Ectopic Pregnancy1.pptx

8/17/2019 Ectopic Pregnancy1.pptx

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PREGNANCYECTOPIC

AREZ ESMAIL QADR

SHAMAL M. AZIZ


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Normal pregnancy implantation

Pregnancy is the period during which a

woman carries a developing fetus normally

in the uterus, starting from conception

(fertilization of ova) until the baby born.

After ovulation the ovum is picked up by the

fimbria of fallopian tubes and then swept

by ciliary action towards the ampulla where

fertilization occurs.

As soon as the zygote develops it begins

dividing very rapidly, it remains in the fallopian

tube for 3 ! days untill reaches morula stage

("3# cell stage)


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Normal pregnancyimplantation$he embryo proceeds through the isthmus to the uterine cavity for up

to %# hours, by the si&th day it enters the uterus and begins to

penetrate the decidua (endometrium) this is called implantation

which takes place within the uterine cavity in normal positioned

pregnancy .

$hen h' is produced by trophoblast, which can be detected in the

serum of the mother in the first week after implantation, its level

doubles every 3!" hours in normal healthy pregnancy starting

from * to *+ ,++, till reaching +++ -/0

1elay or obstruction of the passage of fertilized egg down the fallopian

tube to the uterus may result in implantation in the fallopian tube or

ovary or peritoneal cavity, this known as ectopic pregnancy which

eventually most fails to develop , and the h' fails to raise

dramatically as happens in the normal intra uterine pregnancy.


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Normal pregnancyimplantation


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Ectopic pregnancy ?


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Ectopic pregnancyDefinition:

An ectopic pregnnc!, or ecc!"i" , is a complication of pregnancy 2ccurs when the

site of implantation is outside of the womb (uterine cavity) either in the tubes,ovaries or

abdominal cavity, ith rare e&ceptions, ectopic pregnancies are not viable, Pregnancy

can even occur in both the womb and the tube at the same time (heterotopic

pregnancy).

C#""ifiction:

tubal pregnancy4

$he vast ma5ority of ectopic pregnancies 6*6" 7 implant in the 8allopian tube,

among these4

"+7 in the ampulla

+7 in isthmus

* 7 in fimbria

#7 interstitial #7 in a rudimentary horn of a bicornuate uterus


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classifcation $%Nont&'# ectopic pregnnc!

9are sites (#*7) are: $he ovaries,

broad ligaments,

Abdominal cavity and peritoneum

cervi&.

(%Heterotopic pregnnc!

in rare cases of ectopic pregnancy )*)+++, there may be two fertilized eggs,

one outside the uterus and the other inside. $his is called a heterotopic

pregnancy.

2ften the intrauterine pregnancy is discovered later than the ectopic, mainly

because of the painful emergency nature of ectopic pregnancies.


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classifcation

;ince ectopic pregnancies are normally discovered and removed veryearly in the pregnancy, an ultrasound may not find the additional

pregnancy inside the uterus. hen h' levels continue to rise after

the removal of the ectopic pregnancy, there is the chance that a

pregnancy inside the uterus is still viable. $his is normally

discovered through an ultrasound

Although rare, heterotopic pregnancies are becoming more

common, likely due to increased use of -


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Common sites for ectopicpregnancy


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epidemiology

Inci,ence-

##/+++ live births

/+++ pregnancies

-n ;A from 6%+ = 66# , the risk *& increased from ! to 6 / +++

pregnancies

ft#it! rte :

fatality rate from ectopic pregnancies dropped almost 6+7 (from 3*.*

per +++ ectopics to 3." per +++ ectopics).

1espite the sharp improvement in the fatality rate by the end of thisperiod of time, ectopics were still the second leading cause of

maternal mortality in the ;A (accounting for #7 of all maternal

deaths in 6"%).


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Why?

$he reason for the increase in ectopic pregnancy during this timeperiod is not entirely clear, but it was thought that the increase of

risk factors were responsible for a significant portion of the

increased number of cases of ectopic pregnancy.


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Risk actors

Any mechanism that interferes with the normal function of fallopian

tube increases the risk of ectopic pregnancy

$he mechanism canbe4

Anatomical: scarring that blocks transport of the egg8unctional: impaired tubal mobility


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Ri" /ctor Ri" 0

High Risk P-1

$ubal corrective surgery $ubal sterilization

Previous >P

-n utero 1>; e&posure

-1

1ocumented tubal pathology

Moderate Risk -nfertility

Previous genital infection

?ultiple partners

Slight risk

Previous pelvic or abdominal surgery

;moking

1ouching

-ntercourse before " weeks

#*

#.+

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+.633."#.3#.*

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.


