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ECTOPIC PREGNANCY

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ECTOPIC PREGNANCY

DEFINITION:
  • An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity.
  • The cause of fetal death in ectopic pregnancy is postulated as Vascular accident
  • In Interstitum part of fallopian tube  longest survival 

SITES OF IMPLANTATION:

TUBAL PREGNANCY:

ETIOLOGY:

  • Salpingitis and pelvic inflammatory disease (PID)
  • Genital tuberculosis

Iatrogenic:

  • Contraception failure(least with condom)
  • Tubal surgery
  • Intrapelvic adhesions
  • ART

Others:

  • Previous ectopic pregnancy
  • Prior induced abortion
  • Developmental defects of the tube
  • Transperitoneal migration of the ovum

RISK FACTORS:

  • History of PID
  • History of tubal ligation
  • Contraception failure
  • Previous ectopic pregnancy
  • Tubal reconstructive surgery
  • History of infertility
  • Calendar method
  • ART particularly if the tubes are patent but damaged
  • IUD (Progestasert)use
  • Previous induced abortion
  • Tubal endometriosis

MORBID ANATOMY:

CHANGES IN THE TUBE:

  • Implantation in in between two mucosal folds.

Decidual change:

  • Muscles undergo limited hyperplasia and hypertrophy
  • Blood vessels are engorged
  • Intramuscular implantation
  • Pseudocapsule
  • Blood vessels are eroded
  • Blood accumulates in between the blastocyst and the serous coat
  • Hemoperitoneum

CHANGES IN THE UTERUS:

  • Endometrium sloughs out causing uterine bleeding.
  • Decidual cast:decidua is expelled as a single piece through the cervix

CLINICAL FEATURES:

ACUTE ECTOPIC:

  • 30%
  • Associated with tubal rupture or tubal abortion

Classic triad of symptoms:

  • Abdominal pain (100%),
  • Preceded by amenorrhea (75%)
  • Appearance of vaginal bleeding (70%).
  • Amenorrhea:6–8 weeks
  • Abdominal pain
  • Shoulder tip pain (25%)
  • Vomiting, fainting attack.
  • Pallor
  • Features of shock
  • Abdominal examination:tense, tumid, tender
  • Pelvic examination
  • Vaginal mucosa—blanched white.
  • Extreme tenderness on fornix palpation
  • The uterus Floats as if in water
CHRONIC ECTOPIC:
  • Onset:insidious.

Symptoms:

  • Amenorrhea:6-8 weeks
  • Lower abdominal pain
  • Vaginal bleeding:scanty, sanguinous or dark-colored and continuous
  • Dysuria,
  • Rectal tenesmus
  • Rise of temperature
  • Pallor
  • Pulse persistently high
  • Features of shock are absent.

Abdominal examination:

  • Tenderness and muscle guard
  • A mass in the lower abdomen
  • Cullen‘s sign: Dark bluish discoloration around the umbilicus

Bimanual examination:

  • Uterus often incorporated in the mass occupying the pelvis
  • Extreme tenderness on movement of the cervix

DIAGNOSIS:

Blood examination:

  • Hemoglobin
  • ABO and Rh grouping
  • TLC & DLC
  • ESR
  • Culdocentesis
  • Estimation of ↑β-hCG

Sonography:

  • Transvaginal USG(Most sensitive)
  • Absence of intrauterine pregnancy with a positive pregnancy test.
  • Fluid (echogenic) in pouch of Douglas
  • Adnexal mass
  • Rarely cardiac motion

Color Doppler Sonography:

  • Ring-of-fire pattern
  • Enhanced blood flow pattern
  • Laparoscopy
  • D & C
  • Serum progesterone 
  • Laparotomy

MODE OF TERMINATION:
Tubal mole:
  • Repeated small hemorrhages in the choriocapsular space

The fate of the mole:

  • Complete absorption
  • Expulsion through abdominal ostium as tubal abortion

Tubal abortion:

  • If implantation occurs in ampulla or infundibulum

Tubal rupture:

  • common in isthmic and interstitial implantation
  • Isthmic rupture usually occurs at 6–8 weeks
  • The ampullary one at 8–12 weeks 
  • The interstitial one at about 4 months

Intraperitoneal rupture:

    • Common.
    • Rent is situated on the roof or sides 
    • Bleeding is intraperitoneal

Extra-peritoneal rupture (intraligamentary):

    • Rent lies on the floor
    • Isthmic implantation

Arias-Stella reaction:

  • Typical adenomatous change of the endometrial glands
  • Loss of polarity of cells
  • Pleomorphism 
  • Hyperchromatic nuclei
  • Vacuolated cytoplasm
  • Occasional mitosis
  • Intraluminal budding
  • Progesterone influence

