Ectopicpreg

SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY

Ectopic Pregnancy In normal pregnancy, the blastocyst (fertilized ovum) implants in the endometrial lining of the uterine cavity ECTOPIC: Implantation of the blastocyst outside the uterine cavity

Risk Factors High:

Tubal corrective surgery, tubal sterilization, previous ectopic, in utero DES exposure, Intrauterine device, tubal pathology Moderate: Infertility, previous genital infection, multiple partners Slight: Previous pelvic/abdominal surgery, smoking, douching, intercourse prior to 18 years of age

Epidemiology  2% of all pregnancies each year in the Unites States  Increasing incidence due to:  Increasing prevalence of STIs  Early diagnosis  Contraception that predisposes failures to be ectopic  Use of tubal sterilization techniques  Use of assisted reproductive techniques  Tubal surgery (salpingotomy, tuboplasty) Commonest cause of maternal mortality within the 1st trimester  Overall incidence in non-white women is 1.4 times higher

than in Caucasian women

Female Pelvic Anatomy

Types of Ectopic Pregnancy Abdominal (0.1%) implantation within the peritoneal cavity (can occur secondary to tubal pregnancy)

Cervical Vaginal Angular: A gestation that extends beyond the interstitium into the adjacent uterine cavity

Broad ligament

Interstitial: gestation implants in the interstitial portion of the fallopian tube.

Tubal Pregnancy 

Commonest site of ectopic pregnancy (99%)

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The ampulla is the most frequent location of implantation (64%) Symptoms: Onset occurs ~7 weeks after LMP Abdominal pain Vaginal bleeding Signs: Abdominal tenderness (91%) 1st trimester bleeding (79%) Common associated findings: Adnexal tenderness (54%) , Amenorrhea Early pregnancy symptoms Cullen’s sign (Periumbilical bruising) Nausea, vomiting, diarrhea, dizziness

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Other Signs: Tachycardia, Low grade fever Chadwick’s sign (cervix and vaginal cyanosis) Hegar’s sign (softened uterine isthmus) Hypoactive bowel sounds Cervical Motion Tenderness Enlarged uterus Tender pelvic or adnexal mass Cul-de-sac fullness Decidual cast (Passage of decidua in one piece) Signs suggestive of ruptured ectopic pregnancy:  Usually between 6 and 12 weeks gestation  Severe abdominal tenderness with rebound, guarding  Orthostatic hypotension         

Differential Diagnosis 

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Appendicitis Threatened Abortion Ruptured ovarian cyst PID Salpingitis Endometritis Nephrolithiasis Ovarian torsion Intrauterine pregnancy Alternative diagnoses: o o o o o

Dysmenorrhea Dysfunctional uterine bleed UTI Diverticulitis Mesenteric lymphadenitis

Pathology of Ectopic Pregnancy

 Fertilized ovum borrows through the epithelium  Zygote reaches the muscular wall  Trophoblastic cells at zygote periphery proliferate, invade, and erode

adjacent muscularis  Maternal blood vessels disrupted leading to hemorrhage  Outcome: tubal abortion or rupture with hemorrhage

Case History Presenting Complaint:  23 year old female at 8 weeks gestation admitted for observation following a 2 week history of abnormal serum βhCG levels 

βhCG = 858U/L (normal= 7000-20000 U/L)

 Positive pregnancy test 20/12/05  LMP 12/11/05  EDD 19/08/06  Para 0, gravida 5

Other significant details of the history:  Hx of p/c:

βhCG levels closely monitored for 2/52  No pain  Intermittent bleeding PV for 1/52, no clots Past medical hx:  5 previous miscarriages  Chlamydia 2 yr. ago *risk factor  Tx given, husband treated as well  Retest was negative Medication: none NKDA Social hx:  married  Smoker (pack years unknown) *risk factor 

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 Other important facts that are not known:  

Sexual history ( coitrache, # of partners, etc.) Past menstrual hx

Examination  General appearance: comfortable, no pallor  Vitals signs: within normal limits 

BP 95/60mmHg

 CVS exam: heart sounds 1 and 2 present, no added sounds

or murmurs  Resp exam: normal vesicular breath sounds  Abdominal:  Normal on inspection, no visible swellings, scars, etc.  No pain on palpation  Bowel sounds present

