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EARLY PREGNANCY PAIN AND BLEEDING

EARLY PREGNANCY PAIN AND BLEEDING. Part 2: Ectopic Pregnancy. Ectopic Pregnancy. Definition Pregnancy occurring outside the uterus Sites Fallopian tube 93% (ampullary 70%, isthmic 12%, fimbrial 11.1%) Interstitial 2.4% Ovarian 3.2% Abdominal 1.3% Cervical 1%. Ectopic Pregnancy.

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EARLY PREGNANCY PAIN AND BLEEDING

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  1. EARLY PREGNANCY PAIN AND BLEEDING Part 2: Ectopic Pregnancy

  2. Ectopic Pregnancy Definition • Pregnancy occurring outside the uterus Sites • Fallopian tube 93% (ampullary 70%, isthmic 12%, fimbrial 11.1%) • Interstitial 2.4% • Ovarian 3.2% • Abdominal 1.3% • Cervical 1%

  3. Ectopic Pregnancy Incidence • 1.6% all pregnancies (NSW 1998) • Increasing incidence until about 1992 then plateauing/?falling (1970 0.3%, 1992 1.7%) • ?decreased rates associated with contraceptive failures versus no decrease with reproductive failure • Similar rates Western countries

  4. Ectopic Pregnancy Age • 15-24 years: 0.7% • 25-34 years: 1.3% • 35-44 years: 1.9% Mortality • small but 15% all maternal deaths

  5. Aetiology Tubal damage Change in tubal motility

  6. Ectopic Risk factors Pelvic infection • Especially chlamydial • 45% of patients have evidence of prior salpingitis on pathological specimens • Laparoscopically-proven PID confers a risk of 13% after one episode and 35% after two • Treatment of chlamydia decreases rates

  7. Ectopic Risk factors Previous tubal pregnancy • 10-25% recurrence after one tubal ectopic

  8. Ectopic Risk factors Current IUD • Excellent contraceptive efficacy but prevents implantation in uterus more effectively than in the tube • Copper IUD: 4% of contraceptive failures are ectopics • Progesterone IUD: 17% of contraceptive failures are ectopics • No increased risk once removed

  9. Ectopic Risk factors Progesterone hormonal contraceptives (Likely association) Mechanism: changes to muscular activity of tube • progesterone IUD • mini-pill (4-10% of contraceptive failures are ectopics) • morning after pill • Implants (30% of contraceptive failures are ectopics)

  10. Ectopic Risk factors Infertility • Without treatment – if a woman conceives after >1 year unprotected intercourse she has 2.6 x increased risk • With treatmentSurgery such as reversal of sterilisation and tuboplastyOvulation induction (likely small increase)IVF - 2-8% all conceptions, 17% increased risk if tubal factor for infertility identified (Why- ?Fluid reflux into tube, ?embryo placed high in uterus)

  11. Ectopic Risk factors Other abdominal surgery • Ruptured appendix • Other? – not clear

  12. Ectopic Risk factors Smoking • > 2 x risk (increased with increased dose) • Nicotine affects tubal motility, ciliary function and blastocyst implantation

  13. Ectopic Risk factors Tubal abnormalities • Eg. Salpingitis isthmica nodosa (diverticulae) – abnormal myometrial electrical activity

  14. Ectopic Risk factors In utero diethylstilboestrol (DES) exposure • 4-13%

  15. Natural history • Tubal abortionspontaneous resolutionExpulsion from the fimbrial end of the tube • Involution spontaneous resolution • Rupture (usually about 8 weeks) • Chronic inflammatory mass (uncommon)hCG may be low or absentFrom bleeding into tubal wallPersistent symptoms, usually requires salpingectomy

  16. History Classic triad (50%) • Amenorrhoea • Vaginal bleeding • Pain • Abnormal menstrual pattern • Pain of any sort – unilateral/bilateral, dull/sharp, upper/lower abdomen

  17. Examination • Vital signs • AbdomenNon-tender to mildly tenderSigns of rupture: distension, decreased bowel sounds, peritonism • Cervical motion tenderness • Adnexal mass (50%) – but may be the corpus luteum

  18. Investigation hCG positive in virtually all ectopics presenting • Positive in unstable patient • Not rising appropriately • Not falling appropriately • Not seeing an intra-uterine pregnancy at hCG over the discriminatory zone(1000-2000 on transvaginal scanning)

  19. Investigation Ultrasound Transvaginal and transabdominal important Presence of intrauterine sac virtually excludes ectopic pregnancy • Heterotropic pregnancy 1/30,000 (Increased with IVF/ovulation induction) • Beware pseudogestational sac of ectopic pregnancy (sac-like fluid lucency, probably from bleeding) – ideal to see cardiac activity – yolk sac – double decidual sac sign (concentric echogenic rings) Doppler ultrasound improves diagnosis

