Ectopic

ADVANCES IN THE MANAGEMENT OF ECTOPIC PREGNANCY

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

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INCIDENCE >1 in 100 pregnancies. • Recent evidence indicates 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 07/12/08 23:28

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HISTORY • Ectopic pregnancy was first described in 963 Ad by Albucasis. • 1884 -- Robert Lawson Tait of Birmingham performed the first successful Salpingectomy operation • 1953 -- Stromme – Conservative surgery of Salpingostomy • 1973 -- Shapiro & Adller – Laparoscopic Salpingectomy • 1991 -- Young et al – Laparoscopic Salpingotomy 07/12/08 23:28

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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.

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AETIOLOGY

• CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis • ACQUIRED – Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (lntraluminal adhesion) – Surgical: Tubal reconstructive surgery, Recanalisation of tubes – Neoplastic: Broad ligament myoma, Ovarian tumour – Miscellaneous Causes: IUCD , Endometriosis, ART (IVF & & GIFT), Previous ectopic 07/12/08 23:28

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SITES OF ECTOPIC PREGNANCY

Abdomen (< 2%) Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Cervix (< 2%) 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 07/12/08 23:28

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CLINICAL PRESENTATION • Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic • SYMPTOMS– – – – –

Amenorrhea Abdominal Pain Syncope Vaginal Bleeding Pelvic Mass

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DIAGNOSIS

“Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it.” --Mc. Fadyen - 1981 07/12/08 23:28

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DIAGNOSIS

• In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate. • This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease. • This has resulted in early diagnosis and effective treatment. • Now the rate of tubal rupture is as low as 20%. 07/12/08 23:28

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METHODS OF EARLY DIAGNOSIS

• Immunoassay utilising monoclonal antibodies to beta HCG • Ultrasound scanning – Abdominal & Vaginal including Colour Doppler • Laparoscopy • Serum progesterone estimation not helpful

A combination of these methods may have to be employed. 07/12/08 23:28

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METHODS OF EARLY DIAGNOSIS At 4-5 weeks• TVS can visualise a gestational sac as early as 4-5 weeks from LMP. • During this time the lowest serum beta HCG is 2000 IU/Lt. • When beta HCG level is greater than this and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected. • In such a situation, when the value of beta HCG does not double in 48 hours ectopic pregnancy will be confirmed. 07/12/08 23:28

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METHODS OF EARLY DIAGNOSIS The USG features of ectopic pregnancy after 5 weeks can be any of the following• Demonstration of the gestational sac with or without a live embryo (Begel’s sign) - The GS appears as an intact well defined tubal ring by 6 weeks when it measures 5 mm in diameter. Afterwards it can be seen as a complete sonolucent sac with the yolk sac and the embryonic pole with or without heart activity inside. 07/12/08 23:28

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METHODS OF EARLY DIAGNOSIS The USG features of ectopic pregnancy after 5 weeks can be any of the following1. Poorly defined tubal ring possibly containing echogenic structure and POD typically containing fluid or blood. 2. Ruptured ectopic with fluid in the POD and an empty uterus. 3. In Colour Doppler, the vascular colour in a characteristic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow 07/12/08 23:28

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MANAGEMENT

• Depends on the stage of the disease and the condition of the patient at diagnosis. • Options– Surgery – Laparoscopy / Laparotomy – Medical – Administration of drugs at the site / systemically – Expectant – Observation 07/12/08 23:28

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

• Hospitalisation • Resuscitation – Treatment of shock – Lie flat with the leg end raised – Analgesics – Blood transfusion 07/12/08 23:28

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

Culdocentesis: • Most Helpful in Emergent Situations to Confirm Diagnosis • Highly Specific if performed and Interpreted Correctly: - Presence of FreeFlowing, NON-Clotting Blood • Negative Tap Inconclusive • Remains Controversial

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY • Laparotomy should be done at the earliest. • Salpingectomy is the definitive treatment. • No benefit from removing Ovary along with the tube

• If blood is not available, auto-transfusion can be done. 07/12/08 23:28

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MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY INVESTIGATIONS-

• Laboratory/Chemical test – – Serial quantitative beta HCG level by RIA – Serum progesterone level (<5 mg/ml in ectopic pregnancy) – Low levels of Trophoblastic proteins such as SPI and PAPP-, Placental protein 14 & 12

• USG- usually haematocele is found • Laparoscopy

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MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY TREATMENT – ALWAYS SURGICAL

• Salpingectomy of the offending tube • If pelvic haematocele is infected, posterior. colpotomy is to be done to drain the pelvic abscess • Salpingo-oophorectomy 07/12/08 23:28

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MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY OPTIONS: • SURGICAL• SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT • MEDICAL TREATMENT • EXPECTANT MANAGEMENT 07/12/08 23:28

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SURGICAL TREATMENT OF ECTOPIC PREGNANCY • Carried out either by Laparoscopy / Laparotomy. • The procedures are: – Salpingectomy / Cornual resection / Excision – Conservative surgery (in cases of Infertility & desire for pregnancy) • Linear salpingostomy • Linear salpingotomy • Segmental resection and anastomosis • Milking of the tube 07/12/08 23:28

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SURGICAL TREATMENT OF ECTOPIC PREGNANCY The debate goes on LAPAROTOMY? VS. LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY? 07/12/08 23:28

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COMPARING LAPAROTOMY Vs LAPAROSCOPY

