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Ectopic pregnancy

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  1. Introduction
  2. Incidence
  3. Sites of ectopic pregnancy
  4. Risk factors
    1. High risk
    2. Moderate risk
    3. Slight risk
  5. Natural progression
  6. Time of rupture at various sites
  7. Symptoms
  8. Signs
  9. Clinical presentation
  10. Diagnosis and management
  11. Discriminatory zone
  12. Sonographic findings
  13. Laparoscopy
  14. Culdocentesis
  15. Management of unruptured ectopic
  16. Criteria for methotrexate
  17. Methotrexate dosing for ectopic pregnancy
  18. Pretreatment investigations
  19. Contraindications to methotrexate
  20. Surgical management of unruptured
  21. Segmental resection
  22. Radical surgery - Salpingectomy
  23. Management of ruptured ectopic
  24. Expectant management
  25. Summary
  26. Bibliography

Pregnancy that is implanted outside the uterine cavity at a site that by nature is not designed anatomically or physiologically to accept or permit growth of the conceptus. Doubling timing in normal intrauterine pregnancy is 48 hrs. Minimum 66 % [ range 65 ? 100 %] increase over the preceding value. Laparotomy should be done at the earliest. Salpingectomy is the definitive treatment. Though the incidence of ectopic is rising there is a drastic decrease in case fatality rate. Highly sensitive hCG assays and TVS helps in diagnosis at an early stage.

[...] Incidence Increasing in most countries Increase incidence of PID Better diagnostic modalities Use of ART Popularity of contraception Ranges between 1.5 - of all pregnancies Higher risk for women in 35-44yr age group Accounts for 10-15% of maternal death in the 1st trimester (Am Fam Physician 2000) Sites of ectopic pregnancy Fallopian tube > 95% Ampullary segment- 80% Isthmic segment- 12% Fimbrial end- Interstitial-2% Abdominal Ovarian Cervical Sites of ectopic pregnancy Risk factors High risk Previous tubal surgery Tubal sterilization Previous ectopic pregnancy IUCD Tubal pathology Slight risk Smoking Moderate risk Infertility Previous genital infection Multiple partners Natural progression Spontaneous resolution Conceptus dies early Tubal abortion Complete-extruded via fimbria when placental separation is complete Incomplete-partial expulsion Tubal rupture Uncontrolled invasion of trophoblast More often in antimesenteric border Tubal mole or carneous mole Recurrent choriodecidual haemorrhage Lithopedion Fetus dies but too large to be absorbed so lies within body and calcifies Time of rupture at various sites Isthmic-narrow,less distensible 6 8 weeks Ampullary-wide 8 12 weeks Interstitial-can hypertrophy 12 14 weeks Symptoms CLASSICAL TRIAD -lower abdominal pain -amenorrhoea -irregular vaginal bleeding May be asymptomatic in unruptured ectopic Symptoms Abdominal pain 85 Generalized- rupture, haemorrhage Localized- distension Radiating- shoulder Sudden or progressive & continuous or intermittent Symptoms Amenorrhoea and abnormal bleeding Amenorrhoea < 6 weeks- 75 Vaginal bleeding- 50 Light and recurrent Nausea, syncopal attacks, urge to defecate, vomiting passage of uterine cast- Signs General condition-pulse,BP,pallor Per abdomen Tenderness(80 %),guarding,rigidity Cullen's sign Pelvic examination Tender adnexal mass-(50 lateral or posterior to uterus Uterus slightly enlarged-(30 Cervical motion tenderness Soft boggy mass in POD Clinical presentation Acute Tubal rupture Severe lancinating pain Collapse,weak rapid pulse, hypotension, pallor P/A-severe tenderness,guarding DIAGNOSIS History & Clinical Examination Investigations-? HCG Imaging studies-USG, Color doppler Procedures- Laparoscopy, culdocentesis ? HUMAN CHORIONIC GONADOTROPIN (?hCG) Principal endocrine marker in pregnancy. [...]

[...] DISCRIMINATORY ZONE Transvaginal USG (intrauterine pregnancy identified) hCG 1500- 1800 mIU/ml Transabdominal USG (intrauterine pregnancy identified) hCG 6000-6500 mIU/ml SERUM PROGESTERONE ASSAY Adjuvant to serum ? HCG assay Serum progesterone < 5 ng/ml nonviable pregnancy > 25 ng/ml viable intrauterine pregnancy Progesterone > 20 ng/ml rarely associated with ectopic pregnancy Sensitivity low SONOGRAPHIC FINDINGS INTRAUTERINE PREGNANCY Gestational sac with echogenic thick endometrium and fetal pole and yolk sac Double decidual sac sign Yolk sac earliest embryonic landmark SONOGRAPHIC FINDINGS EXTRAUTERINE PREGNANCY Gestational sac with thick bright echogenic ringlike structure outside the uterus with fetal pole and yolk sac Pseudogestational sac (20 Noncystic adnexal mass Extrauterine cardiac activity Tubal ring earliest evidence Free fluid in cul-de sac Hematosalpinx PSEUDOGESTATIONAL SAC LAPAROSCOPY Gold standard for detecting ectopic pregnancy Useful when inconclusive findings in USG and serial ? HCG Diagnostic and therapeutic use To know the condition of unaffected fallopian tube Disadvantages invasive procedure, cost LAPAROSCOPY CULDOCENTESIS Diagnostic tool for identifying intraperitoneal bleeding Cannot differentiate between ruptured ectopic and other causes of intraperitoneal bleeding Significant when USG facilities not available COLOR FLOW DOPPLER Adenxal mass with peritrophoblastic flow Tubal blood flow 20 - increased over the ectopic site Adenxal ring sign and a ?ring of fire? sign Absence of low resistance endometrial blood flow intrauterine pregnancy Management of unruptured ectopic Medical METHOTREXATE - Folic acid antagonist - Chemotherapeutic agent of choice in trophoblastic disease - Deactivates DHFR -reduces THF [cofactor for DNA and RNA synthesis] Criteria for methotrexate Hemodynamic stability Pretreatment HCG < 3000 mIU/ml Absence of fetal cardiac activity Gestational sac < 3.5 cm Ability and willingness of patient to come for post treatment monitoring Pretreatment investigations Complete blood count Liver and renal function test Base line ?HCG Transvaginal USG Contraindications to methotrexate Documented hypersensitivity Alcoholism Active hepatic disease and renal insufficency Immunodeficency Preexisting blood dyscrasis Peptic ulcer Surgical management of unruptured ectopic CONSERVATIVE SURGICAL TREATMENT Linear salpingostomy Linear salpingotomy Segmental resection RADICAL TREATMENT Total salpingectomy Segmental resection Preferable in isthmic pregnancy Conservative approach 1. [...]

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