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    Ectopic Pregnancy Focus

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    rajaeas
    This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It provides details on risk factors, symptoms, diagnostic tools like ultrasound and hCG levels, and various treatment options for ectopic pregnancy including expectant management, medical management using methotrexate, and surgical interventions. Ectopic pregnancy remains a leading cause of pregnancy-related maternal death.

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    Ectopic Pregnancy Focus

    Uploaded by

    rajaeas
    57 views62 pages
    This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It provides details on risk factors, symptoms, diagnostic tools like ultrasound and hCG levels, and various treatment options for ectopic pregnancy including expectant management, medical management using methotrexate, and surgical interventions. Ectopic pregnancy remains a leading cause of pregnancy-related maternal death.

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    This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It provides details on risk factors, symptoms, diagnostic tools like ultrasound and hCG levels, and various treatment options for ectopic pregnancy including expectant management, medical management using methotrexate, and surgical interventions. Ectopic pregnancy remains a leading cause of pregnancy-related maternal death.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    57 views62 pages

    Ectopic Pregnancy Focus

    Uploaded by

    rajaeas
    This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It provides details on risk factors, symptoms, diagnostic tools like ultrasound and hCG levels, and various treatment options for ectopic pregnancy including expectant management, medical management using methotrexate, and surgical interventions. Ectopic pregnancy remains a leading cause of pregnancy-related maternal death.

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    ECTOPIC PREGNANCY

    • Dr. Arvindh Santhosh


    • 2nd year Junior Resident - OG
    • Madras Medical College
    ECTOPIC PREGNANCY

    • Pregnancy implanted outside uterine cavity


    • 96% of ectopic occur in fallopian tubes
    • Other sites- cervical, cornual/insterstitial,
    ovarian, abdominal, caesarean/ hysterotomy
    scar
    In the fallopian tubes sites :
    Ampulla – 70%
    Fimbrial - 12%
    Isthmus - 11%
    Interstitial / cornual - 3%

    Hysterotomy / LSCS scar-1 / 2000


    ABDOMINAL-1/5000
    OVARIAN-1/7000
    CERVICAL-LESS THAN 1%
    • Incidence – 2% of all pregnancies

    • Increasing in incidence

    • Continues to be the leading cause of


    pregnancy related maternal deaths
    • About 4% of all deaths
    RISK FACTORS
    • PID AND OTHER GENITAL INFECTIONS

    • INFERTILITY AND RELATED FACTORS

    • PREVIOUS ECTOPIC

    • TUBAL SURGERIES

    • ART

    • CONTRACEPTIVES / IUDS

    • PROGESTRONE IMPLANTS

    • SMOKING, INCREASING AGE , VAGINAL DOUCHING


    DIAGNOSIS

    • Symptoms and clinical features

    • Typically manifests around 6 to 8 weeks from


    LMP
    • May lack symptoms when ectopic site other
    than tubes
    Symptoms
    • Amenorrhea
    • Abdominal Pain
    • Vaginal Bleeding
    • Fainting Attack
    • Shoulder Tip Pain

    THINK ECTOPIC
    8
    FEATURES OF RUPTURED ECTOPIC

    • Severe or persistent abdominal pain

    • Fainting episodes / loss of consciousness

    • Abdominal distension

    • Vaginal bleeding –no pathognomonic pattern

    • Scanty brown discharge to bleeding

    • Usually follows amenorrhea


    DIAGNOSTIC EVALUATION

    • Confirm pregnancy with UPT and serum hCG

    • Once confirmed serial measurement of hCG to


    assess doubling
    HETROTROPIC PREGNANCY
    • Now commonly seen
    • Spontaneous incidence – 1/30000
    • Intra uterine pregnancy with extra uterine, usually
    follows ART.
    • ART incidence – 0.9%
    • NO ROLE FOR MEDICAL MANAGEMENT.
    • TREATMENT IS BY SURGICAL MEASURES
    • Heterotopic pregnancy. A 30-year-
    old woman presented at 6 weeks
    with pelvic pain and a positive
    pregnancy test.
    IU • A, Sagittal scan shows a retroverted
    uterus with a normally positioned
    6-week gestational sac with yolk
    sac.
    • B, In the left adnexa, adjacent to

    ectopic the left ovary (LO), there is a tubal


    ring (arrow) that proved to be an
    ectopic sac at laparoscopy
    TVS
    • TO LOCATE PREGNANCY TVS IS GOLD STANDARD

    • IF hCG is above discriminatory zone and no evidence of


    intra uterine pregnancy and symptom suggestive of
    pregnancy then Ectopic is suggested.

