DR. JOHARA AL-MUTAWADR. JOHARA AL-MUTAWA

Asst. Prof. & ConsultantAsst. Prof. & Consultant

Obstetrics & Gynecology Obstetrics & Gynecology DepartmentDepartment

Definition:Definition: Implantation outside uterine cavityImplantation outside uterine cavity Most common site is within fallopian tube Most common site is within fallopian tube

98%, in the distal ampulla than in the 98%, in the distal ampulla than in the proximal isthmus, followed by corneal 2% proximal isthmus, followed by corneal 2% and abdominal1.4%, ovarian 0.15% and and abdominal1.4%, ovarian 0.15% and cervical os 0.15%cervical os 0.15%

Incidence: I in 100 of all pregnancies and Incidence: I in 100 of all pregnancies and to 1 in 30 in high risk population arising in to 1 in 30 in high risk population arising in the west in parallel with the west in parallel with number of number of cases of chlamydia infectioncases of chlamydia infection

Risk Factor for Ectopic PregnancyRisk Factor for Ectopic Pregnancy Previous PID – chlamydia infectionPrevious PID – chlamydia infection Previous ectopic pregnancyPrevious ectopic pregnancy Tubal ligationTubal ligation Previous tubal surgeryPrevious tubal surgery Intrauterine deviceIntrauterine device Prolonged infertilityProlonged infertility Diethylstilbestrol (DES) exposure in-uteroDiethylstilbestrol (DES) exposure in-utero Multiple sexual partnersMultiple sexual partners

THE OUTCOME OF ECTOPIC PREGNANCYTHE OUTCOME OF ECTOPIC PREGNANCY The muscle wall of the tube has not the capacity The muscle wall of the tube has not the capacity

of uterine muscles for hypertrophy and of uterine muscles for hypertrophy and distention and tubal pregnancy nearly always distention and tubal pregnancy nearly always end in rupture and the death of the ovum.end in rupture and the death of the ovum.

Tubal abortion – usually in ampullary about 8 Tubal abortion – usually in ampullary about 8 weeks – forming pelvic haematoceleweeks – forming pelvic haematocele

Rupture into the peritoneal cavityRupture into the peritoneal cavity Occur mainly from the narrow isthmus before 8 Occur mainly from the narrow isthmus before 8

weeks or later from the interstitial portion of the weeks or later from the interstitial portion of the tube. Haemorrhage is likely to be severe.tube. Haemorrhage is likely to be severe.

Sometimes rupture is extraperitoneal between the Sometimes rupture is extraperitoneal between the leaves of the broad ligament – Broad ligament leaves of the broad ligament – Broad ligament haematoma. Haemorrhage is likely to be controlledhaematoma. Haemorrhage is likely to be controlled

Tubal pregnancy – effect on uterusTubal pregnancy – effect on uterus

The uterus enlarge in first 3 months as if the The uterus enlarge in first 3 months as if the implantation were normal, reach the size of a implantation were normal, reach the size of a gravid uterus of the same maturity.gravid uterus of the same maturity.

Uterine decidua grows abundantly and when Uterine decidua grows abundantly and when the embryo dies bleeding occurs as the decidua the embryo dies bleeding occurs as the decidua degenerates due to effect of oestrogen degenerates due to effect of oestrogen withdrawal.withdrawal.

Clinical Finding: Variable - Early diagnosisVariable - Early diagnosis

- location of the implantation- location of the implantation - Whether rupture has occurred- Whether rupture has occurred

Classic symptom trait with unruptured ectopic Classic symptom trait with unruptured ectopic pregnancy:pregnancy:

Amenorrhoea, abdominal pain, abnromal Amenorrhoea, abdominal pain, abnromal vagina bleedingvagina bleeding

Classic signs – adnexal or cervical Classic signs – adnexal or cervical motion motion

tenderness.tenderness. With ruptured ectopic pregnancy, finding parallel With ruptured ectopic pregnancy, finding parallel

with the degree of internal bleeding and with the degree of internal bleeding and hypovolemia – abdominal guarding and rigidity, hypovolemia – abdominal guarding and rigidity, shoulder pain and fainting attacks and shock.shoulder pain and fainting attacks and shock.

