Ectopic pregnancyJEANNET E. CANDA, RN,MAEDJEANNET E. CANDA, RN,MAEDNDDU COLLEGE OF NURSINGNDDU COLLEGE OF NURSING

DefinitionDefinition

An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there

The most common site of occurrence is within a fallopian tube, however, ectopic pregnancies can occur in the ovary, the abdomen and in the lower portion of the uterus (the cervix)

Put very simply, an ectopic pregnancy means "an out-of-place pregnancy„

Ectopic Pregnancy is a common, life–threatening condition affecting one in 100 pregnancies

As the pregnancy grows it causes pain and bleeding. If it is not treated quickly enough it can rupture and cause abdominal bleeding, which can lead to maternal cardiovascular collapse and death

Ectopic PregnancyEctopic Pregnancy

Ectopics happen in about 0.25-1% of all pregnancies The mortality rate is about 1 per 1000 ectopics (10% of all

maternal deaths) Ectopic pregnancy rate increased almost 4 fold (from 4.5

per1000 pregnancies to 16.8 per 1000 pregnancies since 1970)

Fatality rate from ectopic pregnancies dropped almost 90% (from 35.5 per 1000 ectopics to 3.8 per 1000 ectopics)

Most ectopic pregnancies occur in women aged 25-34 years Over 75% of ectopics are diagnosed before 12th week of

gestation

Ectopic PregnancyEctopic Pregnancy

The decrease in maternal morbidity is due to:

early detection of pregnancy (hCG assays) aseptic (sterile) technique antibiotics anesthetic agents availability of blood and transfusions surgical techniques (salpingectomy &

salpingostomy)

ClassificationClassification

Tubal pregnancy (96-98%) ampullary (mid) portion of the fallopian tube (80-90%)isthmic (area closer to uterus) portion of the fallopian tube (5-10%) fimbrial (distal end away from uterus) portion of the fallopian tube (5%)cornual (within the uterine muscle) portion of the fallopian tube (1-2%)

Abdominal (1-2%) primary/secondary (tubo-abdominal/abdomino-ovarian)

Ovarian (0.5-1%) Cervical (less than 0.5%) Heterotopic (combination of ectopic + intrauterine pregnancy)

Uncommon EctopicsUncommon Ectopics

Intraligamentous pregnancy (in broad ligament)

Pregnancy in a uterine diverticulum or sacculation

Angular pregnancy (inside the uterotubal attachment)

Pregnancy in a rudimentary horn of uterus

Intraural pregnancy (in myometrium)

Vaginal pregnancy

Multiple tubal pregnancy

Histology Histology & Anatomy& Anatomy

The fallopian tubes (oviducts) are small, hollow muscular tubes each about ten cm long

Inside the tube is delicate mucous membrane that forms the fimbriae

In the epithelial lining of the tubes half the cells are mucus-secreting and half have cilia- tiny hair like projections which beat gently to propel these secretions towards the uterus

The muscular wall of each tube becomes thicker towards the uterus, and has a natural peristaltic action which assists the movement of mucus

Embryology Embryology && Physiology Physiology

Risk Factors for Ectopic Risk Factors for Ectopic PregnancyPregnancy

Pelvic inflammatory disease (PID) or Salpingitis → 6 -10 times higher risk. Mainly invasion of gonorrhea or chlamydia from the cervix up to the uterus and tubes and infection in these tissues causes an intense inflammatory response and scar tissue adhesions in the tube and may damage the cilia of the fallopian tube

Endometriosis History of IUD use Progesterone–only contraceptive pill (mini–pill) →

alters tubal motility Pregnancy after tubal ligation or coagulation Previous tubal surgery Ovulation induction or ovarian stimulation

Risk Factors for Ectopic Risk Factors for Ectopic PregnancyPregnancy

In vitro fertilization → 2-5% of pregnancies are conected with IVF

Advancing age Previous ectopic → about 10-20% of women attempting

pregnancy after one ectopic will have another Salpingitis Isthmica Nodosa → uncommon diverticulae in

the proximal (isthmic) portion of the tube that enhance tubal implantation of the early developing embryo