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Risk actors

)%Hi"tor! of pe#1ic infection

P-1 is the most common risk factor for ectopic pregnancy " folds increases the risk, due to destruction of the fallopian tubes.

'hlamydia (a common se&ually transmitted disease) and onorrhea

are both able to grow within the fallopian tubes and cause:

tremendous damage to the endosalpin& (lining of the inner tubal

lumen), #agglutination (sticking together) of the mucosal folds in the tube

3peritubal adhesions (scar tissue).

. the risk of an ectopic pregnancy is greater when the woman with the

infection is younger

2ther pelvic or lower abdominal infections can also result in pelvic

adhesions and an increase in the ectopic pregnancy rate (such as

appendicitis).

$he chances of another ectopic in the same fallopian tube also in the

other tube are increased *&


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Risk actors

$%Hi"tor! of "&rger! on t2e f##opin t&'e" or 3it2in t2e pe#1i":

$ubal ligation in the past # years,hen a bilateral tubal ligation (tubes

tied) is followed by either an une&pected pregnancy (failed tubal

ligation) or is @reversed@ with a tubal reanastomosis (tubalreconstruction) there is an increased risk of a tubal ectopic

pregnancy.

hen a woman has a history of pelvic surgery that is associated with

significant adhesion formation (such as myomectomy) there is alsoan increased risk of an ectopic pregnancy.


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Risk actors

(% Prior 2i"tor! of ectopic pregnnc!.

hen an ectopic pregnancy in the fallopian tube is treated conservatively

(by preserving the tube), there is a roughly + fold increase the risk of

recurrence in the same tube

4%Hi"tor! of I5D &"e. $he use of an -1 is a classic @risk factor@ forectopic pregnancy. Actually, all but the progesterone containing -1s

are relatively protective against ectopic pregnancy while the -1 is in

place. $hat is, the number of ectopic pregnancies in women using an

-1 for contraception is about one half that of women using no

contraception. owever, of -1 pregnancies there is a greater chance

of an ectopic location (3!7) since the number of intrauterine

pregnancies with an -1 in place is markedly reduced.


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Risk actors

Additionally, -1s can be associated with infections of the uterine

cavity and fallopian tubes (especially 5ust after insertion) which can

independently increase the chance for an ectopic pregnancy..

$he reason for this increase in the nomber of >Ps with progesterone

-1 is not clear. A theory is that somehow the progesterone

enhances tubal implantation.


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Risk actors

6%Hi"tor! of Diet2!#"ti#'e"tro# 7DES 8e9po"&re in &tero. $his drug is a is a synthetic nonsteroidal estrogen that was used for

certain conditions, including breast and prostate cancers ,8rom

about 6!+ to 6%+, 1>; was given to pregnant women under the

mistaken belief it would reduce the risk of pregnancy complicationsand losses

0ater researches has shown that this drug has many bad medical

effects and female babies of women who used it were at risk of

developmental abnormalities of the genital system

$heir tubes are more likely to be abnormal and predispose to ectopicpregnancy, these females were known as 1>; daughters


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Risk actors

%Hi"tor! of ,e"tr&ction of t2e &terine c1it! or #ining.

;uch as history of uterine synechiae (scar tissue) from previous

surgery (like endometrial ablation for dysfunctional bleeding ) or

presence of multiple submucosal fibroid tumors this cause a largerpercentage of the pregnancies to implant in a space other than the

uterine cavity.

;imilar to the situation with -1s, the total ectopic pregnancy rate may

not be increased but when a pregnancy does occur the reduced

likelihood of an intrauterine pregnancy increases the relativepercentage of ectopic pregnancies.


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Risk actors

;%Hi"tor! of non%infectio&" pe#1ic inf#


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Risk actors

>%5"e of ""i"te, repro,&cti1e tec2no#og! 7"&c2 " I?/ 7in 1etroferti#i@tion8 n, GI/T 7g


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Tubal pregnancy


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Pathophysiology

$he trophoblast develops in the fertilized ovum and invades deeplyinto the tubal wall.

8ollowing implantation, the trophoblast produces h' which

maintains the corpus luteum.

$he corpus luteum produces oestrogen and progesterone which

change the secretory endometrium into decidua. $he uterusenlarges up to " weeks and becomes soft.

$he tubal pregnancy does not usually proceed beyond "+weeks due

to4

C lack of decidual reaction in the tube,

C the thin wall of the tube,

C the inadeBuacy of tubal lumen,

C bleeding in the site of implantation as trophoblast invades.


