Ectopic Pregnancy

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Ectopic Pregnancy Xiaofang Yi, M.D. Hospital of OB/GYN, Fudan University Email: [email protected] Mobile: 15026585241

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Ectopic Pregnancy. Xiaofang Yi, M.D. Hospital of OB/GYN, Fudan University Email: yi.annie [email protected] Mobile: 15026585241. Abbreviations. STD : sexually transmitted disease ART : assisted reproductive technique hCG : human chorionic gonadotropin TVS : transvaginal sonography - PowerPoint PPT Presentation

Transcript of Ectopic Pregnancy

Page 1: Ectopic Pregnancy

Ectopic Pregnancy

Xiaofang Yi, M.D.Hospital of OB/GYN, Fudan University

Email: [email protected]

Mobile: 15026585241

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Abbreviations• STD: sexually transmitted disease• ART: assisted reproductive technique• hCG: human chorionic gonadotropin• TVS: transvaginal sonography• MTX: methotrexate

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Contents1. Definition

2. Classification

3. Epidemiology

5. Tubal Pregnancy

4. Risk Factors

6. Other Site of Ectopic Pregnancy

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Definition

• “ektopos”=out of place• Implantation of blastocyst not in the endometrial lining of the uterine

cavity

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Classification

• Ovarian ~• Cornual ~• Cervical ~• Abdominal ~• Ceasarean scar ~• Heterotopic ~, etc.

Tubal pregnancy (95 % )

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Epidemiology

• 2% of all early pregnancies• 10% of repeat ectopic pregnancy• 6% of all pregnancy-related deaths• Mortality ratio in black 18 times higher than in

white women

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Risk Factors

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Tubal Pregnancy

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Endings of tubal pregnancy Rupture : Isthmic, 12 ~ 16

wks Abortion : Ampullary, 8 ~ 12

wks Secondary abdominal

pregnancy Broad ligament pregnancy Persistent ectopic

pregnancy

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Clinical Manifestations Delayed menstruation Vaginal bleeding or spotting Abdominal & pelvic pain

Sharp, stabbing, or tearing With vasomotor disturbance: vertigo to syncope Tenderness Pelvic mass: tender, boggy

Diaphragmatic irritation: pain in neck or shoulder

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Often subtle or even absentBefore rupture

Pain, bleeding, tendernessRupture

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Symptoms and Signs Pain: 95% Abnormal bleeding: 60-80% Abdominal & pelvic tenderness Uterine changes: pushed to one side,

enlarged Vital signs: BP will fall, P will rise only

when hypovolemia

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Laboratory Tests hCG: the rise over 48 hours ﹤ 66 % Progesterone: 5-10-25 ng/ml Hemogram: decrease in hemoglobin or hematocrit Sonography : TVS Culdocentesis Uterine currettage Laparoscopy / laparotomy

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Arias-Stella reaction

Glands: closely packed , hypersecretory.Nuclei: large, hyperchromatic.

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Laboratory Tests hCG: the rise over 48 hours 66﹤ % Progesterone: 5-10-25 ng/ml Hemogram: decrease in hemoglobin or hematocrit Sonography : TVS Culdocentesis Uterine currettage Laparoscopy / laparotomy

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TVS Findings• Endometrial cavity

– Pseudogestational sac– Decidual cyst

• Adnexa– Extrauterine yolk sac or embryo: 15-30%– Adnexal mass: PPV 96%, NPV 95%

• Rectouterine cul-de-sac– Free peritoneal fluid

Caution in diagnosing an intrauterine pregnancy in the absence of definite yolk sac or embryo

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The “ring of fire”

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Discriminatory hCG • Empty uterus w/ hCG > 1500 mIU/mL

– Ectopic pregnancy– Nonliving uterine pregnancy

– Early multifetal gestation

• Serial assays of hCG, w/ serial TVS evaluation – <66% increase within 48hr– Empty uterus

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Differential Diagnosis

Abortion Pelvic inflammation disease Appendicities Rupture of corpus luteum Torsion of ovarian cyst

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Early diagnosis

allows definitive surgical or medical management

Treatment before rupture

Less morbidity, mortality, better prognosis for fertility

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Surgical Management (1/3)

– Tubal patency following salpingostomy– Subsequent uterine pregnancies– Subsequent ectopic pregnancies– Safety & cost: operative time, blood loss, analgesic

requirements, hospital stays

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Laparoscopy vs Laparotomy

Longer OP time

Limitaion inManipulation

2-DimensionalImage

Expensive Eye-HandDiscrepancy

Less PainEarly recovery Smaller Scar Less Bleeding

Early return to work Less adhesionShort

Hospital StayMagnification of OP field

Advantage in Immunology

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Surgical Management (2/3)

