Ectopic Pregnancy By Rohan Kulkarni. Defination. Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine.

Ectopic Pregnancy

By Rohan Kulkarni

Defination.

• Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.

• 1 in 100 ( from 1:25 to 1:250) normal pregnancies (incidence)

• Recent evidence shows that the incidence of ectopic pregnancy has been rising in many countries.– USA-5 fold– UK-2 fold– France 15/1000 pregnancies– India-1in100 deliveries

• Recurrence rate - 15% after 1st, 25% after 2 ectopics

Overview.

• Incidence Increasing (Ќ 1:66 Pregnancies)• Mortality Decreasing With Better Detection• Surgical and Medical Treatment Available• Recurrence Rate ~ 15%

Aetiology• Any factor that causes delayed transport of the

fertilised ovum through the.• Fallopian tube favours implantation in the tubal

mucosa itself thus giving rise to a tubal ectopic pregnancy.

• These factors may be Congenital or Acquired.• CONGENITAL - Tubal Hypoplasia, Congenital

diverticuli , Accessory ostia , Partial stenosis • Previous Ectopic Pregnancy• PID

• Migration of the Ova Externa• Pelvic Abnormalities (Fundul Fibroma, adenomiosis of

Fallopian Tubes)• Tubal Reconstrustive Surgery• Tubectomy Operation• Infertility• IUD (~4% pregnancies with IUD in Situ are Ectopic,

Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy)

• IVF• Induction Ovulation with Gonadotropins• Extraneous Factors (Appendicitis, Endometriosis)

Sites

• Ampulla (78-95%)• Isthmus (8-12%)• Interstitial portion (2%) - very rare form• Cornua (< 2%) or in accessory horn • Ovary (0,5-3%, 20-30% in IUD users)• Abdomen (< 2%): Primary - very rare. Secondary.• Cervix (< 2%)• Combined Uterine Pregnancy and Ectopic

Gestation - 1-3% in IVF, 1:4 000 - 1: 30 000

1 - Fimbrial 2 - Ampullary 3 - Isthemic

4 - Interstitial 5) Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament 10) Primary abdominal

• 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 Pregnancy at USG

Tubal Pregnancy

Close view of the

same ectopic

After laparoscopic resection of the tube, the tubal stump is seen at S

Tubal Pregnancy

Right tubal ectopicpregnancy in 11 thweek of gestation

Same situation after rupture

Ovarian Pregnancy

Ovary is the white structure in the middlePregnancy is implanted on the far right side of the ovary at the "X„Around the ovary are seen bleeding and clotted blood

Symptoms

• Amenorrhea in 75% cases• Abdominal Pain - in 95% cases. Shoulder and

Epigasrtric Pain• Vaginal Bleeding • Syncope• Pelvic Mass

Clinical classification.

• Unruptured (Progressive) - without specific sings

• Tubal Abortion - minimal sings• Tubal Rupture (into the peritoneal cavity or

between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock

Diagnosis

• History and Physical Exam• Vaginal Examination• Serial Quantitative -hCG (BSU)• Ultrasound TAS & TVS• Progesterone Level?• Culdocentesis• Laparoscopy • D&C

• -hCG* Levels Double Every 48 Hrs• < 66% Rise / 48 Hrs Consistent With Ectopic

Pregnancy• Single Determination Not Helpful• Best If Done Within Same Laboratory• Ultrasound Never May or May Not Be Helpful• Rules Out Ectopic Pregnanc

Culdocentesis

• Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood

• Negative Tap Inconclusive• May Obviate U/S• Most Helpful in Emergent Situations to

Confirm Diagnosis, But Remains Controvers

Differential diagnosis• Appendicitis (Perforated) , PID• Rupture of Follicle or Corpus Luteum Cyst• Threatened Abortion• Splenic Rupture• Perforated Gastric or Duodenal Ulcer• Acute Pancreatities• Myocardial Infarct• Pyosalpinx• Septic Abortion• Pelvic Abcess• Retroverted Gravid Uterus• Twisted Ovarian Cyst, Rupture of Chocolate cyst

Treatment

• Observation• Laparoscopy• Laparotomy• MTX (methotrexate)• Hyperosmolar Glucose• KCl• RU-486• Prostaglandin F2 alfa

Laprotomy

• Acute Ectopic Gestation • Salpingoectomy• Secondary Abdominal Pregnancy• Interstial Pregnancy• Cornual Pregnancy• Cervical Pregnancy

Laparoscopy

• Allows Diagnosis and Treatment • Salpingostomy• Salpingectomy (Total / Partial)• Cornual Resection• Minimally Invasive, Unlike Laparotomy• Few Contraindications: Unstable Patient

(Possibly)

mxt• Toxic to Trophoblast Cells• Minimal Side Effects• May Preserve Fertility in Cases of Cervical Pregnancy• Requires Compliant Patient, Time • Pain Not Uncommon• 25-50 mg into Gestational Sac• Tubal Patency is Restored in 82% cases• Oral - 50-100 mg (toxicity on GIT)• Intramusculary 1 mg/kg

Cervical Pregnancy• Incidence 1:1 000• Profuse painless bleeding following a short period of

Amenorrhea• PE: a patulous external os and products of conception

in the cevical canal, internal os is closed and the uterus is firm and normal in size

• US helps in the correct diagnisis• Treatment: - Suction Evacuation and Tamponade by

inserting a distended Foley Catheter for 24 hours- Hysterectomy

- Hysteroscopic Resection using Resectoscope , MTX

Outcomes

• 15% Repeat Ectopic Rate• Ectopics:

33% Pregnancy Rate25% Ectopic

• No Benefit To Removing Ovary Along With Tube

• Ectopic Pregnancy is a Common, Treatable Problem

• Sensitive -hCG Assays Allow Early Detection• Surgical and Medical Options Exist

Thank you for attention.