Ectopic pregnancy

ECTOPIC PREGNANCY

Definition: a gestation that implants outside the endometrial cavity.

An ectopic pregnancy is estimated to occur in 1 of every 80 spontaneously conceived pregnancies

Site of implantation: 95% fallopian tube (including the ampullary 70-80%, isthmic 12%, infundibular and fimbrial 6-11% and interstiatial 2%) others less common site, ovary, uterine cervix and uterine horn

Risk factors:

History of tubal infection

Cigarette smoking (increased relative risk 1.26)

Prior ectopic pregnancy

History of tubal sterilization within the past 1 to 2 years (higher incidence if cauterization was used)

History of tubal reconstructive surgery

Pregnancy with current intrauterine device,  depot medroxyprogesterone acetate or emergency contraceptive pill use.

Infertility due to tubal factors

Use of assisted reproductive technology

Complication:

1.       Tubal rupture: with resulting intraperitoneal hemorrhage

2.       Pregnancy resorption: as a result of the restricted blood supply

3.       Tubal abortion into the peritoneal cavity

The classic triad of symptoms of ectopic pregnancy

1.       Prior missed menses( period of amenorrhea)

2.       Vaginal bleeding(2^nd symptoms may present or may not present)

3.       Lower  abdominal pain(pain come first)

But it depends on if patient came with acutely ruptured ectopic pregnancy

-          severe abdominal pain and dizziness.

-           Ipsilateral shoulder pain

-          Hemodynamically innstabilty

-          Abdomen: distended and acutely tender with guarding and rebound tenderness

-          +ve cervical excitation

-          Slightly enlarged, globular uterus

(facilitate by UPT +ve and scan: empty uterus with free fluid in POD)

Differential diagnosis for ectopic preganancy

Gynaecology problem

Threatened  or incomplete abortion

Ruptured corpus luteum cyst

Acute PID
adnexal torsion

Degenerating fibroid(especially in pregnancy)

Non-gynae

Acute appendicitis

Pyelonephritis

Pacreatitis

Diagnostic test

1.       Serum BhcG

Healthy normal pregnancy usually the doubling time of BhcG in the serum varies from 1.2 days shortly after implantation to 3.5 days at 2 months after the last menstrual period

normal pregnancies show doubling of hcG levels every 48 hours in the first few weeks of pregnancy or at least 66% and the slowest range is 53%. Therefore, if hcG levels rises below 53%, diagnosis of abnormal IUP or ectopic pregnancy

2.       TVS

Although some IUP may be seen at lower level of hcG but every IUP should be visualized by the time the hcG reach the levels of so called discriminatory zone.

DZ defined as titer of hcG at which an IUGS should be seen by TVS.

On average 1500-2000mIU/ml for singleton pregnancy. So if above this level but no IUGS seen diagnostic of ectopic pregnancy

Inhomogeneous mass

 

 

Tubal

An empty endometrial cavity with:(1) an inhomogeneousadnexal mass or 

(2) anempty extra-uterine sac

or (3) a yolk sac or fetalpole _ cardiac activity in an extra-uterine sac

Interstitial   

An empty endometrial  cavity with products of 

conception located outside of the endometrial echo,

surrounded by a continuous rim of myometrium, within the

interstitial area.

 

Cervical 

 An empty endometrial cavity, with a gestational

sac present below the level of the internal os.

An absent ‘‘sliding sign’’and visible blood flow

around the gestation sac using colour Doppler.

  

Caesarean section scar

An empty endometrial cavity and cervical canal with a gestational

sac implanted within the lower anterior segment of uterine wall,

with evidence of myometrial dehiscence

 

    serum progesterone

Levels greater than 25ng/ml normal IUP and below 5ng/ml indicates abnormal pregnancy. But difficult to determine as most of the values usually falls on range between 5-25ng/ml

Management

        i.            Surgical management

Laparatomy vs laparascopic. If hemodynamically stable may choose laparascopic

Salpingectomy when there is significant damage to the tube

Partial salpingectomy is done only when ectopic pregnancy is implanted at mid-ampullary portion.

Salpingotomy and salpingostomy are both procedures in which the ectopic pregnancy is identified and vasoconstrictive agents are injected beneath the the implantation site prior to an incision. For salpingotomy the incision will be closed later.

      ii.            Medical management with MTX

Indications:

hemodynamically stable without active bleeding or signs of hemoperitoneum.

Patient desires future fertility

GA poses a significant risk

    iii.            Expectant management

Only if they are stable and the diagnosis of ectopic is not yet certain and the symptoms spontaneously resolving