Pelvic adhesions, pelvic tumors Atrophic endometrium Septate uterus Zygote abnormalities (chromosomal abnormatity, neural

tube defects, abnormal spermatozoa)

SymptomsSymptoms

One-sided pain in abdomen (can be persistent and severe, but may not be on the same side as an ectopic pregnancy)

Shoulder-tip pain (due to internal bleeding irritating the diaphragm when woman breathe in and out)

Bladder or bowel problems (woman feels pain when she has her bowels open – tenesmus, or when she passes water)

Collapse (feeling of light-headed or faint, paleness, increasing pulse rate, sickness, diarrhoea and falling blood pressure)

Pregnancy test (from urine may be positive but not always → hCG blood tests to confirm)

Amenorrhoea (missed or late period) Abnormal vaginal bleeding Symptoms of pregnancy Fever (unusual, occuring in 2% of pacients)

Ectopics ManifestationEctopics Manifestation

Emergency presentation - Suddenly, without warning a woman is very unwell, collapses and is taken to hospital in fase of haematoperitoneum and hemorrhage shock

Subacute presentation - The most common presentation is with a missed period, positive pregnancy test, some abdominal pain, and irregular vaginal bleeding

Rrisk pregnancy group - After previous ectopic, tubal surgery or assisted conception ( IVF) → detection rate is high → women are primary observed

DiagnosisDiagnosis

Early diagnosis of an ectopic pregnancy is critically important There is no uniformly accepted diagnostic protocol History Physical examination (pain, adnexal mass, enlarged uterus) Transvaginal or transabdominal ultrasound Quantitative hormone tests (HCG, ß-hCG, progesterone) Occasionally culdocentesis (thin needle is inserted at the top

of the vagina, between the uterus and the rectum, to check forblood in CD)

Sometimes dilatation and curettage (exclude intrauterine pregnancy or incomplete abortion)

DiagnosisDiagnosis

Pseudogestational sac in uterus (is seen in 10-20% of ectopics) Decidual transformed endometrium (thick & hyperechogenic) No presence of developing fetus in uterus Adnexal mass or „Tubal ring“ (gestational sac, yolk sac or fetal

pole) Occasionaly hemosalpinx (tubes fill with blood) Enlargement of uterus (not appropriate for date) Fluid in Cul –De- Sac

Differential DiagnosisDifferential Diagnosis

Abortion (complete,incomplete, inevitable, missed)

Threatened appendicitis Acute dysmenorrhea Placenta previa Shock (hemorrhagic, hypovolemic) Ruptured corpus luteum cyst Adnexal torsion Cornual myoma or abscess Ovarian tumor Endometrioma Cervical cancer

ManagementManagement

Once an ectopic is diagnosed, there are several different treatments

It is not possible to take the pregnancy from the tube and put it into the womb

In all cases, the pregnancy must be terminated Various forms of management The appropriate surgery follow up for the patient are

serial blood tests of the pregnancy hormone (ß-HCG) Within a few weeks, the pregnancy hormone should

not be measureable

Management (cont)Management (cont)

Expectant management - proportion of all ectopics will not progress to tubal rupture, but will regress spontaneously and be slowly absorbedLevel of hCG must falling and a woman becomes clincally well. Situation needs daily hCG, TVS. If hCG increases or sonographic findings are suspicious → active management

Medical treatment – (methotrexate,dyktinomycin, hyperosmolar glucose, potassium chloride, mifepristone) given by injection in form of systemic or local administrationLaparoscopic surgery - (salpingotomy or salpingectomy).