Initial Management    

Initial Investigations: Labs and Radiology Indications for procedure Contraindications for Surgery Patient Outcome Discussion 1. Procedure 2. Desired outcome

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Potential Complications 1. Short Term Injury 2. Long term Injury

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Pre-op Instructions I. Rx/lifestyle/nutritional needs or changes II. Psychological management Legal issues

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Initial Investigations Monitor βhCG levels  βhCG- hormone produced by the placenta (and fetal kidney)  Detectable in plasma and urine following blastocyst implantation  Blood levels rise rapidly, doubling every 2d and plateaus at 8-10

weeks gestation  Serum βHCG levels correlate with the size and gestational age in normal embryonic growth 

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βHCG with inadequate increase may suggest ectopic pregnancy Sensitivity: 36% Specificity: 65%

**βhCG

level does not predict ruptured ectopic, ruptured ectopic may occur at any βHCG level

Serum βhCG Levels 1000 900 800

LOW!!!!!

BhCG (U/L)

700 600 500 400 300 200 100 0 12/23/2005

12/25/2005

12/27/2005

12/30/2005 DATE

1/4/2006

1/6/2006

1/9/2006

Other Labs:  Complete blood count 

Leukocytosis

 Urinalysis with microscopic exam  Blood Type and Rhesus 

A negative 

Therefore, must give anti-D (RhoGAM) prior to surgery

Imaging Studies  US imaging confirms the clinical diagnosis of

suspected ectopic, location, and size Findings suggestive of ectopic pregnancy:

Absence of gestational sac at βHCG 1800 IU/L Free fluid present (71% likelihood of ectopic) Echogenic mass at adnexa (85% likelihood) Echogenic mass with free fluid (100% likelihood)

Transvaginal vs. Transabdominal

Transabdominal Ultrasound  Empty Uterus  Free fluid  Distended portion of left

Fallopian tube  No evidence of rupture  Adnexal mass: 1.7 x 1.6cm adjacent and anterior to left ovary

 Cervical excitation  Tenderness over left iliac

fossa on deep palpation with the probe

(on admission)

Management Options  Expectant Management Indications     

Minimal pain or bleeding in reliable patient bHCG less than 1000 IU/L and falling No signs of tubal rupture Adnexal mass <3 cm No embryonic heart beat

 Medical Management: Methotrexate (anti-metabolite)    

Stable vital signs with normal LFTs, CBC, platelets Unruptured ectopic pregnancy without cardiac activity Ectopic mass <4 cm βHCG <5000 IU/L

 Surgical Management Indications      

Failed or contraindicated non-surgical management Nondiagnostic Transvaginal US and βHCG >1500 Hemoperitoneum Diagnosis unclear Advanced ectopic pregnancy Non-compliant patient

Surgical Options 1. Laparoscopy  “Key hole” surgery  Recommended approach

Advantages: Less blood loss, decreased number of transfusions, less recovery time, less post-op analgesia, cost effective Contraindications: Absolute: ruptured EP, haemodynamic instability, surgeon’s lack of experience Relative: previous multiple pelvic surgeries, Unruptured interstitial EP, morbid obesity

Surgical options (cont’d) 2. Laparotomy 

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Surgical incision through the abdominal wall Pfannensteil incision Mainly used for cases involving haemodynamic instability

Actual Management: Day 1  Admitted for observation following US diagnosis of left tubal pregnancy Day 2  BhCG preformed (slightly increased)  No change in symptoms Day 3: 4pm Examination: o o o

soft abdomen mild lower abdominal and suprapubic pain on palpation Left iliac fossa pain on palpation

 Scheduled laparoscopic removal of ectopic pregnancy  5pm: BP 110/80 mmHg, HR 84 bpm

↑ abdominal pain → OR within 30 min

Radical vs. Conservative Surgery Salpingostomy (Conservative)  Small pregnancy (<2cm) located in distal fallopian tube  Maximizes preservation of affected tube  Associated with a 5% risk or recurrence  Risk of tubal scarring due to incision Salpingotomy  Same as above only incision is sutured closed Salpingectomy (Radical)  Tubal resection Segmental resection and anastomosis