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Pathophysiology

;eparation of the gestational sac from the tubal wall leads to its

degeneration, and fall of h' level, regression of the corpus luteum

and subseBuent drop in the oestrogen and progesterone level.

$his leads to separation of the uterine decidua with uterine bleeding.

/te of t&'# pregnnc!

$ubal mole

$ubal abortion

$ubal rupture


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Fate o tubal pregnancy

)% T&'#


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-f e&pulsion was complete the bleeding usually ceases but it may

continue due to incomplete separation or bleeding from the

implantation site.


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(%T&'# r&pt&re:?ore common if implantation occurs in the narrower portion of the tube

which is the isthmus.

9upture may occur in the

antimesenteric border of the tube.

sually profuse bleeding occurs D

intraperitoneal haemorrhage.

-f rupture occurs in the mesenteric border

of the tube, broad ligament haematomawill occur.


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presentation

>arly symptoms are either absent or subtle. 'linical presentation of

ectopic pregnancy occurs at a mean of %.# weeks after the last

normal menstrual period, with a range of * to " weeks

$he most common presenting symptoms that are suggestive for >Pare4


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Clinical traid !"s#

Amenorhea

ectopic

pregnancy

Abdominal pain Abnormal vaginal bleeding


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symptoms

Pin n, ,i"co


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symptoms

#ee,ing


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signs Gener# e9


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signs

?gin# e9


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diagnosis

$he diagnosis can be difficult

Gour doctor may perform some tests to help confirm suspected ectopic

pregnancy including:

1etailed history of (cycle, pregnancy, P-1,infertility, gynaecological

surgery, contraceptionF)Proper general, abdominal, vaginal e&amination and vital signs

-nvestigations4 including


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$iagnosis

).2or


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$iagnosis

Proge"terone

$he second most common hormone after h' in pregnancy is

progesterone.

enerally, a progesterone concentration of greater than #* ng/m0 is

highly correlated with a normal intrauterine pregnancy while aconcentration of less than * ng/m0 is highly correlated with an

abnormal and nonviable pregnancy


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$iagnosis

$%5#tr"o&n,

-n general, a positive Hh' test with empty uterus by sonar I adne&ial

mass indicates ectopic pregnancy.

1iscriminatory h' zones4 1iagnosis of ectopic pregnancy is made if there is4

An empty uterine cavity by abdominal sonography with b h' value

above +++ m-/ml.

An empty uterine cavity by vaginal sonography with b h' value

above #+++ m-/ml.


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%ltrasound


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$iagnosis(%C,ocente"i"

in this test, a needle is inserted into the space at the top of the vagina, behindthe uterus and in front of the rectum to aspirate fluid and

1etermines if there is blood in the space behind the uterus

-f nonclotting blood is aspirated from the 1ouglas pouch , intraperitoneal

haemorrhage is diagnosed. Eut if not, ectopic pregnancy cannot be

e&cluded.


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$iagnosis

4%#pro"cop! or #proto

ectopic pregnancy. 2ften if a tubal abortion or tubal rupture has occurred.0aparoscopy4 an endoscope is inserted through a small incision in the

womanJs abdomen

$his allows you to see the fallopian tubes and other organs

$his takes place in an operating room with anaesthesia


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%ncommon &ites o EctopicPregnancy

'ornual angular pregnancy#Pregnancy occurs in the blind rudimentary horn of a bicornuate

uterus.

3'ervical pregnancy

!2varian pregnancy

*Abdominal (peritoneal) pregnancy


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Cornual angular pregnancy

-t is implantation in the interstitial portion of the tube.

-t is uncommon but dangerous because when rupture occurs bleeding

is severe and disruption is e&tensive that needs hysterectomy.

-n some cases, the pregnancy is e&pelled into the uterus and rupture

does not occur.

'''(reeli)edoctor(co


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Cer)ical pregnancy -mplantation in the substance of the cervi& below the level of uterine

vessels.?ay cause severe

vaginal bleeding.

'an be diagnosed by

trans vaginal ultrasound


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*)arian pregnancy

Aetio#og!:

K Pelvic adhesions.

K 8avourable ovarian surface for implantation as in ovarian

endometriosis.

Pt2ogene"i":

K 8ertilization of the ovum inside the ovary or,

K implantation of the fertilized ovum in the ovary.


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*)arian pregnancy

Spiege#'erg criteri for diagnosis of ovarian pregnancy4

K $he gestational sac is located in the region of the ovary,

K the ectopic pregnancy is attached to the uterus by the ovarian

ligament,

K ovarian tissue in the wall of the gestational sac is proved

histologically,

K the tube on the

involved side is intact.

