Ectopic Pregnancy Xiaofang Yi, M.D. Hospital of OB/GYN, Fudan University Email: [email protected] Mobile: 15026585241.

Ectopic Pregnancy

Xiaofang Yi, M.D.

Hospital of OB/GYN, Fudan University

Email: [email protected]

Mobile: 15026585241

Abbreviations• STD: sexually transmitted disease

• ART: assisted reproductive technique

• hCG: human chorionic gonadotropin

• TVS: transvaginal sonography

• MTX: methotrexate

Contents1. Definition

2. Classification

3. Epidemiology

5. Tubal Pregnancy

4. Risk Factors

6. Other Site of Ectopic Pregnancy

Definition

• “ektopos”=out of place• Implantation of blastocyst not in the endometrial lining of the uterine

cavity

Classification

• Ovarian ~

• Cornual ~

• Cervical ~

• Abdominal ~

• Ceasarean scar ~

• Heterotopic ~, etc.

Tubal pregnancy (95 ％ )

Epidemiology

• 2% of all early pregnancies

• 10% of repeat ectopic pregnancy

• 6% of all pregnancy-related deaths

• Mortality ratio in black 18 times higher than in

white women

Risk Factors

Tubal Pregnancy

Endings of tubal pregnancy

Rupture ： Isthmic, 12 ～ 16

wks

Abortion ： Ampullary, 8 ～ 12

wks

Secondary abdominal

pregnancy

Broad ligament pregnancy

Persistent ectopic

pregnancy

Clinical Manifestations Delayed menstruation

Vaginal bleeding or spotting

Abdominal & pelvic pain

Sharp, stabbing, or tearing

With vasomotor disturbance: vertigo to syncope

Tenderness

Pelvic mass: tender, boggy

Diaphragmatic irritation: pain in neck or shoulder

Often subtle or even absentBefore ruptureBefore rupture

Pain, bleeding, tendernessRuptureRupture

Symptoms and Signs Pain: 95%

Abnormal bleeding: 60-80%

Abdominal & pelvic tenderness

Uterine changes: pushed to one side,

enlarged

Vital signs: BP will fall, P will rise only

when hypovolemia

Laboratory Tests hCG: the rise over 48 hours ﹤ 66 ％

Progesterone: 5-10-25 ng/ml

Hemogram: decrease in hemoglobin or hematocrit

Sonography ： TVS

Culdocentesis

Uterine currettage

Laparoscopy / laparotomy

Arias-Stella reaction

Glands: closely packed , hypersecretory.Nuclei: large, hyperchromatic.

Laboratory Tests hCG: the rise over 48 hours 66﹤ ％

Progesterone: 5-10-25 ng/ml

Hemogram: decrease in hemoglobin or hematocrit

Sonography ： TVS

Culdocentesis

Uterine currettage

Laparoscopy / laparotomy

TVS Findings• Endometrial cavity

– Pseudogestational sac– Decidual cyst

• Adnexa– Extrauterine yolk sac or embryo: 15-30%– Adnexal mass: PPV 96%, NPV 95%

• Rectouterine cul-de-sac– Free peritoneal fluid

Caution in diagnosing an intrauterine pregnancy in the absence of definite yolk sac or embryo

The “ring of fire”

Discriminatory hCG

• Empty uterus w/ hCG > 1500 mIU/mL

– Ectopic pregnancy

– Nonliving uterine pregnancy

– Early multifetal gestation

• Serial assays of hCG, w/ serial TVS evaluation

– <66% increase within 48hr

– Empty uterus

Differential Diagnosis

Abortion

Pelvic inflammation disease

Appendicities

Rupture of corpus luteum

Torsion of ovarian cyst

Early diagnosis

allows definitive surgical or medical management

Treatment before rupture

Less morbidity, mortality, better prognosis for fertility

Surgical Management (1/3)

– Tubal patency following salpingostomy

– Subsequent uterine pregnancies

– Subsequent ectopic pregnancies

– Safety & cost: operative time, blood loss, analgesic

requirements, hospital stays

Laparoscopy vs Laparotomy

Longer OP time

Limitaion inManipulation

2-DimensionalImage

Expensive Eye-HandDiscrepancy

Less PainEarly recovery Smaller Scar Less Bleeding

Early return to work Less adhesionShort

Hospital Stay

Magnification of OP field

Advantage in Immunology

Surgical Management (2/3)