Pre-Operative Work-Up     

Full blood count (Leukocytosis) Blood group serology Coagulation workup Vital signs → stable for surgery Review tests  

βhCG- ectopic still present US imaging- location, size

6. Medications:  NKDA, GA (no allergy)

Patient Preparation 1. Pre-op nutrition- fasting (unless emergency) 2. Bowel prep- enema 3. Shave suprapubic hair 4. Patient information  Risks and complications  Risks of conversion to laparotomy  Risks of salpingectomy

Surgical Complications The patient MUST be made aware of these risks when informed consent is obtained: Hemorrhage and hypovolemic shock Infection Loss of reproductive organs following surgery Infertility *** Urinary and/or intestinal fistulas following complicated surgery  Disseminated intravascular coagulation (rare)     

Prognosis for Future Conception  Conception rate post-ectopic: 77%  Recurrent ectopic pregnancy risk:  After 1st ectopic: 5-20% risk  After 2nd ectopic: 32% risk

Operative Requirements 1) Equipment

Surgical Instrument (preference list) • Patient Positioning 3) Procedure Overview

Objective: laparoscopic salpingectomy Procedure 1. Opening

 Landmarks  Trocar placement  Localisation, Identification, Excision  Wound Closure

Equipment

Laparoscopic Tools

Video monitor

1.Bipolar grasper 2.Atraumatic grasper 3.Grasping forceps 4.Toothed forceps 5.Sharp-tipped monopolar device 6.5-10mm suction-

Patient Positioning

Low lithotomy position 30 degree Trendelenburg Urinary catheter NG tube (?) Uterine cannulation

Trocar Placement for Surgery

A)12mm optical trocar placed at umbilical level B)and C) 5mm lateral operative trocars placed 3 fingerbreadths above the symphysis pubis

 Peritoneum is inflated with CO2  Needle inserted at the umbilical level (primarily used)  OR at Palmer’s point (3cm below costal margin in midclavicular line)  Pressure should not exceed 14 mmHg- respiratory

Trendelenburg postion:  Caused the small intestine loops and sigmoid to move cephalically  Exposes the pelvis  Should not exceed 30 degrees Uterine Manipulation:

 Anteversion (exposure of rectouterine pouch)  Displaced to contralateral side of ectopic

Exposure 1st Assistant: • Holds laparoscope • Pushes intestinal loops cephalically using grasping forceps 2nd Assistant: • Anteverts uterus and pushes it CL to the ectopic pregnancy

Exploration  To determine the precise location of the ectopic pregnancy

 To evaluate the extent of Hemoperitoneum  To determine the condition of the adnexa  Visualize active bleeding  Rule out any other associated pathology  Examine contralateral tube to rule out retrograde reflux and haematosalpinx

Anatomical Review

1. Medial tubal A. 2. Lateral tubal A. 3. Uterine A. 4. Ovarian A.

Laparoscopic Salpingectomy Main Risk: devascularization of the ovary  Operate close to the tube, away from ovarian vessels and suspensory ligament

 Proximal tube division  Isthmus is held upwards and outwards  Isthmus is cauterized  Take care not to cauterized the internal ovarian A. and ovarian branch of the uterine A.  Divide tube with scissors

1. Mesosalpinx

Division  Divide the mesosalpinx with scissors

 Cauterize and divide

the infundibulo-ovarian ligaments and the lateral tubal A.

1. Extraction of the tube  Remove tube through an extraction bag  Verification of hemostasis  Careful lavage  Removal of equipment  Suture/ Steri-strip Caution: laparoscopic incisions  Endometriosis  Utero-peritoneal fistula

Post-operative Plan  Remove urinary catheter and NG tube  Observation and analgesia  Remove IV on the evening of the procedure  Food on evening of procedure  Discharge following day  Discuss use of contraceptives  Pregnancy 2-3 months post-op (2-3 cycles)  Information regarding the risk of ectopic recurrence

Follow-Up: 

Smoking cessation

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Folic acid

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Early pregnancy clinic @ 6/52 gestation in subsequent pregnancy

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Investigation regarding underlying pathology due to past obstetrical hx

The End