    • hCG can be detected in serum and urine as early as 8 days


    after the LH surge - 21-22 Days after LMP.
    TVS in Ectopic

    • Diagnose

    • Triage patient for management

    • Follow up in those with conservative

    management
    • Evaluate haemodynamic stability and if

    haemodynamically unstable, may be

    transferred to acute care facility and may need

    surgical intervention
    • Physical examination

    • look for pallor, abdominal tenderness - diffuse or


    localized , abdominal distension
    • Vaginal examination to confirm presence of vaginal
    bleed
    • P/V examination for cervical motion tenderness and
    extra ovarian adnexal mass.
    FAST ULTRASOUND
    • Focused assesment with sonography for trauma
    • IF HAEMODYNAMICALLY UNSTABLE FAST done
    FOR INTRA PERITONEAL BLEEDING
    • Diagnosed as ruptured ectopic in a lady in reproductive
    age group unless proved otherwise.
    • Complete haemogram /HCT blood grouping and Rh to
    be done.
    TVS FINDINGS
    • EMPTY UTERINE WINDOW WITH AN ADNEXAL RING SIGN IS THE TYPICAL ULTRA
    SOUND FEATURE IN 89% OF CASES
    • GESTATIONAL SAC WITH YOLK SAC IS MORE SPECIFIC FOR DIAGNOSIS.
    • LIVE EXTRAUTERINE EMBRYO – 100% SPECIFIC
    • COMPLEX ADNEXAL MASS – ROUND ECHOGENIC TUBAL RING SEPARATE FROM OVARY
    WITH GOOD PERIPHERAL COLOR FLOW.
    • RING OF FIRE APPEARANCE
    • IN ECTOPIC GESTATION PSEUDO SAC IS FORMED THAT IS MERELY FLUID / BLOOD IN
    ENDOETRIAL CAVITY LIKE GESTATIONAL SAC.
    • FREE ECHOGENIC FLUID IN PELVIS AND UPPER ABDOMEN.
    Empty uterine window with adnexal ring

    Empty uterus

    Adnexal ring with YS


    Ring of fire
    • B, Sagittal transvaginal scan
    • shows a large pseudogestational sac with echogenic
    debris. Note the acute angle at the lower end,
    uncommon in a gestational sac.
    • Pseudogestational sac. A, Coronal transvaginal scan of a 33-year-old
    woman (G2P1) at 8 weeks with pelvic pain. There is a rounded intrauterine
    sac filled with low-level echoes. No yolk sac or embryo is seen. There is a
    single echogenic ring around the fluid (arrow). This is a fluid-filled
    endometrial canal, a decidual cast, or pseudogestational sac.
    HCG DISCRIMINATORY ZONE
    • SERUM HCG ABOVE WHICH GESTATIONAL
    SAC SHOULD BE VISUALISED BY TVS IF
    INTRAUTERINE PREGNANCY is PRESENT

    • D zone 2000 IU/litre - in most institutions.


    Setting D zone at 3100 IU/L minimizes the risk of
    interfering with a viable IUP with a relative risk of
    delaying diagnosis.
    • If HCG is between 2000 – 3510, patient stable
    follow up with a close surveillance and repeat tvs.
    • HCG concentration increases atleast 66% every
    48 hrs in 85% viable iup
    • Only 15% viable iup had a rate of rise less than
    this level.
    • Slowest rise is more than 35 % only.
    • Current protocol is to measure HCG every 48 hrs.

    • But more practical approach is to measure every


    72 hrs.
    • In this HCG rise more than 35% in 48 hrs and
    doubles in 72 hrs then do a tvs when hcg reaches
    3500 when intra uterine or ectopic can be
    diagnosed.
    • LACK OF NORMAL RISE OF HCG ACROSS 3
    MEASUREMENTS is CONSISTENT WITH
    ABNORMAL PREGNANCY EITHER ECTOPIC /
    IUP THAT WILL ULTIMATELY ABORT
    • HCG above 2000 wihtout visualisation of iup / extra
    uterine pathology may represent multiple gestation
    since there is no proven discriminatory level for
    multiple pregnancy.
    PREGNANCY OF UNKNOWN LOCATION

    • In absence of definite usg finding of IUP or


    histopathology findings impossible to
    differentiate ectopic and an early failed Iu
    pregnancy.
    INTERSTITIAL ECTOPIC
    • Color flow Doppler ultrasound
    • shows increased vascularity around the sac with
    high-velocity flow.
    • At laparoscopy, ectopic site can be seen bulging the isthmic portion
    • of the tube (arrow). It was successfully removed by salpingostomy.
    • Postoperative specimen of the wedge resection
    • and removal of the left cornua.
    Cornual pregnancy
    • Pregnancy located in the rudimentary horn of a bicornuate uterus.

    • Usg criteria:

    • Visualisation of single interestitial portion of fallopian tube in the main


    uterine body.

    • Gestational sac completely surrounded by myometrial mantle.

    • GS mobile and separate from uterus.

    • A vascular pedicle adjoining the GS to the unicornuate uterus.


    Management of Cervical Pregnancy

    • Methotrexate

    • Ligation of descending branch of uterine artery.