Open surgery (laparotomy) - involves a 5-8 cm incision at the top of the pubic hairlineThe affected tube is brought out and either salpingotomy or ectomy is performed

The options are as follows:

Criteria for Expectant Criteria for Expectant ManagementManagement

Decreasing hCG titers (less than 1500 mIU/mL ) Tubal location (rather than ovarian, abdominal,

cervical) No evidence of rupture or significant bleeding Ectopic mass with size less than 4 cm Highly motivated patient with strong desire to avoid

both surgery and medical management Hemodynamically stable healthy woman Absence of fetal heart tones

Methotrexate TreatmentMethotrexate Treatment

Anti-metabolite drug Inexpensive, easy to obtain, well tolerated Mixture containing at least 85% of folic acid antagonist "4-

amino-10-methylfolic acid„ and 25% of Leucovorum calcium (folic acid agonist)

The initial dose regimen MTX (1 mg/kg IM ) or single IM dose of 50 mg/square meter Leukovorum (0.1 mg/kg IM )

Don´t exceed 4 doses 70-95% efficiency of cases treated Methotrexate management takes 4-6 weeks for complete

resolution of the ectopic pregnancy

Complications of Complications of MethotrexateMethotrexate

Bone marrow suppression Acute and chronic hepatotoxicity transient elevations in

serum liver transaminases Progressive pulmonary toxicity (pneumonitis and

pulmonary fibrosis) Dermatologic effects (rashes, itch, folliculitis,

photosensitivity, pigment changes, rarely alopecia) Renal impairment GI side effects (stomatitis, gastritis, diarrhoea)

Invasive TreatmentInvasive Treatment

The standard aim of care is to control the bleeding and remove the ectopic pregnancy

Prior to the late 1980's, this was accomplished by first making a large incision in the woman's abdomen and "looking" to find if there was a swollen fallopian tube containing the ectopic

With the advent of advanced laparoscopic technique, the ectopic pregnancy can be identified with only a small incision below the umbilicus (navel)

Microinvasive technique

Surgical TreatmentSurgical Treatment FormsForms

Salpingotomy: Making an incision on the tube and removing the pregnancy

Salpingectomy: Cutting the tube out Segmental resection: Cutting out the affected portion of the

tube Fimbrial expression: "Milking" the pregnancy out the end of

the tube Usually, if the tube is not ruptured → laparoscopy Cases of rupture with significant hemorrhage into the

abdomen → laparotomy

ComplicationsComplications

Hemorrhage and hypovolemic shock Infection Loss of reproductive organs following surgery Infertility, sterility Urinary and/or intestinal fistulas following complicated

surgery Disseminated intravascular coagulation Persistent ectopic (complication of conservative

surgical treatment, incomplete removal of trofoblastic tissue)

Rh disease

Emotions ChangesEmotions Changes

Ectopic pregnancy can be a devastating experience (loss of baby, loss of part of fertility, recovery from surgery)

Postsurgery depression

Sudden end to pregnancy → hormonal disarray

Distress and disruption of family life

PrognosisPrognosis

The prognosis with an ectopic pregnancy is good for patients with an early diagnosis

Good when fertility is preserved (as much as possible)

Patients with a previous ectopic pregnancy should be educated regarding the potential increased risk for another ectopic pregnancy

The Future PregnancyThe Future Pregnancy

If one of the tubes was removed, woman ovulate as before, but chances of conceiving will be reduced to about 50%

Woman can still become pregnant and have a successful pregnancy with one intact tube

Overall chances of a repeat ectopic are between 7–10% and depends on the type of surgery

If infertility occurs, fertility treatment techniques can still help a woman achieve pregnancy (IVF)

Tubal PregnancyTubal Pregnancy

Is a pregnancy that grows in the fallopian tube, not the uterus

If the pregnancy continues and the tube ruptures, there may be life-threatening intraabdominal bleeding

Even with the modern practice of medicine, the rupture of the tubal ectopic pregnancy is still one of the leading causes of gynecological deaths

Tubal Pregnancy Tubal Pregnancy FindingsFindings

Acute tubal rupture (40% of tubal pregnancies) Chronic tubal rupture (60% of tubal

pregnancies) Early unruptured tubal pregnancy Tubal abortion

Tubal Pregnancy at USGTubal Pregnancy at USG

Ultrasound showing uterus and tubal pregnancy

2D scan Uterus outlined in red Uterine lining in green Ectopic pregnancy

yellow Fluid in uterus at blue

circle is called a "pseudogestational sac"