– Subsequent uterine pregnancies– Persistent ectopic pregnancies

Indications for conservative surgery < 3 cm in length Unruptured hCG < 3000 mIU/mL Hemodynamically stable

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Surgical Management (3/3)

– Salpingostomy– Salpingotomy: suture the tubal incision– Salpingectomy– Cornual resection

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Salpingostomy Salpingotomy

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Salpingectomy

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Cornual Resection

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Persistent Ectopic Pregnancy• Post-op day 1: hCG > 50% of the pre-op value• Post-op day 12: hCG > 10% of the pre-op value • Risk factors

– Small pregnancies: < 2 cm– Early therapy: before 42 menstrual days– hCG > 3000 mIU/mL– Implantation medial to the salpingostomy site

• Additional surgical or medical therapy is necessary

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Medical Management • Indications

– Asymptomatic, motivated, compliant

– Mass ≤ 3.5 cm– hCG < 2000

mIU/mL

Contraindication Active intra-abdominal

hemorrhge Intrauterine pregnancy Breast feeding Immunodeficiency,

alcoholism Chronic hepatic, renal, or

pulmonary disease Blood dyscrasias Peptic ulcer disease

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Methotrexate (MTX)

• Folic acid antagonist

• Dose & administration

Toxicity Liver: 12% Stomatitis: 6% Gastroenteritis: 1%

Failure rate: 1.5% (hCG <1000 mIU/mL) 14.3% (hCG > 5000

mIU/mL)

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MTX Therapy

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Monitoring Efficacy of Therapy• “15%, day 4 and 7 rule”• Weekly serum hCG determination until

undetectable• Resolution time

– Salpingostomy: 20 days– Single-dose MTX: 27-34 days

• Rupture of persistent ectopic pregnancy: 5-10%

The longest resolution time: 109 days

Tubal rupture can occur in the face of declining hCG.

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Schematic of comparative patterns of serum-hCG level decline after single-dose methotrexate treatment or laparoscopic salpingostomy for unruptured ectopic pregnancy.

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• Indications– Tubal ectopic pregnancies only– Decreasing serial hCG levels– Mass ≤ 3.5 cm– TVS: no intra-abdominal bleeding or rupture

Expectant treatment

Resolution rate: hCG < 1000 mIU/mL: 50-

73% hCG < 200 mIU/mL: 88%

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Other Sites of Ectopic Pregnancies

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Abdominal Pregnancy• Incidence: 1 in 85,000• Symptoms: vague,

nonspecific• Sonography, MRI: might

be helpful• Life threatening• Pre-op angiographic

embolization• Surgical termination

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Ovarian Pregnancy• Symptoms: Mimic tubal pregnancy or a bleeding

corpus luteum• Surgery:

– Ovarian wedge resection– Cystectomy– Ovariectomy

• MTX: if unruptured

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Cervical Pregnancy

Incidence: 1 in 18,000 Clinical feature : painless vaginal bleeding Treatment:

Cerclage Curretage and tamponade Arterial embolization

Laparoscopically assisted uterine artery ligation followed by hysteroscopic endocervial resection

MTX: 50-75 mg/m2

Sonographically guided fetal intracardiac injection of 2 mL KCl was added when needed

Intracervical Foley catheter was placed for 3 days

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A. TVS of a cervical pregnancy. (1) an hourglass uterine shape and ballooned cervical canal; (2) gestational tissue at the level of the cervix (black arrow); (3) absent intrauterine gestational tissue (white arrows); (4) a portion of the endocervical canal seen interposed between the gestation and the

endometrial canal. B. In a transverse view of the cervical pregnancy, Doppler color flow shows abundant

vascularization. (From Dr. Elysia Moschos.)

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Cesearean Scar Pregnancy Incidence: 1 in 2,000 Clinical presentation :

Pain & bleeding Asymptomatic: 40%

Treatment: MTX Curretage Hysteroscopic resection Uterine-preserving rection Hysterectomy

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A. TVS shows a uterus with CSP. An empty uterine cavity appearing as a bright hyperechoic endometrial stripe (long, white arrow); an empty cervical canal (short, white arrow); and an intracavitary mass seen in the anterior wall of the uterine isthmus (red arrows). (From Dr. Elysia Moschos.)

B. This hysterectomy specimen with a CSP is transversely sectioned at the level of the uterine isthmus and through the gestational sac.