Symptoms and Signs:Symptoms and Signs: Pain Pain – constant– constant

- Cramp-like- Cramp-like- It may be referred to the shoulder if blood tracks to It may be referred to the shoulder if blood tracks to

the diaphragm and stimulate the phernic nerve and it the diaphragm and stimulate the phernic nerve and it may be severe as to cause fainting.may be severe as to cause fainting.

- The pain caused by the distension of the gravid tube The pain caused by the distension of the gravid tube by its effort to contract and expel the ovum and by by its effort to contract and expel the ovum and by irritation of the peritoneum, by leakage of blood.irritation of the peritoneum, by leakage of blood.

- Vaginal bleeding – occur usually after death of the Vaginal bleeding – occur usually after death of the ovum and is an effect of oestrogen withdrawal. It is ovum and is an effect of oestrogen withdrawal. It is dark, scanty and its irregularity may lead the patient dark, scanty and its irregularity may lead the patient to confuse it with the menstrual flow and give to confuse it with the menstrual flow and give misleading history. misleading history.

25% of cases presents without any vaginal bleeding25% of cases presents without any vaginal bleeding

Cont.Cont.- Internal blood loss – severe and rapid. The usual sign Internal blood loss – severe and rapid. The usual sign

of collapse and chock and it is less common than the of collapse and chock and it is less common than the condition presenting by slow trickle of blood into the condition presenting by slow trickle of blood into the pelvic cavity.pelvic cavity.

- Peritoneal irritation – muscle guardingPeritoneal irritation – muscle guarding - frequency of micturation- frequency of micturation - fever- fever

- misleading of appendicitis- misleading of appendicitis- Pelvic examination – extreme tendernessPelvic examination – extreme tenderness

- cystic mass may be felt- cystic mass may be felt- Abdominal - tenderness in one or other fossa.Abdominal - tenderness in one or other fossa.

- General tenderness and resistance to palpation over whole General tenderness and resistance to palpation over whole abdomen.abdomen.

Differential diagnosis:Differential diagnosis:1.1. SalpingitisSalpingitis

2.2. AbortionAbortion

3.3. AppendecitisAppendecitis

4.4. Torsion of pedicle of ovarian cystTorsion of pedicle of ovarian cyst

5.5. Rupture of corpus luteum or follicular cystRupture of corpus luteum or follicular cyst

6.6. Perforation of peptic ulcer.Perforation of peptic ulcer.

Diagnosis:Diagnosis:-- Careful history about LMP its timing and Careful history about LMP its timing and appearance.appearance.-- Always think of tubal pregnancy women with Always think of tubal pregnancy women with lower abdomen pain in whom there is possibility lower abdomen pain in whom there is possibility of of pregnancy should be regarded as having an pregnancy should be regarded as having an ectopic ectopic until proved otherwise.until proved otherwise.

-- Pregnancy test nearly always be found by the Pregnancy test nearly always be found by the time time of clinical presentation.of clinical presentation.-- Ultrasound to exclude intrauterine pregnancyUltrasound to exclude intrauterine pregnancy-- Laparoscopy: for identifying an unruptured tubal Laparoscopy: for identifying an unruptured tubal

pregnancy which is producing equivocal pregnancy which is producing equivocal symptoms and for exclude salpingitis and symptoms and for exclude salpingitis and bleeding bleeding from small ovarian cyst.from small ovarian cyst.-- For operative treatment using minimally invasive For operative treatment using minimally invasive

methods.methods.

Treatment:Treatment: If haemorrhage and shock presentIf haemorrhage and shock present

Restore blood volume by the transfusion of red cells or Restore blood volume by the transfusion of red cells or volume expandervolume expander

Proceed with LaparotomyProceed with Laparotomy The earlier diagnosis of tubal pregnancy has The earlier diagnosis of tubal pregnancy has

allowed a more conservative approach to allowed a more conservative approach to management where the tube is less damage.management where the tube is less damage.

Pregnancy removed from the tube by laparoscopy Pregnancy removed from the tube by laparoscopy (salpingostomy) hopefully retaining tubal function.(salpingostomy) hopefully retaining tubal function.

