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ADVANCES IN THEADVANCES IN THE

MANAGEMENT OF ECTOPICMANAGEMENT OF ECTOPIC

PREGNANCYPREGNANCY

Prof. Surendra Nath Panda, M.S.

Department of Obst.Gynaec

M.K.C.G.Medical College

Berhampur-760010, Orissa, India

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21/12/2010 11:09 Ectopic Pregnancy 2

ECTOPIC PREGNANCY

DEFINITION

Any pregnancy where the fertilised ovum

gets implanted & develops in a site other

than normal uterine cavity.

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INCIDENCE

>1 in 100 pregnancies.

Recent evidence indicates that the incidence ofectopic pregnancy has been rising in manycountries.

USA-5 foldUK-2 fold

France 15/1000 pregnancies

India-1in100 deliveries

Recurrence rate - 15% after 1st, 25% after 2ectopics

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HISTORY

Ectopic pregnancy was first described in 963 Ad byAlbucasis.

1884 -- Robert Lawson Tait of Birmingham

prformed the first successful Salpingectomy

operation

1953 -- Stromme Conservative surgery of

Salpingostomy

1973 -- Shapiro & Adller LaparoscopicSalpingectomy

1991 -- Young et al Laparoscopic Salpingotomy

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AETIOLOGY

Any factor that causes delayed transport of the

fertilised ovum through the.

Fallopian tube favours implantation in the

tubal mucosa itself thus giving rise to a tubal

ectopic pregnancy.

These factors may be Congenital or Acquired.

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AETIOLOGY

CONGENITAL - Tubal Hypoplasia , Tortuosity ,Congenital diverticuli , Accessory ostia , Partial

stenosis

ACQUIRED -

Inflammatory: PID, Septic Abortion, Puerperal Sepsis,

MTP (lntraluminal adhesion)

Surgical: Tubal reconstructive surgery, Recanalisation of

tubes

Neoplastic: Broad ligament myoma, Ovarian tumour

Miscellaneous Causes: IUCD , Endometriosis, ART (IVF

& & GIFT), Previous ectopic

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CLINICAL PRESENTATION

Ectopic Pregnancy remains asymptotic untilit ruptures when it can present in two

variations - Acute &. Chronic

SYMPTOMS-Amenorrhea

Abdominal Pain

Syncope

Vaginal Bleeding

Pelvic Mass

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DIAGNOSIS

Pregnancy in the fallopian tube is a black cat on

a dark night. It may make its presence felt in

subtle ways and leap at you or it may slip past

unobserved. Although it is difficult to distinguish

from cats of other colours in darkness,

illumination clearly identifies it.--Mc. Fadyen - 1981

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DIAGNOSIS

In recent years, inspite of an increase in the

incidence of ectopic pregnancy there has been

a fall in the case fatality rate.

This is due to the widespread introduction ofdiagnostic tests and an increased awareness of

the serious nature of this disease.

This has resulted in early diagnosis andeffective treatment.

Now the rate of tubal rupture is as low as 20%.

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METHODS OF EARLY DIAGNOSIS

Immunoassay utilising monoclonalantibodies to beta HCG

Ultrasound scanning Abdominal &

Vaginal including Colour Doppler Laparoscopy

Serum progesterone estimation not helpful

A combination of these methods may

have to be employed.

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TVS can visualise a gestational sac as early as 4-5weeks from LMP.

During this time the lowest serum beta HCG is 2000IU/Lt.

When beta HCG level is greater than this and there isan empty uterine cavity on TVS, ectopic pregnancycan be suspected.

In such a situation, when the value of beta HCG doesnot double in 48 hours ectopic pregnancy will beconfirmed.

At 4-5 weeks-

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The USG features of ectopic pregnancy after 5weeks can be any of the following-

1. Demonstration of the gestational sac with or without

a live embryo (Begels sign) - The GS appears as an

intact well defined tubal ring by 6 weeks when itmeasures 5 mm in diameter. Afterwards it can be

seen as a complete sonolucent sac with the yolk sac

and the embryonic pole with or without heart activity

inside.

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2. Poorly defined tubal ring possibly containing

echogenic structure and POD typically containing

fluid or blood.3. Ruptured ectopic with fluid in the POD and an

empty uterus.

4. In Colour Doppler, the vascular colour in a

characteristic placental shape, the so-called firepattern, can be seen outside the uterine cavity while

the uterine cavity is cold in respect to blood flow

The USG features of ectopic pregnancy after 5weeks can be any of the following-

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MANAGEMENT

Depends on the stage of the disease and the

condition of the patient at diagnosis.

