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Ectopic Pregnancy

Ectopic Pregnancy. Xiaofang Yi, M.D. Hospital of OB/GYN, Fudan University Email: yi.annie .1@gmail.com Mobile: 15026585241. Abbreviations. STD : sexually transmitted disease ART : assisted reproductive technique hCG : human chorionic gonadotropin TVS : transvaginal sonography

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Ectopic Pregnancy

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  1. Ectopic Pregnancy Xiaofang Yi, M.D. Hospital of OB/GYN, Fudan University Email: yi.annie.1@gmail.com Mobile: 15026585241

  2. Abbreviations • STD: sexually transmitted disease • ART: assisted reproductive technique • hCG: human chorionic gonadotropin • TVS: transvaginalsonography • MTX: methotrexate

  3. 6. Other Site of Ectopic Pregnancy 1. Definition 2. Classification 3. Epidemiology 5. Tubal Pregnancy 4. Risk Factors Contents

  4. Definition • “ektopos”=out of place • Implantation of blastocyst not in the endometrial lining of the uterine cavity

  5. Classification • Ovarian ~ • Cornual ~ • Cervical ~ • Abdominal ~ • Ceasarean scar ~ • Heterotopic ~, etc. • Tubal pregnancy (95％)

  6. Epidemiology • 2% of all early pregnancies • 10% of repeat ectopic pregnancy • 6% of all pregnancy-related deaths • Mortality ratio in black 18 times higher than in white women

  7. Risk Factors

  8. Tubal Pregnancy

  9. Endings of tubal pregnancy • Rupture：Isthmic, 12～16 wks • Abortion：Ampullary, 8～12wks • Secondary abdominal pregnancy • Broad ligament pregnancy • Persistent ectopic pregnancy

  10. Clinical Manifestations • Delayed menstruation • Vaginal bleeding or spotting • Abdominal & pelvic pain • Sharp, stabbing, or tearing • With vasomotor disturbance: vertigo to syncope • Tenderness • Pelvic mass: tender, boggy • Diaphragmatic irritation: pain in neck or shoulder

  11. Before rupture Often subtle or even absent Pain, bleeding, tenderness Rupture

  12. Symptoms and Signs • Pain: 95% • Abnormal bleeding: 60-80% • Abdominal & pelvic tenderness • Uterine changes: pushed to one side, enlarged • Vital signs: BP will fall, P will rise only when hypovolemia

  13. Laboratory Tests • hCG: the rise over 48hours ﹤66％ • Progesterone: 5-10-25 ng/ml • Hemogram: decrease in hemoglobin or hematocrit • Sonography：TVS • Culdocentesis • Uterine currettage • Laparoscopy / laparotomy

  14. Arias-Stella reaction • Glands: closely packed , hypersecretory. • Nuclei: large, hyperchromatic.

  15. Laboratory Tests • hCG: the rise over 48hours ﹤ 66％ • Progesterone: 5-10-25 ng/ml • Hemogram: decrease in hemoglobin or hematocrit • Sonography：TVS • Culdocentesis • Uterine currettage • Laparoscopy / laparotomy

  16. TVS Findings • Endometrial cavity • Pseudogestational sac • Decidual cyst • Adnexa • Extrauterine yolk sac or embryo: 15-30% • Adnexal mass: PPV 96%, NPV 95% • Rectouterine cul-de-sac • Free peritoneal fluid Caution in diagnosing an intrauterine pregnancy in the absence of definite yolk sac or embryo

  17. The “ring of fire”

  18. DiscriminatoryhCG • Empty uterus w/ hCG > 1500 mIU/mL • Ectopic pregnancy • Nonliving uterine pregnancy • Early multifetal gestation • Serial assays of hCG, w/ serial TVS evaluation • <66% increase within 48hr • Empty uterus

  19. Differential Diagnosis • Abortion • Pelvic inflammation disease • Appendicities • Rupture of corpus luteum • Torsion of ovarian cyst

  20. Early diagnosis allows definitive surgical or medical management Treatment before rupture Less morbidity, mortality, better prognosis for fertility

  21. Surgical Management (1/3) • Tubal patency following salpingostomy • Subsequent uterine pregnancies • Subsequent ectopic pregnancies • Safety & cost: operative time, blood loss, analgesic requirements, hospital stays C1: Laparoscopy or laparotomy ?

  22. Early recovery Smaller Scar Less Bleeding Less Pain Early return to work Less adhesion Short Hospital Stay Magnificationof OP field Advantage in Immunology LAPAROSCOPIC SURGERY Expensive Eye-Hand Discrepancy Longer OP time 2-Dimensional Image Limitaion in Manipulation Laparoscopy vsLaparotomy

  23. Surgical Management (2/3) • Subsequent uterine pregnancies • Persistent ectopic pregnancies C2: Conservative or radical? • Indications for conservative surgery • < 3 cm in length • Unruptured • hCG < 3000 mIU/mL • Hemodynamically stable

  24. Surgical Management (3/3) • Salpingostomy • Salpingotomy: suture the tubal incision • Salpingectomy • Cornual resection C3: Surgical types?

