ECTOPIC PREGNANCY

Dr Isameldin Elamin MD DOWH MBBSAssistant Professor Obstetrics & Gynaecology department

Objectives• Discuss the epidemiology, aetiology and deferential diagnosis of ectopic pregnancy.

• Describe the clinical picture and examination of a patient with ectopic pregnancy.

• Discuss the investigations and the management options of an ectopic pregnancy.

Definition• Ectopic pregnancy is defined as implantation of a conceptus outside the normal uterine cavity.

• Heterotopic pregnancy is simultaneous development of a conceptus within and outside the uterine cavity.

Epidemiology • The incidence of ectopic pregnancy in the UK is 11.1/1000 pregnancies.

• Approximately 11 000 cases of ectopicpregnancies are diagnosed each year in the UK.

Risk Factors • Tubal Disease Due To Previous Pelvic Infection Commonly with chlamydial infection.

• Previous Ectopic Pregnancy.• Previous Tubal Surgery.• Subfertility.• Use Of Assisted Reproductive Techniques.• Use Of IUCD.

Common Sites of Ectopic PregnancyFallopian tubes (95 percent).ovaries (3 per cent).peritoneal cavity (1 percent).In the Fallopian tubes:

• ampulla (74 per cent).• isthmus(12 per cent).• fimbrial end of the tube (12 per cent).• interstitium (2 per cent).

Natural history of untreated Ectopic

• Tubal rupture.• Pregnancy resorption.• Tubal abortion into the peritoneal cavity.

Clinical presentation• Sub acute abdominal pain and vaginalbleeding in early pregnancy.

• Vaginal bleeding is usually dark red.• The abdominal/pelvic pain may be localized to the iliac fossa.

• shoulder tip pain

Symptoms and signsCan resemble the symptoms and signs of other conditions.

Pregnancy tests should be available to all women in reproductive age

Symptoms and signs…CONT. common symptoms:• abdominal pain.• Amenorrhoea.• vaginal bleeding.other symptoms:• breast tenderness• gastrointestinal symptoms• dizziness, fainting or syncope• shoulder tip pain

Symptoms and signs…CONT.urinary symptoms.passage of tissue.rectal pressure or pain on defecation.Common signs of ectopic pregnancy:

• pelvic tenderness• adnexal tenderness• abdominal tenderness

Symptoms and signs…CONT.other reported signs:

• cervical motion tenderness.• rebound tenderness or peritoneal signs.• Pallor.• abdominal distension.• enlarged uterus.• Tachycardia.• Hypotension.• shock or collapse.• orthostatic hypotension.

Pelvic examinationBimanual examination:• tenderness in the fornixes.• cervical excitation,• in ruptured ectopic there are signs of hypovolaemic shock and acute abdomen.

Differential diagnosis ectopic pregnancy

Gynecologic problems:• Threatened or incomplete miscarriage• Ruptured corpus luteum• Acute PID• Adnexal torsion• Red degeneration of fibroid

Differential diagnosis…CONT.Nongynecologic problem• Acute appendicitis• Pyelonephritis• pancreatitis

Investigations Investigations for suspected ectopic:• Pregnancy test.• CBC.• Blood group.• Transvaginal ultrasound (TVS).• serial βhCG.

Investigations..CONT. • Identification of an intrauterine pregnancy excludes the possibility of an ectopic pregnancy in most patients.

• In IVF incidence of heterotopic pregnancy is high (1 per cent)

InvestigationsTransvaginal ultrasonography should be the initial investigation

Ultrasonographic features:• extra uterine sac with a live embryo. • adnexal mass • empty uterus.• pseudo sac .• free fluid in the pelvis

Us pictures

Important • All women of reproductive age are pregnant until proved otherwise and it is ectopic until clearly demonstrated to be intra uterine.

BhCG Discriminatory zone• Visualization of an intrauterine gestation sac above that βhCG level.

• βhCG level greater than 1500 IU (TVS). • It depends on the user-and machine.

Acutely ruptured ectopic pregnancySevere abdominal pain and dizziness due to haemoperitoneal .

Ipsilateral shoulder tip pain.Hemodynamic instability.

• tachycardia • hypotension • shock.

• Distended abdomen.• Tenderness.

