Ectopic Pregnancy

ECTOPIC PREGNANCY

Definition An ectopic pregnancy or extrauterine pregnancy is one in which a fertilized ovum (the zygote) implants in an area outside the uterine cavity.

INCIDENCE Between 0.20% and 1.4% of all pregnancies Incidence of ectopic pregnancy is increasing worldwide Here in UPTH, we probably see a ruptured ectopic, pregnancy every week Combined intra & extrauterine pregnancy (Heterotropic Pregnancy) 1:17 – 30,000 pregnancy

SITES 99% of ectopic pregnancy occur in the fallopian tubes 55% at the ampulla 25% at the isthmus 17% at the Fimbriae 2% at the interstitium 1% at the corna, ovary, peritoneum, cervix

AETIOLOGY The primary causes of ectopic pregnancy include conditions that either prevent or impede passage of a fertilized ovum through the fallopian tube. Tubal factors PID, STD, Surgery Developmental abnormalities of the tubes – congenital diverticula, accessory ostia or atresia – abnormal tubal anatomy due to exposure to diethylstilbestrol (DES) exposure in utero – endometriosis, Tortuosity of tube

AETIOLOGY cont.  Zygote abnormalities Sperm abnormalities

 Ovarian factors Fertilization of an unextruded ovum Transmigration of an ovum

 Other factors • • •

IUCD (2 in 1000 IUD cases) (1 in 8 being primary ovarian pregnancy) Endometriosis IVF ET

PATHOLOGY Trophoblast implants may invade tubal musculature to grow The wall becomes very thin and eventually ruptures Growth may be predominantly intraluminal Penetration of tubal blood vessel, haemorrhage and separation of the product of conception from the implantation site Leads to embryonal death, cessation of trophoblastic activity and tubal abortion An abdominal pregnancy is very rare (1 per 15000 pregnancies) May be secondary to tubal rupture or abortion with trophoblast maintaining its tubal attachment or the entire ovum implanting again at another site

CLINICAL FEATURES Ectopic pregnancy remains the great mimic of gynaecology No specific symptoms or signs are pathognomonic of ectopic pregnancy There should be a high index of suspicion patient may experience fainting attack, shoulder tip pain and symptoms and signs of blood loss

SYMPTOMS AND SIGNS Abdominal pain(99% of cases)

– may be present even prior to rupture – Extensive intraperitoneal bleeding – decidual cast passed per vaginam will mimic products of conception as in abortion – Syncopy or fainting, collapse is present in 37% of cases

Evidence of blood loss.

Pulse

Bp

Abdominal tenderness present in 80% of cases If ruptured with haemoperitineum, rebound tenderness, fluid in peritoneum Adnexal tenderness on VE. Fullness of POD Adnexal mass if unruptured Bimanual exam should be gentle Fever is unusual and occurs in only 2%

INVESTIGATIONS Hb + Pregnancy Test Culdocentesis USS Laparoscopy

• very useful in unruptured and ruptured ectopic pregnancy • Rule out differentiate diagnosis.

D&C Exploratory laparotomy Quantitative HcG Transvaginal ultrasound scan

DIFFERENTIAL DIAGNOSIS Ruptured or twisted ovarian cyst acute PID and tubovarian abscess Mittleschmerz Abortion Ruptured corpus luteum cyst Appendicitis

COMPLICATION If untreated or missed diagnosis; – Maternal death – Majority of these death are preventable 1:1000 ectopic. – Infertility or sterility may follow surgery for extrauterine pregnancy.

TREATMENT Emergency treatment If there is evidence of haemoperitoneum with clinical shock, Bp, pulse following rupture, there is little room for delay Withdraw blood for Hb and crossmatch immediately and set up a plama expander to correct shock Take patient to theatre for a laparotomy – – – –

Salpingostomy Milking Salpingectomy end/end anastomosis

TREATMENT cont. Autotrasfusion using the patients own citrated and filtered blood

Other Surgical Techniques Through Laparoscopy Aspiration End/end anastomosis Salpingostomy Fetocide injectionMethotrexate KCL PG E2 or F2 & Mifepristone

TREATMENT cont. Medical Treatment Systemic Methotrexate Response must be monitored with 48 hourly HCG determinations and TVS –

Ru 486 mifepostone, Actinomycin D

TREATMENT cont. RADICAL OR CONSERVATIVE Conservation •Funbrial evacuation •Linear Salpingostomy •Mid-tubal resection

Radial Surgery •Salpingectomy •Oophorectomy •Cornual resection

PROGNOSIS Another ectopic pregnancy will occur in 10 – 28% of patients treated. 50% of patient treated may have infertility.

SUMMARY Common life threatening emergency in gynae. Incidence is increasing. High index of suspicious in our practice: Commonly ruptured ectopic present in our casualty. Commonly diagnosed unruptured ectopic in Western world therefore a move to more conservative surgery. Diagnosis by quantitative HCG + TVS with laparoscopy.