Ectopic Pregnancy
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Transcript of Ectopic Pregnancy
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 !