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.
Slide 4
Definition An ectopic pregnancy is one that implants outside
the uterine cavity (not the uterus) in a place other than the
endometrium
Slide 5
Where outside the uterine cavity?
Slide 6
Then.. Implantation occurs in the fallopian tube in up to 98%
of cases 2 nd comes the abdominal implantation, where the placenta
could attach to the bowel. With an incidence of ~ 1% 3d: ovarian
~0.2% 4 th : cervical ~0.2%
Slide 7
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: 1. STIs 2. Assisted fertility 3. PIDs
Slide 8
Why does it happen? several risk factors predispose patients to
extrauterine implantation. Many affect the fallopian tubes leading
to either: 1. Tubal scarring 2. Decreased peristaltic motility of
the tube.
Slide 9
Risk factors for ectopic pregnancy Table 2-1, Blueprints
Obs&Gyne 5 th edition, page 15 History of STI or PID Prior
ectopic pregnancy Previous tubal surgery Prior pelvic or abdominal
surgeries leading to adhesions Endometriosis Current use of
exogenous hormones including progesterone and estrogen IVF and
assisted reproduction Congenital abnormalities of the fallopian
tubes Use of IUD for birth control
Slide 10
However.. in as many as one third to one half of ectopic
pregnancies, no risk factors can be identified.
Slide 11
Through the R.Fs PIDs 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.
Slide 12
.. 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.
Slide 13
CLINICAL MANIFESTATIONS Clinical 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.
History The 3 classical symptoms of ectopic pregnancy are: 1.
Amenohrea 2. Abdominal pain 3. Vaginal bleeding
Slide 16
History In any lady presenting with those symptoms during her
first trimester, EP should be excluded. you should also think of:
1. Normal intrauterine pregnancy 2. Spontaneous abortion 3.
Salpingitis 4. appendicitis
Slide 17
Physical Examination Usually associated with minimal findings
but may reveal: - Tender adnexal mass - A uterus that is small for
gestational age - Cervical bleeding. Patients with RUPTURED EP may
be hypotensive, unresponsive, or show signs of peritoneal
irritations sec. to haemoperitoneum.
Slide 18
( -hCG) ( -hCG) EXTREMELY important Lab 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.
Slide 19
However In 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
Slide 20
Progesterone levels Good specificity and sensitivity for normal
intrauterine pregnancy. Not reliable If its low, its a marker of
abnormal pregnancy Cannot differentiate b/w EP and abortion
Slide 21
U/S Might show normal IUP, hence we are most probably dealing
with an abortion. might show an adnexal mass Fetal heart activity
in the adenxia could be monitored Bleeding in doglus pouch
Slide 22
Diagnostic method of a choice is: LAPROSCOPY
Slide 23
What 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 utilized Those patients are labelled as
rule-out ectopic. Should be followed with B-hCG levels every 48
hours and undergo a transvaginal U/s
Slide 24
Management (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. 36.8 Urine 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 IUP
Slide 25
We take into consideration: 1. Patient stability (immediate
surgical interferance if unstable) 2. desire of future fertility
Site of E/P State of EP (ruptured or intact)
Slide 26
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: 1. Medically 2. Surgically
Slide 27
Medical Tx: The drug of a choice used at most institution is
MTX Its 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 50gm Patient 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 2 nd dose should be given. If it stays high MUST
go for surgery
Slide 28
Serum b-hCG levels after one MTX injection
Slide 29
Management (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 ago Upon 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 peritoneum
Slide 30
Surgical 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 pregnancy
Slide 31
If 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 pregnancy
Slide 32
Resection can be either through: 1. Salpingostomy: the EP is
removed leaving the fallopian tube in place 2. Salpingectomy: where
the entire EP along with the tube are removed. * Ovarian EP are
normally treated surgically by oophorectomy
Slide 33
Thank you..
Slide 34
Miscarriage Aasem Zeidan Abu-Shtaya
Slide 35
Definition also 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
Slide 36
Incidence Most common gyanecological and obstetric disorder
About 15-25% of all clinically recognized pregnancies.
Underestimated because losses that occur 4 to 6 weeks gestational
age are often confused with late menses Real incidence could reach
30-35%
Slide 37
Risk factors Age Previous spontaneous abortion Smoking Alcohol
Gravidity Cocaine NSAIDs Fever Caffeine Prolonged ovulation to
implantation interval Prolonged time to pregnancy Low folate levels
Maternal weight
Slide 38
Aetiology
Slide 39
First trimester abortions 60-80% 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
pyrexia Maternal anatomic defects: uterine anomalies, submucous
fibroid, asherman syndrome etc.. Endocrine and immunological
factors Multiple pregnancy Cigarette smoking Psychological
disorders All together comprise the remaining 20-30%
Slide 40
Second trimester abortions Between 13 to 26 weeks gestational
age Less common than first trimester abortions Have multiple
etiologies: Genital tract infections and PROM Maternal uterine or
cervical anatomic defects Maternal systemic diseases Cervical
incompetance TRAUMA Multiple pregnancy.