Tubal Pregnancy at USGTubal Pregnancy at USG

Detailed view of ectopic (thick, brightly echogenic, ringlike structure outside the uterus)

Tubal pregnancy circled in red 4.5 mm fetal pole (between cursors) in green Pregnancy yolk sac in blue

Tubal PregnancyTubal Pregnancy

A right tubal ectopic pregnancy seen at laparoscopy The swollen right tube containing the ectopic

pregnancy is on the right at E The stump of the left tube is seen at L - this woman

had a previous tubal ligation

Tubal PregnancyTubal Pregnancy

Close view of the same ectopic

After laparoscopic resection of the tube, the tubal stump is seen at S

Tubal PregnancyTubal Pregnancy

Right tubal ectopicpregnancy in 11 thweek of gestation

Same situation after rupture

Tubal PregnancyTubal Pregnancy

Laparoscopist must try to remove the ectopic pregnancy, preserve the fallopian tube, and early send the patient home

Diagnostic LSK picture below

DIAGNOSIS & TREATMENT OPERATIVE LAPAROSCOPIC SURGERY

Tubal PregnancyTubal Pregnancy

The first step of this technique involves making a linear slit into the fallopian tube over the ectopic with a monopolar needle tip.

Tubal PregnancyTubal Pregnancy

The second step involves teasing out the ectopic pregnancy intact, and then irrigating the incision to make sure it is free of any ectopic tissue

LAPAROSCOPIC SALPINGECTOMY LAPAROSCOPIC SALPINGECTOMY FOR ECTOPIC PREGNANCYFOR ECTOPIC PREGNANCY

Laparoscopic left salpingectomy after attempted salpingostomy for a left tubal ectopic pregnancy in a 32-year-old gravida 3 para 2

Because patient wished to retain her fertility, salpingostomy was initially attempted to save the tube,but hemorrhage and retained trophoblastic tissue dictated a partial salpingectomy (removal of part of the tube)

The ectopic pregnacy is visualized in the ampullary region of the left fallopian tube

CASE REPORT

LSC salpingectomy (cont)LSC salpingectomy (cont)

Salpingostomy on the anti-mesenteric border. Is perfomed to allow withdrawof the products of conception and preservation of the tube

After the tube is opened, a grasper is used to remove the products of conception

LSC salpingectomy (cont)LSC salpingectomy (cont)

Bleeding occuring after removal of the products of conception →Electrocoagulation is used to achieve hemostasis

Electrocoagulation has achieved hemostasis The tube was partially removed due to the retained trophoblastic tissue

LSC salpingectomy (cont)LSC salpingectomy (cont)

Successive electocoagulation ofthe mesosalpinx and subsequentsharp dissection allows partialsalpingectomy

The distal tube has been removed through the port

LSC salpingectomy (cont)LSC salpingectomy (cont)

Once hemostasis is assured, the hemo-peritoneum is evacuated

A single follow up ß-HCG

should be examine for 2-3 weeks post operation

Ovarian PregnancyOvarian Pregnancy

Ovary is the white structure in the middle

Pregnancy is implanted on the far right side of the ovary at the "X„

Around the ovary are seen bleeding and clotted blood

Abdominal PregnancyAbdominal Pregnancy

Incidence of 1 in 8000 births Mostly secondary form of abdominal pregnancy Predominant symptom si pain with hemorrhage Genitourinary symptoms discomfort Immediate surgical removal of the fetus Retain attached placenta in site and start with MTX

treatment High maternal & fetal mortality rate

Keep in MindKeep in Mind

If the ectopic does´nt die, the thin wall of the tube will stretch and cause pain, discomfort in the lower abdomen

There may be some vaginal bleeding at this time As the pregnancy grows, the tube may rupture,

causing severe abdominal bleeding, pain, collapse and if not recognized ► death

Even if woman has ectopic, first urine pregnancy test-may be negative !

Why is ectopic pregnancy so dangerous?

End with FunnyEnd with Funny

Thanks for your attention !