    • Uterine artery embolisation

    • Cervical cerclage

    • If Bleeding Persist
    Foley’s bulb Tamponade or Cervical Packing
    • Hysterectomy Last Resort

    39
    CAESEREAN SCAR PREGNANCY
    • Empty uterine cavity and cervix
    • Implantation into deficient scar with a
    gestational sac partially or completely located
    within the myometrial mantle.
    • Thin or absent myometrial layer between GS
    and Bladder
    • Sustained peri-trophoblastic flow on color
    doppler.
    CAESEREAN SCAR PREGNANCY
    CAESEREAN SCAR PREGNANCY
    ABDOMINAL pregnancy
    ○ Potential sites for Abdominal
    pregnancy
    ○ the omentum
    ○ pelvic sidewall
    ○ broad ligament
    ○ posterior cul-de-sac
    ○ abdominal organs (eg, spleen, bowel,
    liver) large pelvic vessels
    ○ diaphragm
    ○ uterine serosa .
    CHRONIC ECTOPIC PREGNANCY
    • PREGNANCY DOES NOT COMPLETELY RESORB DURING EXPECTANT
    MANAGEMENT.
    • PERSISTENCE OF CHORIONIC VILLI WITH BLEEDING INTO TUBAL
    WALL AND DISTORTS IT BUT DOESN’T RUPTURE.
    • SYMPTOMS: LOWER ABDOMINAL PAIN , VAGINAL BLEEDING,
    AMENORRHEA.
    • MAY FORM PELVIC MASS.
    • BETA hCG LEVEL MAYBE LOW OR ABSENT.
    • DIAGNOSIS BY USG.
    • TREATMENT-SURGICAL REMOVAL.
    MANAGEMENT OF ECTOPIC PREGNANCY

    • MEDICAL

    • SURGICAL

    • EXPECTANT

    • Anti D Prophylaxis to Rh D -ve women.


    INDICATION FOR EXPECTANT
    MANAGEMENT
    • Asymptomatic patient

    • Should be informed about the clinical implication like risk


    of rupture
    • Ready access to medical facility and follow up

    • Transvaginal scan should not show an extra uterine gs or


    demonstrable mass suspicious of ectopic.
    • Serum hcg below 200 miu/l and decreasing across 2
    consecutive measurement by more than 10%.
    • IF HCG NOT REACHING UNDECTABLE

    LEVEL WITHIN 10 WEEKS OFFER

    METHOTREXATE.
    PHARMACOLOGICAL THERAPY
    WITH MTX – MOST PREFERRED
    SELECTION CRITERIA

    Haemodynamically stable

    NO CI FOR MTX

    SERUM BETA HCG < 5000 MIU/L

    No fetal cardiac activity on TVS

    Willing and able to comply with post treatment follow up with


    access to emergency medical service.

    ECTOPIC MASS < 3- 4 CM

    Comply with post treatment and follow up.


    CONTRA INDICATION
    • Intra uterine pregnancy

    • Ruptured ectopic

    • Abnormalities in haemotological / renal parameters

    • Immune deficient.

    • Fetal cardiac activity

    • Active pulmonary disease.

    • Hyper sensitivity

    • Breast feeding
    • Single dose administration of MTX 1MG/KG IM
    Approxi.15-20% women will require a second dose
    • HCG Estimation done on 4 and 7th day should show
    a decrease of 15%.
    • If not observed second dose is given.

    Increase in HCG from day 1 to day4 seen due to


    continued production HCG by syncytiotrophoblast
    despite cessation of production by cyto trophoblast.
    • After 7th day then weekly HCG is checked

    • If there is <15% reduction then a third dose is


    given.
    • Still not reducing adequately laparoscopic
    salpingostomy / salpingectomy .
    • Use of 2 dose MTX regimen on day 0 and day
    4 has been proposed with 89 % success.
    • Multiple dose MTX therapy for interstitial /
    cervical pregnancy.
    • Serum hCG checked on day 4 and 7 and
    followed up.
    • Multiple dose regimen on day 1 , 3, 5 and 7
    and folinic acid on 2, 4, 6 and 8 days .
    • Reassure patients that there is no effect on
    ovarian reserve after treatment with
    methotrexate.
    • Can try pregnancy 3 months after treatment.
    SURGICAL TREATMENT
    • 2 choices of surgical approach

    • salpingectomy and salpingostomy

    • Emergency surgery indications

    – 1. Haemodynamically unstable

    – 2. Signs and symptoms of impending or ongoing rupture.

    – 3. Concurrent surgical procedures needed like desire for


    sterilisation , removel hydrosalpinx or with hetrotropic
    pregancy
    PERSISTENT ECTOPIC
    • After salpingostomy for 4- 15 % cases persistent ectopic
    occur.
    • Usually 50% reduction of beta hcg occurs by day 1 after
    surgery. THEN DAY 4th.
    • No cases of persistent ectopic seen when post op HCG on
    day1 fell >76%
    • If not certain about the completeness of removal of products
    a single dose of mtx given prophylactically post op.
    Fertility after tubal ectopic
    • Prior fertility most important factor

    • PRIOR TUBAL DAMAGE DECREASE RATE OF future PREGNANCY

    • Women who had an IUD at the time of ectopic appear to have better
    fertility
    • 93% of spontaneous pregnancy after surgical treatment occur in the first 18
    months following the procedure.
    • If not conceiving after 12 -18 months other tube may be damaged should
    be referred for IVF.
    • Recurrent ectopic occurs in 50 %

    • Recurrence rate increases to 30 % following 2 ectopics.

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