'''(reeli)edoctor(co

"bd i l i l#


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"bdominal peritoneal#pregnancy

T!pe":

Pri


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"bdominal peritoneal# pregnancy

Digno"i":

Hi"tor!: of amenorrhoea followed by an attack of lower abdominal

pain and slight vaginal bleeding which subsided spontaneously.

A',o


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"bdominal peritoneal# pregnancySpeci# in1e"tigtion":

P#in %r!4 shows abnormal lie. -n lateral view, the foetusovershadows the maternal spines .

5#tr"o&n,: shows no uterine wall around the foetus

Mgnetic re"onnce i


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DI//ERENTIAL

DIAGNOSISDD


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SepticAbortion

'reatenedAbortion

Pyosalpin)

PelvicAbcess

'*isted#varian

Cyst

Acute pelvicinflammatory

disease

Rupture of+ollicle or

Corpus&uteum Cyst

Degeneratingleiomyoma

RetrovertedGravidUterus

(2) Gynecologic disorders


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R9

TREATMENT

% c t o p i c


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• % , P % C ' A " '

M A " A G % M % " '

- • M % D I C A &

M A " A G % M % " '

. • S U R G I C A & M A " A G % M % " '

Tret


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EPECTANT

MANAGEMENT


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M Criteri for "e#ection

= asymptomatic women no evidence

of rupture or hemodynamicinstability

= less than ++ ml fluid in the pouch

of 1ouglas

= h' less than +++ iu/l at initialpresentation

= Adne&al mass less than 3cm

= they should ob5ective evidence of

resolution, such as declining bh'levels.

= $hey must be fully compliant and

must be willing to accept the

potential risks of tubal rupture.


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= +nitial ollo' up

M t'ice 'eekly 'ith serialhC,measurements

M 'eekly by trans)aginal e-aminations

= .y the frst 'eek

M drop in /C, le)el

M "dne-al mass si0e

=*ther'ise reassess the options1edical2&urgical#

= + the all o /C, 3 reduction in si0e oadne-al mass satisatory

M 'eekly hC, and trans)aginal ultrasounde-aminations

M#"I'#RI"G


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M 789:6; o pregnancies o unkno'nlocation resol)e spontaneously 'ithe-pectant management

M Ectopic pregnancy 'as subse; o cases opregnancy o unkno'n location

M +nter)ention has been sho'n to be

re


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MEDICAL

MANAGEMENT

$


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M &election criteria

= 1inimal symptoms 3 The patient must behemodynamically stable

= no signs or symptoms o acti)e bleeding orhaemoperitoneum(

= "bsence o oetal heart beat

= Normal F.C@%3Eurea 3 electrolytes#@AFTli)erunction tests#

M E-clusion criteria

= "ny hepatic dysunction@ thrombocytopeniaplatelet count 4=66@666#@ blood dyscrasiaWCC

45666 cells cm!#( = $iBculty or un'illingness o patient orprolonged ollo'up a)erage ollo'up !8days#(

= Ectopic mass D!(8cm

= The presence o cardiac acti)ity in an ectopicpregnancy

CRI'%RIA for M%DICA& MA"AG%M%"'


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• M e t ( o t r e ) a t eS$S'%MIC

• i n j e c t i o n s o f p r o s t a g l a n d i n s , p o t a s s i u m c h l o r i d e O R

h y p e r o s m o l a r g l u c o s e O R l o c a l m e t h o t r e x a t e

CA&&$


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AD0IC%S

M Patient should be gi)en inormation onpreerably'ritten#

= Need or urther treatment

= "d)erse eects

M Women should be able to return easily or

assessment at any time during ollo'upM "d)ice

= a)oid se-ual intercourse during treatment

= to maintain uid intake

= use reliable contraception or three months

ater methotre-ate has been gi)en@ barrier orhormonal#

= ")oid e-posure to sunlight(

M G ")oid alcohol and )itamin preparationscontaining olic acid until the hormone le)el isback to 0ero(

M ")oid aspirin or drugs such as +buproen or


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= 6+7 successful treatment with single dose

regime.

= 9ecurrent ectopic pregnancy rate + = #+7.

= $ubal patency appro&imately "+7.

= ! 7 of medical management second dose of

methotre&ate

= %*7 would e&perience abdominal pain

separation pain. $his usually occurs between

day 3%

= +7 would finally reBuire surgical management

*%TC*1E


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S5RGICALMANAGEMENT

(


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E1ER,ENC H


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M et help call senior /'onsultant on call

M AE' of resuscitation

= give facial o&ygen

= ;ite two -< lines , commence -< fluids (crystalloid) = ;end blood for 8E', 'lotting screen and crossmatch at least ! units

of blood.