Acutely ruptured ectopic pregnancy• Guarding.• rebound tenderness.• cervical motion tenderness.• Mass.• free fluids.• Diagnosis is by urine for pregnancy test.• Ultrasound although is not necessary would reveal significant fluids in the cul-de-sac

Acutely ruptured ectopic pregnancyManagement:• It is surgical emergency .• Two wide bore intravenous lines.• Resuscitation by IV fluids.• Blood transfusion but should not delay surgery• Surgery is by Laparotomy, although laparoscopy may be appropriate if hemdynamically stable.

Management Of Ectopic Pregnancy Systemic methotrexate when:• Able to return for follow-up.• No significant pain• Unruptured ectopic pregnancy.• Adnexal mass smaller than 35 mm.• No visible heartbeat.• hCG level less than 1500 IU/litre• No intrauterine pregnancy.

Management …CONT.surgical treatment if:• methotrexate is not acceptable.• significant pain• adnexal mass of 35 mm or larger.• fetal heartbeat.• hCG level of 5000 IU/litre or more.

Management …CONT.• Methotrexate or surgery if:• hCG level at 1500 IU/litre to 5000 IU/litre.• able to return for follow-up.• no significant pain• unruptured ectopic.• adnexal mass smaller than 35 mm.• No visible heartbeat• no intrauterine pregnancy

Management …CONT.After methotrexate:• hCG measurements at days (4 and 7).• hCG weekly until a negative.

surgical treatment Laparoscopic surgery should be done whenever possible.

Take into account:• Condition of the woman.• Competency of the Surgeon.• complexity of the surgical procedure

Laparoscopic surgeryAdvantages:• Shorter hospital stay with quicker post-op recovery.

• Lower blood loss .• Lower analgesic requirement. • Lower cost.• Lower risk of adhesion formation.

Laparoscopic surgery…CONT.Disadvantages:risk of visceral injury

• requires specialised equipment.• additional surgical expertise• Patient should be haemodnamically stable. • Cornual ectopics may not be suitable for laparoscopic treatment

Salpingectomy and salpingotomysalpingectomy if no other risk factors for infertility.salpingotomy if contralateral tube damage.After salpingotomy women may need further treatment like:

• methotrexate.• salpingectomy.

Salpingectomy and salpingotomy• After salpingotomy measture hCG after 7 days and weekly until a negative result is obtained.

• Urine pregnancy test after 3 weeks.• further assessment if the test is positive.

hCG measurements in pregnancy of unknown location (PUK)

• Take 2 serum hCG measurement 48 hours apart.

• Developing intrauterine pregnancy if HCG

increase greater than 63%.

Offer her a transvaginal ultrasound scan between

7 and 14 days later.

hCG measurements in PUK• pregnancy is unlikely to continue if hCG decrease greater than 50%.

• Do urine pregnancy test after 14 days• hCG between a 50% decline and 63% rise.• refer her for clinical review and further assessment .• serum progesterone should not be used to to diagnose either viable intrauterine pregnancy or ectopic pregnancy.

HCG measurements in PUL

• Pregnancy of unknown location (PUL) can be an ectopic pregnancy.

• Do not use serum hCG measurements to determine the location of the pregnancy.

• Clinical symptoms more important than serum hCG results.

• Use serum hCG measurements only for assessing trophoblastic proliferation to.

Anti-D rhesus prophylaxisOffer anti-D to all rhesus negative after surgical management of ectopic pregnancy.

Do not offer anti-D to:• medical management only.• threatened miscarriage • complete miscarriage • pregnancy of unknown location.

conclusion

• Management based on the clinical presentation, bHCG and ultrasound findings

• By TVS An intrauterine gestational sac seen at 4-5 weeks if bHCG at 1500 mIU/mL.

• intrauterine pregnancy excludes an ectopic pregnancy except in those with rare heterotopic pregnancy.

Conclusion…CONT.• Methotrexate for haemodynamically stable and compliant.

• Surgical treatment will remain the mainstay treatment modality for ectopic pregnancy in most units.

Further reading

• Ten Teachers Gynaecology 19 editions.• Essential of obstetrics and gynaecology. Hacker & Moore, Fifth Edition.• NICE clinical guideline 154. Ectopic pregnancy and miscarriage December 2012.

• http://www.uptodate.com.

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