MANAGEMENT:
ACUTE:

Antishock treatment:

  • Ringer’s solution
  • Blood transfusion & laparotomy
  • Laparoscopy :Decreased hospital stays

Laparotomy:

  • Patient hemodynamically unstable
  • Laparoscopy contraindicated
  • Evidence of rupture

Steps:

  • Abdomen is opened by infraumbilical longitudinal incision
  • To grasp the uterus and draw it up under vision
  • Salpingectomy
  • Ipsilateral ovary and its vascular supply is preserved
  • Place of subtotal hysterectomy
CHRONIC ECTOPIC:
  • Laparotomy
UNRUPTURED TUBAL PREGNANCY:
Expectant management:Indications
  • Initial serum hCG level less than 1,000 IU/L
  • Gestation sac size less than 4 cm
  • No fetal heart beat
  • No evidence of bleeding

Conservative management:

  • Medical management:Conservative Surgery:laparoscopically or by microsurgical laparotomy.
  • hCG level is less than 10,000 IU/L & size < 4 cms
  • The drugs commonly used for salpingocentesis are
  • Methotrexate, potassium chloride,Actinomycin D, prostaglandin(PGF2α), hyperosmolar glucose
  • Linear Salpingostomy(nulliparous woman)
  • Linear Salpingotomy
  • Segmental Resection
  • Fimbrial Expression
  • Salpingectomy

Exam Important

  • The commonest complication of pregnancy after complete treatment of genital tuberculosis is Ectopic pregnancy
  • Ectopic pregnancy is a reported complication of calendar method
  • IUCD with highest incidence of ectopic pregnancy is Progestasert
  • Condoms  has the least risk of ectopic pregnancy
  •  In comparing laparoscopic salpingostomy vs. laparotomy with salpingectomy for the treatment of ectopic pregnancy, laparoscopic therapy results in Decreased hospital stays
  • Most sensitive diagnosis test for ectopic pregnancy Transvaginal USG
  • The cause of fetal death in ectopic pregnancy is postulated as Vascular accident
  • Hormone responsible for decidual reaction and Arias stella reaction in ectopic pregnancy is  Progesterone
  • Medical treatment of ectopic pregnancy should be offered to those patients whose hCG level is less than 10,000  IU/L and the size of the mass is less than 4 cms
  • 6 weeks of amenorrhoea p,pain in abdomen; USG shows fluid In pouch of douglas. Aspiration yields dark color blood that fails to clot. Most probable diagnosis is Ruptured ectopic pregnancy
  • Acute abdominal pain , prolong amenorrhoea with collection of fluid in the pouch of douglas and empty gestational sac are suggestive of  ectopic pregnancy
  • Ectopic pregnancy is most commonly associated with Tubal inflammatory diseases
  • Most common manifestation of ectopic pregnancy is  Pain abdomen
  • In Interstitum part of fallopian tube ectopic pregnancy will have longest survival 
  • Ectopic pregnancy Associated with decidual reaction
  • In ectopic interstitial ring sign is seen
  • Potassium Chloride, Methotrexate & Actinomycin D are used in medi­cal management of ectopic pregnancy
  • In Presence of fetal heart activity the medical treatment of Ectopic pregnancy is contraindicated
  • Salpingo-oophorectomy  is not done in ectopic pregnancy 
  • In a nulliparous woman, the treatment of choice in ruptured ectopic pregnancy is Linear salpingostomy
  • Ectopic pregnancy differs from threatened abortion by  that it Manifests at an early age
  • Commonest cause of ectopic pregnancy is Previous salpingitis
  • Causes of ectopic pregnancy includes IUCD, & Tubal ciliary damage
  • Commonest site of ectopic pregnancy is tube
  • Commonest type of ectopic pregnancy with rupture is Isthmic
  • In a young patient with abdominal pain and fea­ture most suggestive of ectopic pregnancy is  Increase beta HCG in urine
  • The most consistent sign in disturbed ectopic pregnancy is Vaginal bleeding
  • The expelled products in ectopic pregnancy originate from  Decidua vera
  • Pathognomonic of ectopic pregnancy is  Decidual casts
  • Best endometrial reaction In ectopic pregnancy is Decidual reaction without chorionic villi
  • Medical treatment of ectopic pregnancy is methotrexate
  • Absolute contraindication to intra-uterine device is History of ectopic pregnancy
  • Ectopic pregnancy is commonest in ampulla of fallopian tube
  • Ectopic pregnancy can be ruled out on ultrasound by Finding foetus in uterus
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