  20. Investigation Possible Ultrasound Findings • Absence of intrauterine pregnancy over the hCG discriminatory zone • Adnexal gestation with fetal pole and cardiac activity – 10-17% • Adnexal rings (fluid sacs with thick echogenic rings) – 38% • Complex or solid adnexal rings (DDx corpus luteum, other cysts, pedunculated fibroid) • Intra-abdominal free fluid or cul-de-sac fluid (the latter doesn’t necessarily represent rupture)

  21. Investigation Chorionic villi in saline test • Useful to distinguish products of intrauterine gestation (chorionic villi) from decidual cast of ectopic pregnancy • Chorionic villi have a lacy frond appearance and float in saline • Tissue should also be sent for histopathology to confirm • Suction curettage may be used to diagnose (hCG <2000, indeterminant ultrasound & <50% rise in hCG over 48 hours) • hCG should fall by >15% within 24 hours of evacuation of normal intrauterine pregnancy

  22. Investigation Culdocentesis • Aspiration of fluid from cul-de-sac • Positive test if non-clotting blood obtained • 70-90% of patients with ectopic pregnancy have a haemoperitoneum • Rarely used now hCG and transvaginal ultrasound available

  23. Investigation Laparoscopy • Gold standard for diagnosis • Missed in 3-4% (if very small)

  24. Management Surgical • Laparoscopy vs Laparotomy • Salpingostomy vs Salpingectomy • (Salpingo-oophorectomy) Medical • Methotrexate • Other (RU-486, KCl, hyperosmolar glucose, prostaglandins). Salpingocentesis Remember Anti-D in Rh-ve women

  25. Management Laparoscopy • Shorter hospital stay • Less post-operative pain • Less cost • Shorter convalescence • Less blood loss • Less adhesions (but similar tubal patency rates) • Similar: pregnancy rate, persistent trophoblast rate, operating time

  26. Management Laparotomy for • Haemodynamic instability • Lack of laparoscopic expertise/equipment • Cornual/interstitial pregnancy • Ovarian/abdominal pregnancy • Patient factors eg. Obesity, adhesions

  27. Management Salpingectomy vs Salpingostomy • Controversial • No difference in future intrauterine pregnancy rates?Some studies suggest differenceNot enough evidence yet • Increase in persistent trophoblast rates (failure to remove all tissue) with salpingostomy • No difference in recurrence of ectopic in future • Milking tubeFimbrial – may be effectiveAmpullary – double recurrence risk

  28. Management Salpingo-oophorectomy • No evidence of decreased recurrence rates • Improved intrauterine pregnancy rates with conservation of ovary therefore no longer performed

  29. Management Methotrexate • Chemotherapeutic agent which prevents synthesis of DNA (inhibits dehydrofolate reductase) • Much lower doses used for ectopic than malignancy • Use as primary treatment or if plateauing/ inadequately falling hCG after surgical treatment

  30. Management Methotrexate Patient Selection • Mild/no pain • Haemodynamically stable • Ectopic pregnancy <3cm? • No fetal heart seen • hCG < 2000 ?10000 • Compliant/understanding patient

  31. Management Methotrexate • Baseline LFTs/FBE/UEC/hCG • Dose 50mg/m2 (calculated from height and weight) given IM • Repeat hCG day 4 • Repeat LFTs/FBE/UEC/hCG day 7 • hCG should fall at least 15% from day 4 to 7 (normal to rise from days 1-4) • Give second dose if inadequate fall • Single dose successful in 91-93% of appropriately chosen patients

  32. Management Methotrexate Side Effects • <1% • Stomatitis, gastritis, photosensitive rash • Impaired liver or renal function • Pancytopaenia • No evidence of increased malignancy in future • (Contraindications: liver disease, blood dyscrasias, ulcerative colitis, peptic ulcer disease, concomitant infection) • Warn patient re: moderate increase in pain and bleeding first week

  33. Management Methotrexate • Follow hCG until <2 • Surgery if becomes unstable/failed treatment • Intrauterine pregnancy rates post-methotrexate comparable to surgical treatment

  34. Follow-up • hCG should be followed weekly to <2 in all patients treated with methotrexate or tube-conserving surgery (salpingostomy). Some would follow patients after salpingectomy also • Patient told no pregnancy 2 months (use barrier method or OC pill). No IUD • Ultrasound at 6 weeks in subsequent pregnancy to ensure intrauterine

  35. Future Fertility Overall pregnancy rates after one ectopic: • Intrauterine 50-80% • Ectopic 10-25% • Others infertile

  36. Interesting fact • Pregnancy after hysterectomy is possible (tube, cervix) • ALWAYS DO A hCG • ALWAYS THINK OF POSSIBILITY OF ECTOPIC PREGNANCY

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