M insert indwelling catheter

M arrange theatre for laparotomy

M whilst awaiting transfer to theatre continue fluid resuscitation and ensure

intensive monitoring of haemodynamic state

M do not wait for EP and pulse to normalise prior to transferresuscitation

and surgery need to go hand in hand.

M Pfannensteil incision,

M salpingectomy and wash out of abdomen

M assess bloods /consider '


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Aaparascopy *R laparatomy??

M 0aparoscopy has become the recommended approach inmost cases.

M 0aparotomy is usually reserved for patients4

who are hemodynamically unstable

patients with cornual ectopic pregnancies.

for surgeons ine&perienced in laparoscopy and in patients

where laparoscopic approach is difficult


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Aaparoscopy

• Aess intraoperati)e

blood loss

• &horter operation time

• &horter hospital stay

• Ao'er analgesicre


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Salpingectomy #R Salpingotomy 11

M S#pingecto

where there is tubal rupture

M S#pingoto


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&alpingectomy &alpingotomy

•

There may be a highersubse


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Per"i"tent trop2o'#"t

M hen salpingotomy is done, protocols should

be in place for the identification and treatment

of women with persistent trophoblast.

M ?onitoring serum ' levels would help to

identify the persistent trophoblast.

M ?ost >asily $reated ith ?$O


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H e t e r o t r o p i c

C e r 1

i c # A ' ,

o


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%vacuation and cervical pac2ing *itaemostatic agent as 3brin glue andgau4e5

Arterial emboli4ation

If bleeding continues or e)tensiverupture occurs ysterectomy isneeded5

Cer)ical pregnancy


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M 0aparotomy and inoculation of the

ectopic pregnancy and

reconstruction of the ovary if

possible. 2therwise, removal of theaffected ovary is indicated.

M 2varian cystectomy is the

preferred treatment

M $reatment with ?$O andprostaglandin in5ection has also

been reported

*)arian pregnancy


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/ i


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/eterotropic pregnancy

M 1epends upon

the state of the

woman

and the skill ofthe doctor.

M .;urgical

0 i th id l i l th d t

http://www.womens-health.co.uk/diaglap.asphttp://www.womens-health.co.uk/diaglap.asp


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M 0aparoscopy is the ideal surgical method to

remove an ectopic pregnancy before it ruptures

without interrupting the viable pregnancy. Although the intrauterine pregnancy can still

survive if the ectopic pregnancy ruptures, there

is an increased danger of miscarriage. $he

surgery must be done with great skill and it isimportant that bleeding be addressed Buickly.

?edical therapies include in5ecting the ectopic

pregnancy in order to terminate the gestation.

" ti $

http://www.womens-health.co.uk/diaglap.asphttp://www.womens-health.co.uk/miscarr.asphttp://www.womens-health.co.uk/miscarr.asphttp://www.womens-health.co.uk/diaglap.asp


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"nti $

M Non "en"iti@e, 3o


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"$I+CE

M Lot using -'1

M Lot using progesterone only pills

M $reatment for any P-1

M 8ollow up by ' that should disappear after month

M 1o ; after !+ day to see patency of the tube

Mse barrier method of contraceptionM $iming of pregnancy, visit specialist in any

missed period

C*1PA+C"T+*N


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M 9ecurrence of ectopic

M -nfertility

M ;hock N death

M $ubal rupture N organ damageM Psychological

M ;urgical 9&

M ?edical 9&

C*1PA+C"T+*N

Progno"i"


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Progno"i"

M 8ertility following ectopic pregnancy

depends upon several factors, the most

important of which is a prior of infertility.

$he treatment choice history , whethersurgical or nonsurgical, also plays a role.

8or e&ample, the rate of intrauterine

pregnancy may be higher following

methotre&ate compared to surgicaltreatment. 9ate of fertility may be better

following salpingostomy than

salpingectomy.

Reference

http://en.wikipedia.org/wiki/Infertilityhttp://en.wikipedia.org/wiki/Infertility


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Reference

=(,ynecology 3 obstetrci by Tenteachers =th edition

5(RC*, guidelines Royal college oobstetric 3 gynecology#!("C*,"merican college oobstetric 3 gynecology#

7("&R1"merican society oreproducti)e medicine#8(Wikipedia (comJ(Ai)emedicine(com:($r("braham laparascopy Iideo#


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Ectopic Pregnancy1.pptx

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