  25. Salpingostomy Salpingotomy

  26. Salpingectomy

  27. Cornual Resection

  28. Persistent Ectopic Pregnancy • Post-op day 1: hCG > 50% of the pre-op value • Post-op day 12: hCG > 10% of the pre-op value • Risk factors • Small pregnancies: < 2 cm • Early therapy: before 42 menstrual days • hCG > 3000 mIU/mL • Implantation medial to the salpingostomy site • Additional surgical or medical therapy is necessary

  29. Medical Management • Indications • Asymptomatic, motivated, compliant • Mass ≤ 3.5 cm • hCG＜ 2000 mIU/mL • Contraindication • Active intra-abdominal hemorrhge • Intrauterine pregnancy • Breast feeding • Immunodeficiency, alcoholism • Chronic hepatic, renal, or pulmonary disease • Blood dyscrasias • Peptic ulcer disease

  30. Methotrexate (MTX) • Folic acid antagonist • Dose & administration • Toxicity • Liver: 12% • Stomatitis: 6% • Gastroenteritis: 1% • Failure rate: • 1.5% (hCG <1000 mIU/mL) • 14.3% (hCG > 5000 mIU/mL)

  31. MTX Therapy

  32. Monitoring Efficacy of Therapy • “15%, day 4 and 7 rule” • Weekly serum hCG determination until undetectable • Resolution time • Salpingostomy: 20 days • Single-dose MTX: 27-34 days • Rupture of persistent ectopic pregnancy: 5-10% The longest resolution time: 109 days Tubal rupture can occur in the face of declining hCG.

  33. Schematic of comparative patterns of serum-hCG level decline after single-dose methotrexate treatment or laparoscopic salpingostomy for unruptured ectopic pregnancy.

  34. Expectant treatment • Indications • Tubal ectopic pregnancies only • Decreasing serial hCG levels • Mass ≤ 3.5 cm • TVS: no intra-abdominal bleeding or rupture • Resolution rate: • hCG < 1000 mIU/mL: 50-73% • hCG < 200 mIU/mL: 88%

  35. Other Sites of Ectopic Pregnancies

  36. Abdominal Pregnancy • Incidence: 1 in 85,000 • Symptoms: vague, nonspecific • Sonography, MRI: might be helpful • Life threatening • Pre-op angiographic embolization • Surgical termination

  37. Ovarian Pregnancy • Symptoms: Mimic tubal pregnancy or a bleeding corpus luteum • Surgery: • Ovarian wedge resection • Cystectomy • Ovariectomy • MTX: if unruptured

  38. Cervical Pregnancy • Incidence: 1 in 18,000 • Clinical feature：painless vaginal bleeding • Treatment: • Cerclage • Curretage and tamponade • Arterial embolization • Laparoscopically assisted uterine artery ligation followed by hysteroscopicendocervial resection • MTX: 50-75 mg/m2 • Sonographically guided fetal intracardiac injection of 2 mLKCl was added when needed • Intracervical Foley catheter was placed for 3 days

  39. TVS of a cervical pregnancy. • (1) an hourglass uterine shape and ballooned cervical canal; • (2) gestational tissue at the level of the cervix (black arrow); • (3) absent intrauterine gestational tissue (white arrows); • (4) a portion of the endocervical canal seen interposed between the gestation and the endometrial canal. • In a transverse view of the cervical pregnancy, Doppler color flow shows abundant vascularization. (From Dr. ElysiaMoschos.)

  40. Cesearean Scar Pregnancy • Incidence: 1 in 2,000 • Clinical presentation： • Pain & bleeding • Asymptomatic: 40% • Treatment: • MTX • Curretage • Hysteroscopic resection • Uterine-preserving rection • Hysterectomy

  41. TVS shows a uterus with CSP. An empty uterine cavity appearing as a bright hyperechoic endometrial stripe (long, white arrow); an empty cervical canal (short, white arrow); and an intracavitary mass seen in the anterior wall of the uterine isthmus (red arrows). (From Dr. ElysiaMoschos.) • This hysterectomy specimen with a CSP is transversely sectioned at the level of the uterine isthmus and through the gestational sac. • (From Drs. Sunil Balgobin, Manisha Sharma, and Rebecca Stone.)

  42. Heterotopic pregnancy • A condition in which ectopic and intrauterine pregnancies coexist. • Incidence: 1 in 30 000.

  43. Summary

  44. Summary

  45. Abortion

  46. 5. Management 1. Definition 2. Type of abortion 4. Diagnosis 3. Etiology Contents

  47. Definition • Latin “Aboriri”-”to miscarry” • A pregnancy termination prior to 20 weeks of gestation, or with a fetus born weighing < 500 g. • China: 28 wks, 1000g • Vary widely.

  48. Type of Abortion • Spontaneous abortion • Induced abortion • Septic abortion • Recurrent spontaneous abortion:The loss of more than three pregnancies before 20 weeks of gestation

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