(From Drs. Sunil Balgobin, Manisha Sharma, and Rebecca Stone.)

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Heterotopic pregnancy

• A condition in which ectopic and intrauterine pregnancies coexist.

• Incidence: 1 in 30 000.

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Summary

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Summary

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Abortion

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Contents1. Definition

2. Type of abortion

4. Diagnosis

3. Etiology

5. Management

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Definition

Latin “Aboriri”-”to miscarry” A pregnancy termination prior to

20 weeks of gestation, or with a fetus born weighing < 500 g.

China: 28 wks, 1000g Vary widely.

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Type of Abortion

• Spontaneous abortionInduced abortionSeptic abortion• Recurrent spontaneous abortion: The loss of

more than three pregnancies before 20 weeks of gestation

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Type of Spontaneous AbortionThreatened ~:Vaginal bleeding before 20 weeks of gestation.Inevitable ~: Uterine bleeding from a gestation of less than 20 weeks,

accompanied by cervical dilation but without expulsion of placental or fetal tissue through the cervix.

Anembryonic gestation: An intrauterine sac without fetal tissue present at more than 7.5 weeks of gestation.

Incomplete ~: Expulsion of some but not all of the products of conception before 20 completed weeks of gestation.

Complete ~: Spontaneous expulsion of all fetal and placental tissue from the uterine cavity before 20 weeks of gestation.

Missed ~

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Bleeding Abdominal Pain Tissue Expulsion

Cervical Os Uterus

Threatened Abortion

Inevitable Abortion

Incomplete Abortion

Complete Abortion

Light

Mild to heavy

Light to heavy

Light to none

None/light

Intensified

Relieved

None

None

None

Partial

Complete

Closed

Dilated

Dilated or obstructed

Closed

Normal

Normal or slightly small

Small

Normal or slightly large

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Etiology Fetal factors

Maternal factors: Infections Chronic debilitating diseases Endocrine anomalies Uterine defects

Drug use and environmental factors

Paternal factors

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Symptoms

Amenorrhea Vaginal bleeding Abdominal pain

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Diagnosis

History & physical examination Transvaginal ultrasonography hCG Serum progesterone

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Differential Diagnosis• Cervical polyps• Vaginitis• Cervical carcinoma• Gestational trophoblastic disease• Ectopic pregnancy• Trauma• Foreign body

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Management

• There is no effective therapy for a threatened intrauterine pregnancy.– Bed rest– Progesterone? sedative?

• All patients with an incomplete abortion should undergo suction curettage as quickly as possible.

• Genetic consulting• Cervical cerclage

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Abortion Techniques

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A Hegar dilator. Note that the fourth and fifth fingers rest against the perineum and buttocks, lateral to the vagina.

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A suction curette is simultaneously rotated 360° several times to remove tissue circumferentially from the uterine walls.

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A sharp curette is held with the thumb and forefinger. In the upward movement of the curette, only the strength of these two fingers should be used.

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When floated in saline, chorionic villi are often readily distinguishable as lacy fronds of tissue.

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Regimens for Medical Termination of Early Pregnancy

aDoses of 200 versus 600 mg similarly effective.bOral route may be less effective and with more nausea and diarrhea. May be given sublingually, or buccally. Postprocedure pelvic infection significantly higher with vaginal versus oral route. Possibly more effective when given at 36-48 hours instead of at 6 hours.cEfficacy similar for routes of administration.dSimilar efficacy when given on day 3 versus day 5.

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References• Williams Obstetrics, 23rd Edition

– Chapter 10. Ectopic Pregnancy

• Berek & Novak’s Gynecology, 14th Edition

• Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage. National Institute for Health and Clinical Excellence: Guidance. Editors: National Collaborating Centre for Women's and Children's Health (UK). Source: London: RCOG; 2012 Dec.

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Quizs If a patient has documented cardiac activity in the ectopic, what

should be initiated, MTX or surgery ? How to monitor hCG levels and evaluate transvaginal ultrasound

while instituting MTX ? Does surgical management and medical therapy appear to be

equivalent ? Summarize the management strategies for tubal pregnancy and

its indications. What conditions should be differentiated from abortion?

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Which statement about ectopic pregnancy is true?

• Implantation of the fertilized egg outside the uterine cavity

• Rarely involves the fallopian tubes

• Usually associated with cervical carcinoma

• The most common site of involvement is the ovary

• Rarely a surgical emergency

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THANK YOUXiaofang Yi, M.D.Hospital of OB/GYN, Fudan University

Email: [email protected]

Mobile: 15026585241