Hospital cost Post operative adhesions Risk of future ectopic Future fertility Experience of Surgeon Instruments

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L’tomy More? More Same Same Trained General

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L’scopy Less? Less Same Same Special Special

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SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY

 All tubal pregnancies can be treated by partial or total Salpingectomy  Salpingostomy / Salpingotomy is only indicated when: 1. The patient desires to conserve her fertility 2. Patient is hemodynamically stable 3. Tubal pregnancy is accessible 4. Unruptured and < 5Cm. In size 5. Contralateral tube is absent or damaged 07/12/08 23:28

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SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY

 The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment  Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy. 07/12/08 23:28

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SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY • • • • • • • •

Fertility reducing factor Antecedent one Ectopic pregnancy Antecedent each further Ectopic pregnancy Antecedent Adhesiolysis Antecedent Tubal micro surgery Antecedent Salpingitis Solitary tube Homolateral Adhesions Contralateral Adhesions

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SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY

• The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy. • Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more. 07/12/08 23:28

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LAPAROSCOPIC SALPINGECTOMY • It is carried out by laparoscopic scissors and diathermy or Endo-loop. • After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch. • The excised tissue is removed by piece meal or in a tissue removal bag. 07/12/08 23:28

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LAPAROSCOPIC SALPINGOTOMY • To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal saline is injected into the mesosalpinx. • Then the tube is opened through an antimesenteric longitudinal incision over the tubal pregnancy by a Co2 laser (Paulson, 1992) – Argon laser (Keckstein et al; 1992) – Laparoscopic scissors and ablating the bleeding points with bipolar diathermy. – Fine diathermy knife (Lundorff, 1992) 07/12/08 23:28 Ectopic Pregnancy 30

LAPAROSCOPIC SALPINGOTOMY

• The tubal pregnancy is then evacuated by suction irrigation. • Hemostasis of the trophpblastic bed is ensured. • The tubal incision is left open.

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PERSISTENT ECTOPIC PREGNANCY (PEP) • This is a complication of salpingotomy / Salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy. • Diagnosis is made because of a raised postoperative serum HCG • If untreated, can cause life threatening haemorrhage 07/12/08 23:28

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PERSISTENT ECTOPIC PREGNANCY (PEP) • TREATMENT is by– Reoperation and further evacuation / Salpingectomy – Administration of IM / oral Methtrexate in a single dose of 50 mg/m2 of body surface

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SAM TREATMENT • Aim- trophoblastic destruction without systemic side effects • Technique- Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by– Laparoscopy or – Ultrasonographically guided • Transabdominal (Porreco, 1992) • Transvaginal (Feichtingar, 1987)

– With Falloposcopic control (Kiss, 1993) 07/12/08 23:28

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SAM TREATMENT • Trophotoxic substances used– Methtrexate (Pansky, 1989) – Potassium Chloride (Robertson, 1987) – Mifiprostone (RU 486) – PGF2α (Limblom, 1987) – Hyper osmolar glucose solution – Actinomycin D 07/12/08 23:28

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MEDICAL TREATMENT WITH METHOTREXATE • Resolution of tubal pregnancy by systemic administration of Methotrexate was first described by Tanaka et al (1982) • Mostly used for early resolution of placental tissue in abdominal pregnancy. Can be used for tubal pregnancy as well • Mechanism of action- Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the trophoblast. 07/12/08 23:28

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MEDICAL TREATMENT WITH METHOTREXATE • Ectopic pregnancy size should be < 3.5 cm. • Can be given IV/IM/Oral, usually along with Folinic acid • Recent concept is to give Methtrexate IM in a single dose of 50mg/m2 without Folinic acid. • If serum HCG does not fall to 15% with in 4-7 days, then a second dose of Methtrexate is given and resolution confirmed by HCG estimation 07/12/08 23:28

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MEDICAL TREATMENT WITH METHOTREXATE • Advantages – – Minimal Hospitalisation.Usually outdoor treatment – Quick recovery – 90% success if cases are properly selected

• Disadvantages– Side effects like GI & Skin – Monitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative 07/12/08 23:28

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EXPECTANT TREATMENT

• Tubal Pregnancies are known to Abort / Resolve • Befor the advent of salpingectomy in 1884, ectopic pregnancies were being treated expectantly with 70% mortality. • Today only selected cases are managed expectantly, screened and identified by high resolution ultrasound scanner and monitored by serial serum HCG assay 07/12/08 23:28

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EXPECTANT TREATMENT

• Identification criteria (Ylostalo et al , 1993)– – – – –

Diameter of ectopic pregnancy <4 Cm. No sign of intrauterine pregnancy No sign of rupture by TVS No sign of acute bleeding by TVS Falling level of serum HCG at 2 day intervals

• If any deviation from the above criteria occurs, then emergency treatment is necessary. 07/12/08 23:28

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EXPECTANT TREATMENT • Spontaneous resolution occurs in 72%,while 28% will need laparoscopic salpingostomy • In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant level. • The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2. • Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low. 07/12/08 23:28

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SUMMARY - KEY POINTS • Incidence of ectopic pregnancy is rising while maternal mortality from it is falling. • Early diagnosis is the key to less invasive treatment. • The choice today is Laparoscopic treatment of unruptured ectopic pregnancy. • The trend is towards conservative treatment. • Careful monitoring and proper counselling of patients is mandatory. • Ruptured ectopics should be unusual with compliant patients and appropriate medical care. 07/12/08 23:28

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