– Subsequent uterine pregnancies

– Persistent ectopic pregnancies

Indications for conservative surgery

< 3 cm in length

Unruptured

hCG < 3000 mIU/mL

Hemodynamically stable

Surgical Management (3/3)

– Salpingostomy

– Salpingotomy: suture the tubal incision

– Salpingectomy

– Cornual resection

Salpingostomy

Salpingotomy

Salpingectomy

Cornual Resection

Persistent Ectopic Pregnancy• Post-op day 1: hCG > 50% of the pre-op value

• Post-op day 12: hCG > 10% of the pre-op value

• Risk factors

– Small pregnancies: < 2 cm

– Early therapy: before 42 menstrual days

– hCG > 3000 mIU/mL

– Implantation medial to the salpingostomy site

• Additional surgical or medical therapy is necessary

Medical Management

• Indications

– Asymptomatic,

motivated,

compliant

– Mass ≤ 3.5 cm

– hCG ＜ 2000

mIU/mL

Contraindication Active intra-abdominal

hemorrhge

Intrauterine pregnancy

Breast feeding

Immunodeficiency,

alcoholism

Chronic hepatic, renal, or

pulmonary disease

Blood dyscrasias

Peptic ulcer disease

Methotrexate (MTX)

• Folic acid

antagonist

• Dose &

administration

Toxicity Liver: 12%

Stomatitis: 6%

Gastroenteritis: 1%

Failure rate: 1.5% (hCG <1000 mIU/mL)

14.3% (hCG > 5000 mIU/mL)

MTX Therapy

Monitoring Efficacy of Therapy• “15%, day 4 and 7 rule”• Weekly serum hCG determination until

undetectable• Resolution time

– Salpingostomy: 20 days– Single-dose MTX: 27-34 days

• Rupture of persistent ectopic pregnancy: 5-10%

The longest resolution time: 109 days

Tubal rupture can occur in the face of declining hCG.

Schematic of comparative patterns of serum-hCG level decline after single-dose methotrexate treatment or laparoscopic salpingostomy for unruptured ectopic pregnancy.

• Indications

– Tubal ectopic pregnancies only

– Decreasing serial hCG levels

– Mass ≤ 3.5 cm

– TVS: no intra-abdominal bleeding or rupture

Expectant treatment

Resolution rate:

hCG < 1000 mIU/mL: 50-

73%

hCG < 200 mIU/mL: 88%

Other Sites of Ectopic Pregnancies

Abdominal Pregnancy• Incidence: 1 in 85,000• Symptoms: vague,

nonspecific• Sonography, MRI: might

be helpful• Life threatening• Pre-op angiographic

embolization• Surgical termination

Ovarian Pregnancy• Symptoms: Mimic tubal pregnancy or a bleeding

corpus luteum

• Surgery:

– Ovarian wedge resection

– Cystectomy

– Ovariectomy

• MTX: if unruptured

Cervical Pregnancy

Incidence: 1 in 18,000 Clinical feature ： painless vaginal bleeding Treatment:

Cerclage Curretage and tamponade Arterial embolization

Laparoscopically assisted uterine artery ligation followed by hysteroscopic endocervial resection

MTX: 50-75 mg/m2

Sonographically guided fetal intracardiac injection of 2 mL KCl was added when needed

Intracervical Foley catheter was placed for 3 days

A. TVS of a cervical pregnancy. (1) an hourglass uterine shape and ballooned cervical canal; (2) gestational tissue at the level of the cervix (black arrow); (3) absent intrauterine gestational tissue (white arrows); (4) a portion of the endocervical canal seen interposed between the gestation and the

endometrial canal. B. In a transverse view of the cervical pregnancy, Doppler color flow shows abundant

vascularization. (From Dr. Elysia Moschos.)

Cesearean Scar Pregnancy Incidence: 1 in 2,000 Clinical presentation ：

Pain & bleeding Asymptomatic: 40%

Treatment: MTX Curretage Hysteroscopic resection Uterine-preserving rection Hysterectomy

A. TVS shows a uterus with CSP. An empty uterine cavity appearing as a bright hyperechoic endometrial stripe (long, white arrow); an empty cervical canal (short, white arrow); and an intracavitary mass seen in the anterior wall of the uterine isthmus (red arrows). (From Dr. Elysia Moschos.)

B. This hysterectomy specimen with a CSP is transversely sectioned at the level of the uterine isthmus and through the gestational sac.

(From Drs. Sunil Balgobin, Manisha Sharma, and Rebecca Stone.)