Options-

Surgery Laparoscopy / Laparotomy

Medical Administration of drugs at the site /

systemically

Expectant Observation

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MANAGEMENT OF ACUTE

ECTOPIC PREGNANCY

Hospitalisation

Resuscitation -

Treatment of shock

Lie flat with the leg end raised

AnalgesicsBlood transfusion

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MANAGEMENT OF ACUTE

ECTOPIC PREGNANCY

Culdocentesis: -

Most Helpful in Emergent Situations to

Confirm Diagnosis

Highly Specific if performed and Interpreted

Correctly: - Presence of Free-Flowing, NON-

Clotting Blood

Negative Tap Inconclusive

Remains Controversial

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MANAGEMENT OF ACUTE

ECTOPIC PREGNANCY

Laparotomy should be done at theearliest.

Salpingectomy is the definitivetreatment.

No benefit from removing Ovary along with thetube

If blood is not available, auto-transfusioncan be done.

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MANAGEMENT OF CHRONIC

ECTOPIC PREGNANCY

INVESTIGATIONS-

Laboratory/Chemical test

Serial quantitative beta HCG level by RIA

Serum progesterone level (

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MANAGEMENT OF CHRONIC

ECTOPIC PREGNANCY

TREATMENT ALWAYS SURGICAL

Salpingectomy of the offending tube

If pelvic haematocele is infected, posterior.colpotomy is to be done to drain the pelvic

abscess

Salpingo-oophorectomy

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MANAGEMENT OF UNRUPTURED

ECTOPIC PREGNANCY

SURGICAL-

SURGICALLY ADMINISTERED MEDICAL(SAM) TREATMENT

MEDICAL TREATMENT

EXPECTANT MANAGEMENT

OPTIONS: -

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SURGICAL TREATMENT OF ECTOPIC

PREGNANCY

Carried out either by Laparoscopy /Laparotomy.

The procedures are: -

Salpingectomy / Cornual resection / ExcisionConservative surgery (in cases of Infertility &

desire for pregnancy)

Linear salpingostomy

Linear salpingotomy Segmental resection and anastomosis

Milking of the tube

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SURGICAL TREATMENT OF ECTOPIC

PREGNANCY

LAPAROTOMY?

VS.LAPAROSCOPY?

SALPINGECTOMY?

VS

SALPINGOSTOMY / SALPINGOTOMY?

The debate goes on

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COMPARING LAPAROTOMY Vs LAPAROSCOPY

Ltomy Lscopy

Hospital cost More? Less?

Post operative adhesions More LessRisk of future ectopic Same Same

Future fertility Same Same

Experience of Surgeon Trained SpecialInstruments General Special

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SALPINGECTOMY

VS

SALPINGOSTOMY / SALPINGOTOMY

All tubal pregnancies can be treated by partialor total Salpingectomy

Salpingostomy / Salpingotomy is onlyindicated when:1. The patient desires to conserve her fertility

2. Patient is haemodinmically stable

3. Tubal pregnancy is accessible4. Unruptured and < 5Cm. In size

5. Contralateral tube is absent or damaged

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The choice of surgical treatment does notinfluence the post treatment fertility, but priorhistory of infertility is associated with a markedreduction in fertility after treatment

Making the choice Chapron et al (1993) havedescribed a scoring system, based on the

patients previous gynaecological history andthe appearance of the pelvic organs, to decidebetween salpingostomy / salpingotomy andsalpingectomy.

SALPINGECTOMY

VS


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Fertility reducing factor Score

Antecedent one Ectopic pregnancy 2

Antecedent each further

Ectopic pregnancy 1

Antecedent Adhesiolysis 1

Antecedent Tubal micro surgery 2

Antecedent Salpingitis 1

Solitary tube 2

Homolateral Adhesions 1

Contralateral Adhesions 1

SALPINGECTOMY

VS


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The rationale behind the scoring system

is to decide the risk of recurrent ectopicpregnancy.

Conservative surgery is indicated with a

score of 1-4 only, while radical treatmentis to be performed if the score is 5 or

more.

SALPINGECTOMY

VS


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It is carried out by laparoscopic scissors

and diathermy or Endo-loop.

After passing a loop of No.1 catgut overthe ectopic pregnancy the stitch is

tightened and then the tubal pregnancy is

cut distal to the loop stitch.

The excised tissue is removed by piece

meal or in a tissue removal bag.

