ECTOPIC PREGNANCY ECTOPIC PREGNANCY ASSOCIATE PROFESSOR IOLANDA BLIDARU, MD, PhD.
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Transcript of ECTOPIC PREGNANCY ECTOPIC PREGNANCY ASSOCIATE PROFESSOR IOLANDA BLIDARU, MD, PhD.
ECTOPIC PREGNANCYECTOPIC PREGNANCY
ASSOCIATE PROFESSOR IOLANDA BLIDARU, MD, PhD
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ECTOPIC PREGNANCY
DEFINITION
Any pregnancy where the fertilised ovum gets implanted & develops in a site other than uterine cavity.
ectopic / extrauterine
heterotopic
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INCIDENCE >1 in 100 pregnancies.
• The incidence of ectopic pregnancy has been rising:– USA - 5 fold– UK - 2 fold– France - 15/1000 pregnancies– India - 1/100 deliveries
• Recurrence rate - 15% after 1, 25% after 2 ectopics
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ETIOLOGY
• Any factor that causes delayed transport of the fertilised ovum through the Fallopian tube (tubal ectopic pregnancy).
• These factors may be:
1. congenital or acquired;
2. mechanical or functional
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ETIOLOGY
• CONGENITAL - tubal hypoplasia, tortuosity, congenital diverticuli, accessory ostia, partial stenosis
• ACQUIRED – Inflammatory: PID, septic abortion, puerperal sepsis,
medical termination → intraluminal / peritubal adhesions– Surgical: tubal reconstructive surgery, recanalisation of
tubes – Tumoral: broad ligament myoma, ovarian tumour– Miscellaneous causes: IUD, endometriosis, ART,
hormonal perturbations → tubal disfunctions– Previous ectopic pregnancy
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SITES OF ECTOPIC PREGNANCY
1)Fimbrial 2)Ampullary 3)Isthmic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal
Ampulla (>85%)Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)
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PATHOLOGIC ANATOMY
• minimal reaction against trophoblast invasion
• local hemorrhage → hematoma
• The uterus - some of the changes associated with normal early pregnancy, (softening of the cervix and isthmus, increase in size).
• the Arias-Stella reaction in the endometrium – in pregnancy both endocervical gland hyperplasia and hypersecretory appearance
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EVOLUTION
Tubal pregnancy • tubal abortion in ampullary pregnancy • tubal rupture in isthmic pregnancy, interstitial
(cornual) pregnancy• hematosalpinx• pelvic hematoceleAbdominal/ovarian pregnancy (primary/secondary)Broad ligament pregnancyCervical pregnancy• spontaneous regresion
Ruptured tubal (ampullary) early pregnancy
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CLINICAL PRESENTATION
• Ectopic pregnancy remains almost asymptomatic until it ruptures.
• In contemporary practice, syptoms and signs of ectopic pregnancy are often subtle or even absent.
• In recent years, in spite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.
•
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DIAGNOSIS
• SYMPTOMS1. Amenorrhea – abnormal menstruation
2. Abdominal pain – absent / different sites; pain in the neck or shoulder (diaphragmatic irritation); tenderness on bimanual ex. + motion of the cervix
3. Syncope, vaso-vagal response (bradycardia, hypotension)
4. Vaginal bleeding – scanty, dark brown, intermitent / continuous
5. Pelvic mass - lateral or posterior to the uterus, +/- uterine displacement; painful; bulging of Douglas pouch
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EARLY MULTI-MODAL DIAGNOSIS
• Vaginal ultrasound scanning (+ colour Doppler) • Serum beta HCG level • Serum progesterone levels < 5ng/mL• Uterine curettage• Culdocentesis• Hemogram • Laparoscopy / laparotomy
A combination of these methods may have to be employed, but only to hemdynamically stable women; those with presumed rupture must undergo surgical therapy.
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METHODS OF EARLY DIAGNOSIS
Multi-modality diagnosis results
1. TV – US - Demonstration of the gestational sac with or without an alive embryo outside the uterus .
- Ruptured ectopic with fluid in the cul-de-sac and an empty uterus.
2. Culdocentesis - in emergent situations to confirm diagnosis, highly specific if performed and interpreted correctly → presence of free-flowing, NON-clotting blood
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DIFFERENTIAL DIAGNOSIS
• Threatened or incomplete abortion
• Salpingo-ooforitis
• Appendicitis
• Twisted ovarian cyst
• Rupture of a corpus luteum / follicular cyst
• Other abdominal conditions
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MANAGEMENT
• Depends on the stage of the disease and the condition of the patient at diagnosis.
1. COMPLICATED ECTOPIC PREGNANCY
2. NON-COMPLICATED ECTOPIC PREGNANCY
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MANAGEMENT OF COMPLICATED ECTOPIC PREGNANCY
TREATMENT – ALWAYS SURGICAL
• Salpingectomy of the offending tube
• Posterior colpotomy - if pelvic haematocele is infected → to drain the pelvic abscess
• Salpingo-oophorectomy
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MANAGEMENT OF NON-COMPLICATED = UNRUPTURED ECTOPIC PREGNANCY
• SURGICAL
• MEDICAL TREATMENT
• EXPECTANT MANAGEMENT
OPTIONS
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SURGICAL TREATMENT OF UNRUPTURED ECTOPIC PREGNANCY
• Carried out by Laparoscopy / Laparotomy.
• The procedures are: – Salpingectomy / Cornual resection /
Excision
– Conservative surgery (in cases of Infertility & desire for pregnancy)
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MEDICAL TREATMENT • Trophotoxic substance:
– Methtrexate - resolution of tubal / abdominal pregnancy by systemic administration
– Interferes with the DNA synthesis
• Ectopic pregnancy size should be < 3.5 cm.
• IV/IM/Oral, usually along with Folinic acid.
• Injection into the ectopic pregnancy sac or affected tube
CLINICAL FORMSDIAGNOSIS AND MANAGEMENT
• Tubal pregnancy
• Abdominal pregnancy - laparatomy
• Cervical pregnancy - hysterectomy
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