Heterotopic pregnancy

• A condition in which ectopic and intrauterine

pregnancies coexist.

• Incidence: 1 in 30 000.

Summary

Summary

Abortion

Contents1. Definition

2. Type of abortion

4. Diagnosis

3. Etiology

5. Management

Definition

Latin “Aboriri”-”to miscarry”

A pregnancy termination prior to

20 weeks of gestation, or with a

fetus born weighing < 500 g.

China: 28 wks, 1000g

Vary widely.

Type of Abortion

• Spontaneous abortion

Induced abortion

Septic abortion

• Recurrent spontaneous abortion: The loss of

more than three pregnancies before 20 weeks of

gestation

Type of Spontaneous AbortionThreatened ~:Vaginal bleeding before 20 weeks of gestation.

Inevitable ~: Uterine bleeding from a gestation of less than 20 weeks, accompanied by cervical dilation but without expulsion of placental or fetal tissue through the cervix.

Anembryonic gestation: An intrauterine sac without fetal tissue present at more than 7.5 weeks of gestation.

Incomplete ~: Expulsion of some but not all of the products of conception before 20 completed weeks of gestation.

Complete ~: Spontaneous expulsion of all fetal and placental tissue from the uterine cavity before 20 weeks of gestation.

Missed ~

Bleeding Abdominal Pain Tissue Expulsion

Cervical Os Uterus

Threatened Abortion

Inevitable Abortion

Incomplete Abortion

Complete Abortion

Light

Mild to heavy

Light to heavy

Light to none

None/light

Intensified

Relieved

None

None

None

Partial

Complete

Closed

Dilated

Dilated or obstructed

Closed

Normal

Normal or slightly small

Small

Normal or slightly large

Etiology Fetal factors

Maternal factors: Infections Chronic debilitating diseases Endocrine anomalies Uterine defects

Drug use and environmental factors

Paternal factors

Symptoms

Amenorrhea

Vaginal bleeding

Abdominal pain

Diagnosis

History & physical examination

Transvaginal ultrasonography

hCG

Serum progesterone

Differential Diagnosis• Cervical polyps

• Vaginitis

• Cervical carcinoma

• Gestational trophoblastic disease

• Ectopic pregnancy

• Trauma

• Foreign body

Management

• There is no effective therapy for a threatened

intrauterine pregnancy.

– Bed rest

– Progesterone? sedative?

• All patients with an incomplete abortion should undergo

suction curettage as quickly as possible.

• Genetic consulting

• Cervical cerclage

Abortion Techniques

A Hegar dilator. Note that the fourth and fifth fingers rest against the perineum and buttocks, lateral to the vagina.

A suction curette is simultaneously rotated 360° several times to remove tissue circumferentially from the uterine walls.

A sharp curette is held with the thumb and forefinger. In the upward movement of the curette, only the strength of these two fingers should be used.

When floated in saline, chorionic villi are often readily distinguishable as lacy fronds of tissue.

Regimens for Medical Termination of Early Pregnancy

aDoses of 200 versus 600 mg similarly effective.bOral route may be less effective and with more nausea and diarrhea. May be given sublingually, or buccally. Postprocedure pelvic infection significantly higher with vaginal versus oral route. Possibly more effective when given at 36-48 hours instead of at 6 hours.cEfficacy similar for routes of administration.dSimilar efficacy when given on day 3 versus day 5.

References• Williams Obstetrics, 23rd Edition

– Chapter 10. Ectopic Pregnancy

• Berek & Novak’s Gynecology, 14th Edition

• Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage. National Institute for Health and Clinical Excellence: Guidance. Editors: National Collaborating Centre for Women's and Children's Health (UK). Source: London: RCOG; 2012 Dec.

•

Quizs If a patient has documented cardiac activity in the ectopic, what

should be initiated, MTX or surgery ？ How to monitor hCG levels and evaluate transvaginal

ultrasound while instituting MTX ？ Does surgical management and medical therapy appear to be

equivalent ？ Summarize the management strategies for tubal pregnancy and

its indications. What conditions should be differentiated from abortion？

Which statement about ectopic pregnancy is true?

• Implantation of the fertilized egg outside the uterine cavity

• Rarely involves the fallopian tubes

• Usually associated with cervical carcinoma

• The most common site of involvement is the ovary

• Rarely a surgical emergency

THANK YOUXiaofang Yi, M.D.

Hospital of OB/GYN, Fudan

University

Email: [email protected]

Mobile: 15026585241