Ectopic Pregnancy

GYN

ECTOPIC PREGNANCY

DR Mona Ahmed

Ectopic pregnancy

Definition and Sites

Ectopic pregnancy is implantation of a pregnancy outside the normal uterine cavity.

Sites:

• Over 98% implant in the Fallopian tube.
• Rarely:
  • ✓ in the interstitium of the tube.
  • ✓ Ovary.
  • ✓ Cervix.
  • ✓ abdominal cavity.
  • ✓ or in caesarean section scars.

Heterotopic Pregnancy is the simultaneous development of two pregnancies: one within and one outside the uterine cavity.

Incidence : One in 80 pregnancies are ectopic.

Aetiological factors for ectopic pregnancy:

• Damage of Fallopian tube due to :
  • pelvic infection (e.g. Chlamydia/Gonorrhoea) previous ectopic pregnancy.
• Functional alterations in Fallopian tube due to smoking and increased maternal age.

Additional risk factors include :

• previous abdominal surgery (e.g. appendicectomy, caesarean section).
• Subfertility.
• IVF.
• Intrauterine contraceptive devices.
• Endometriosis
• Conception on oral contraceptive/morning after pill.

ECTOPIC PREGNANCY SYMPTOMS

• Symptoms of pregnancy.
• Abdominal pain.
• and/or vaginal bleeding in early pregnancy. very acutely with rupture of the EP and massive intraperitoneal bleeding.
• The free blood in the peritoneal cavity can cause diaphragmatic irritation and shoulder tip pain.

Symptoms associated with ectopic pregnancy include:

1. DIZZINESS OR FAINTING
2. ABDOMINAL OR PELVIC PAIN
3. NAUSEA OR VOMITING
4. LOSS OF APPETITE

Diagnosis of ruptured EP:

• Acute abdomen.
• hypovolaemic shock with positive PT.
• Bleeding.
• Abdominal pain.

Without viable intrauterine pregnancy.(US)

Signs of a Ruptured Ectopic Pregnancy

• Sudden, severe abdominal or pelvic pain
• Pain in the lower back
• Dizziness or fainting
• Pain in the shoulders (due to leakage of blood into abdomen affecting diaphragm)

Investigations

• important to assess clinically : (abdominopelvic examination).
• TVUSS:
  • A TVUSS showing :
    • Empty uterus.
    • Adnexal mass.
    • Moderate to significant free fluid during TVUSS is suggestive Of a ruptured EP.

Serum hCG: the serum hCG level in EP the rise of hCG is often suboptimal Doubling .ie. less than double every two days of quantitive hcg test

• Haemoglobin and ‘Group and Save’Z

  • (or cross-match if pt is severely compromised)

• measure to assess degree of intra-abdominal bleeding and rhesus status.

Pregnancy of unknown location

• In up to 40% of women with an EP.
• Diagnosis is not made on first attendance and they are labelled as having a ‘pregnancy of unknown location’ (PUL).

Diagnosis :

• Empty uterus + adnexal mass on TVUSS(+positive pregnancy test)
• The mainstay of investigation is consecutive measurement of serum hCG concentrations.
• Endometrial biopsy (occasionally when hCG levels are static).

All PUL must be investigated to determine the location of the pregnancy.

Management

can be managed using (expectant, medical or a surgical ) …depending on clinical presentation and patient choice.

Expectant management is suitable for patients who are … haemodynamically stable. … and asymptomatic.

The patient requires serial hCG measurements until levels are undetectable

Medical management

Intramuscular methotrexate is a treatment option for patients with

• minimal symptoms.
• adnexal mass <40 mm in diameter.
• serum hCG concentration under 3,000 IU/l. until negative -

Methotrexate is a folic acid antagonist that inhibits trophoblastic cells.

• The dose is calculated based on the patient’s body surface area and is 50 mg/m2
• After methotrexate treatment serum hCG is usually routinely measured on days 4, 7 and 11. every 4 days, if increased, double or triple dose
• then weekly thereafter until undetectable.

Medical treatment should therefore only be offered if facilities are present for regular follow-up visits

Contraindications to medical treatment include:

1. chronic liver, renal or haematological disorder.
2. active infection.
3. immunodeficiency.
4. breastfeeding.

side-effects

stomatitis, conjunctivitis, gastrointestinal upset and photosensitive skin reaction, and causing abdominal pain.

It is important to avoid

• conceiving for 3 months after, coz of teratogenicity risk.
• Alcohol
• prolonged exposure to sunlight during treatment

Surgical management

• The standard & definite surgical treatment approach is
  • laparoscopy (for stable patient),
  • or
  • Laparotomy (for severely compromised patients or where there are no endoscopic facilities).

The operation of choice is:

• salpingectomy (if contralateral tube is healthy)
• or
• salpingostomy.

RR Micrope - novel approaches to operative ectopic pregnancy?

Salpingostomy

• Recommended only if the contralateral tube is absent or damaged.
• It is associated with a higher rate of subsequent EP.

Pregnancy rates subsequently remain high if the contralateral tube is normal

Anti-D administration

• All rhesus-negative women who have a surgical procedure to manage an EP or miscarriage should be offered anti-D immunoglobulin.

• Anti-D is not required for:

  • Threatened miscarriage.
  • Incomplete miscarriage.
  • complete miscarriage.

medical management of miscarriage or EP but guidelines differ, and prophylaxis is often given

Summary of other early pregnancy disorders

Disorder	Definition	Risk factors	Clinical presentation
Gestational trophoblastic disease (GTD) (abnormal trophoblast proliferation)	Spectrum of conditions that includes complete and partial hydatidiform mole, invasive mole and choriocarcinoma	Previous molar pregnancy High or low maternal age Asian origin	Ultrasound features of intrauterine vesicles (‘cluster of grapes’) Persistently raised hCG levels after miscarriage	Registration Uterine evacuation by suction curettage (without misoprostol) Serial hCG measurements Avoid oestrogens
Hyperemesis gravidarum		Multiple pregnancies GTD	Excessive nausea and vomiting, often accompanied by dehydration	Antiemetics Fluid and electrolyte replacement Multivitamins Thromboprophylaxis
Ectopic Pregnancy Q&A Discussion