal anatomy should be examined initially by a HSG, if its abnormal or non diagnostic we can prosceed to hysteroscopic or laproscopic exploration,Screening tests for hypothyroidism, DM, APA syndrome, hypercoagulability and SLE.Level of serum progesterone should be obtained in the luteal phase of menstrual cycleCultures of the cervix, vagina and endometrium to R/O infectionManagementTreatment depends on the etiologyE.g.Endocrine disorders:Control DM and thyroid disorders before pregnancy, give progesterone or hCG in corpus luteum insuffeciencyIn APA syndrome:Give low dose aspirin and prednisilone starting when pregnancy is diagnosed till 37 weeks.*these drugs are not teratogenic