Slide 41
Types Defined by 1.any or all of the products of conception
have passed 2. whether the cervix is dilated or not
Threatened abortion Any 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
pain P/ECervix is closed Uterus size is correct for GA U/SShows the
presence of fetal heart activity
Slide 44
Threatened abortion- Management 1. reassurance: if fetal heart
activity is present, in more than 90% pregnancy will progress in a
satisfactory way 2. advice to decrease physical activity and avoid
intercourse 3. Give progesterone and hCG which are used in the
first trimester to support pregnancy 4. adequate dose of anti-D
should be given to all Rh ve non-immunised patients, whose husbands
are Rh +ve 5. label as high risk patients because those patients
are liable to late pregnancy complications such as APH and preterm
labour.
Slide 45
Inevitable abortion Inevitable heavy vaginal bleeding and
dilatation of the cervix WITHOUT expulsion of any POC HxVaginal
bleeding P/EDilating cervix Uterus may be in correct size for date
U/SFetal heart activity may or may not be present
Slide 46
Incomplete abortion Incomplete heavy vagial bleeding and
dilatation of the cervix WITH partial expulsion but not all the POC
HxVaginal bleeding with passage of POC P/EThe uterus is small for
date U/sRetained POC could be visualized
Slide 47
Inevitable and Incomplete - Management Hb, blood grouping, XM 2
units of blood Resucitation, 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
contractions
Slide 48
Complete abortion Complete 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
closed U/SShowed emty uterine cavity
Slide 49
Complete -Management 1. conservative management if the uterine
cavity is empty Evacuation and curettage in the presence of RPOC
Post abortion management
Slide 50
Missed abortion Death of the embryo or fetus before 20 weeks
gestation with complete retention of all POC Mostly diagnosed
accidentaly during routine U/S in early pregnancy Hx-episodes of
mild vaginal bleeding. -regression of early symptoms of pregnancy
-stoppage of fetal movement P/EUterus may be small for date
U/SEssential for diagnosis Performed twice at least 7 days apart
showing no evidence of heart activity
Slide 51
Missed - management Hb, blood grouping and XM 2 units of blood.
Platelet count, to exclude risk of DIC Options for treatment: -
Conservative tx: if left alone, spontaneous expulsion will occur. -
Surgical evacuation of the uterus: by D&C, indicated in 1 st
trimester missed abortion - Medical termination of pregnancy: by
misoprostol (PGE1) - Post abortion management.
Slide 52
Septic abortion It 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
are 1. E.coli, strep & staphylococcus 2. 2. anaerobics:
bacteroids.
Slide 53
Septic abortion Types: 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%)
Slide 54
Septic - Management 1. investigations: - Hb, blood grouping XM2
units of blood - Cervical swab for culture and sensitivity -
Coagulation profile, serum electrolytes & blood culture if
pyrexia is more than 38.5 2. antibiotics: IV cephalosporin + IV MDZ
3. Surgical evacuation of uterus, usually 12 hrs after ABX therapy
5. Post abortion management
Slide 55
Post abortion management Support: from the husband, family and
medical staff Anti 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
Slide 56
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 pregnancy
Slide 57
Complication of abortion Hemorrhage Complications related to
surgical evacuation i.e. E&C and D&C - Uterine perforation
or rupture - Cervical tear incompetance - Excessive dilatation
incompetance - Excessive curettage Adenomyosis - Infection
infertility + asherman syndrome. Rh iso immunization: if the anti-D
is not given or if the dose is inadequate Psychological trauma
Slide 58
Recurrent abortion A recurrent habitual aborter is a woman who
has had 3 or more consecutive SABs. Types: - Primary all
pregnancies have ended in loss - Secondary one pregnancy or more
has proceeded to viability witll all others ending in loss.
Incidence: - Less than 1% of women of reproductive age - The 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%
Slide 59
Causes In about 50% of cases its idiopathic and no cause can be
identified Known causes are: Fetal chromosomal abnormalities and
structural abnormalities. Endocrine disorders: DM, thyroid
diseases, PCOS.. Immunological disorders: anticardiolipin syndrome
Thrombophilia: protein C&S defeciency Uterine disorders:
submucous fibroids, cervical incompetance, ashermans syndrome
Infections: e.g. CMV Rh isoimmunization
Slide 60
Recurrent abortion Diagnosis Hx-Previous abortion -medical hx:
DM, thyroid, autoimmune diseases and thrombophilia P/EGeneral:
weight. Thyroid and hair distribution Pelvic: cervix (length and
dilatation) and uterine size Investigations
Slide 61
Investigations First, a karyotype of both parents is obtained,
as well as the karyotype of the POC of each SAB if possible
Maternal 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
cycle Cultures of the cervix, vagina and endometrium to R/O
infection
Slide 62
Management Treatment depends on the etiology E.g. - Endocrine
disorders: Control DM and thyroid disorders before pregnancy, give
progesterone or hCG in corpus luteum insuffeciency - In APA
syndrome: Give low dose aspirin and prednisilone starting when
pregnancy is diagnosed till 37 weeks. *these drugs are not
teratogenic