Trophoblast destroyed by chemotherapeutic agent such Trophoblast destroyed by chemotherapeutic agent such as methotrexateas methotrexate

DIAGNOSIS:DIAGNOSIS: BHCG levelBHCG level TVUTVU

Medical ManagmentMedical Managment Methotrexate 1 mg/kg body weightMethotrexate 1 mg/kg body weight

Indicationss:Indicationss: Haemodynamically stable, no active bleeding, No Haemodynamically stable, no active bleeding, No

haemoperitneum, minimal bleeding and no painhaemoperitneum, minimal bleeding and no pain No contra indication to methotrexateNo contra indication to methotrexate Able to return for follow up for several weeksAble to return for follow up for several weeks Non laparoscopic diagnosis of ectopic pregnancyNon laparoscopic diagnosis of ectopic pregnancy General anaesthesia poses a significant riskGeneral anaesthesia poses a significant risk Unruptured adenexal mass < 4cm in size by scanUnruptured adenexal mass < 4cm in size by scan No cardiac activity by scanNo cardiac activity by scan

HCG does not exceed 5000 IU/LHCG does not exceed 5000 IU/L Contraindications:Contraindications:

BreastfeedingBreastfeeding Immunodeficiency / active infectionImmunodeficiency / active infection Chronic liver diseaseChronic liver disease Active pulmonary diseaseActive pulmonary disease Active peptic ulcer or colitisActive peptic ulcer or colitis Blood disorderBlood disorder Hepatic, Renal or Haematological Hepatic, Renal or Haematological

dysfunctiondysfunction

Side Effects:Side Effects: Nausea & VomitingNausea & Vomiting StomatitisStomatitis Diarrhea, abdominal painDiarrhea, abdominal pain Photosensitivity skin reactionPhotosensitivity skin reaction Impaired liver function, reversibleImpaired liver function, reversible PneumoniaPneumonia Severe neutropeniaSevere neutropenia Reversible alopeciaReversible alopecia Haematosalpinx and haematocelesHaematosalpinx and haematoceles

Treatment Effects:Treatment Effects: Abdominal pain (2/3 of patient)Abdominal pain (2/3 of patient) HCG during first 3 days of treatmentHCG during first 3 days of treatment Vaginal bleedingVaginal bleeding

Signs and Treatment failure and tubal Signs and Treatment failure and tubal rupture:rupture: Significantly worsening abdominal pain, Significantly worsening abdominal pain,

regardless of change in serum HCG (Check CBC)regardless of change in serum HCG (Check CBC) Haemodynamic instabilityHaemodynamic instability Level of HCG do not decline by at least 15% Level of HCG do not decline by at least 15%

between Day 4 & 7 post treatmentbetween Day 4 & 7 post treatment or plateauing HCG level after first week of or plateauing HCG level after first week of

treatmenttreatment

Follow-Up:Follow-Up: Repeat HCG on Day 5 post injection if <15 % Repeat HCG on Day 5 post injection if <15 %

decrease – consider repeat dosedecrease – consider repeat dose If BHCG >15 If BHCG >15 recheck weekly until <25 ul/l recheck weekly until <25 ul/l Surgery should also considered in all women Surgery should also considered in all women

presenting with pain in the first few days presenting with pain in the first few days after methotrexate and careful clinical after methotrexate and careful clinical assessment is required. If these is assessment is required. If these is significant doubt surgery is the safest optionsignificant doubt surgery is the safest option

SURGICAL MANAGEMENT:SURGICAL MANAGEMENT: Laparoscopy approach – salpingostomuyLaparoscopy approach – salpingostomuy Laprotomy – salpingostomyLaprotomy – salpingostomy

salpingectomysalpingectomy

1. Positive pregnancy test

Lowe abdominal pain +Minimal Vaginal bleeding

Asymptomatic with factorsfor ectopic pregnancy

Risk factorsPrevious ectopic pregnancyPrevious PIDTubal surgeryTubal SurgeryTubal pathology (PID, endometriosisInfertility, ovarian stimulationIUCD failureSterilization failurePrevious abdominal surgeryDES exposure in uteroMultiple sexual partners

2. History + clinical examination

MANAGEMENT OF ECTOPIC PREGNANCY

If sure of date of LMP and /or Regular cycle, i.e. >6 wks. gestation,

Arrange TV ultrasound

If unsure of date of LMP and /or irregular cycle,Measure serum hCG

If hCG <100 (?early Intrauterine/? Ectopic pregnancy

If Hcg >1000, useprotocol forsuspected

Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000

Meet criteria for Methorexate treatment

Does not meet criteria for methotrexate treatment

Use methotrexateprotocol

Laproscopic /salpingotomy/Salpingectomy ?Proceed to

laparotomy OR Laparotomy if haemodynamically unstable