LAPAROSCOPIC SALPINGECTOMY

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To reduce blood loss, first 10-40 IU ofvasopressin diluted in10 ml of normal saline is

injected into the mesosalpinx.

Then the tube is opened through anantimesenteric longitudinal incision over the

tubal pregnancy by a

Co2 laser (Paulson, 1992)

Argon laser (Keckstein et al; 1992)

Laparoscopic scissors and ablating the bleedingpoints with bipolar diathermy.

Fine diathermy knife (Lundorff, 1992)

LAPAROSCOPIC SALPINGOTOMY

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The tubal pregnancy is then evacuated by

suction irrigation.

Hemostasis of the trophpblastic bed is

ensured.

The tubal incision is left open.

LAPAROSCOPIC SALPINGOTOMY

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PERSISTENT ECTOPIC PREGNANCY

(PEP)

This is a complication of salpingotomy /

salpingostomy when residual trophoblast

continues to survive because of incomplete

evacuation of the ectopic pregnancy. Diagnosis is made because of a raised

postoperative serum HCG

If untreated, can cause life threateninghemorrhage

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PERSISTENT ECTOPIC PREGNANCY

(PEP)

TREATMENT is by-

Reoperation and further evacuation /

SalpingectomyAdministration of IM / oral Methtrexate in a

single dose of 50 mg/m2 of body surface

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SAM TREATMENT

Aim- trophoblastic destruction withoutsystemic side effects

Technique- Injection of trophotoxic substance

into the ectopic pregnancy sac or into theaffected tube by-

Laparoscopy or

Ultrasonographically guided

Transabdominal (Porreco, 1992) Transvaginal (Feichtingar, 1987)

With Falloposcopic control (Kiss, 1993)

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SAM TREATMENT

Trophotoxic substances used-

Methtrexate (Pansky, 1989)

Potassium Chloride (Robertson, 1987)

Mifiprostone (RU 486)PGF2E (Limblom, 1987)

Hyper osmolar glucose solution

Actinomycin D

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MEDICAL TREATMENT WITH

METHOTREXATE

Resolution of tubal pregnancy by systemic

administration of Methotrexate was first described by

Tanaka et al (1982)

Mostly used for early resolution of placental tissue inabdominal pregnancy. Can be used for tubal

pregnancy as well

Mechanism of action- Interferes with the DNA

synthesis by inhibiting the synthesis of pyrimidines

leading to trophoblastic cell death. Auto enzymes and

maternal tissues then absorb the trophoblast.

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METHOTREXATE

Ectopic pregnancy size should be < 3.5 cm.

Can be given IV/IM/Oral, usually along withFolinic acid

Recent concept is to give Methtrexate IM in asingle dose of 50mg/m2 without Folinic acid.If serum HCG does not fall to 15% with in 4-7

days, then a second dose of Methtrexate isgiven and resolution confirmed by HCGestimation

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METHOTREXATE

Advantages

Minimal Hospitalisation.Usually outdoor treatment

Quick recovery

90% success if cases are properly selected

Disadvantages-

Side effects like GI & Skin

Monitoring is essential- Total blood count, LFT &

serum HCG once weekly till it becomes negative

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EXPECTANT TREATMENT

Tubal Pregnancies are known to Abort /Resolve

Befor the advent of salpingectomy in 1884,

ectopic pregnancies were being treatedexpectantly with 70% mortality.

Today only selected cases are managed

expectantly, screened and identified by highresolution ultrasound scanner and monitored by

serial serum HCG assay

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EXPECTANT TREATMENT

Identification criteria (Ylostalo et al , 1993)-Diameter of ectopic pregnancy

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EXPECTANT TREATMENT

Spontaneous resolution occurs in 72%,while

28% will need laparoscopic salpingostomy

In spontaneous resolution, it may take 4-67days (mean 20 days) for the serum HCG to

return to non pregnant level. The percentage fall in serum HCG by day 7 is

a better indicator than the percentage fall byday 2.

Warning: - Tubal pregnancies have beenknown to rupture even when Serum HCGlevels are low.

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SUMMARY - KEY POINTS

Incidence of ectopic pregnancy is rising while

maternal mortality from it is falling.

Early diagnosis is the key to less invasive treatment.

The choice today is Laparoscopic treatment of

unruptured ectopic pregnancy. The trend is towards conservative treatment.

Careful monitoring and proper counselling of patients

is mandatory.

Ruptured ectopics should be unusual with compliant

patients and appropriate medical care.

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