ECTOPIC PREGNANCY

1. ECTOPIC PREGNANCY Pirvulescu Andra Maria Gr.9, an IV

3. Definition: Pregnancy in which the fertilized egg or embryo implants on any tissue other than the endometrial lining of the uterus.

4. Etiology: • Pelvic inflammatory disease • History of prior ectopic pregnancy • History of tubal surgery and conception after tubal ligation • Use of fertility drugs or assisted reproductive technology • Use of an intrauterine device • Increasing age • Smoking • Salpingitis isthmica nodosum • previous diethylstilbestrol (DES) exposure • T-shaped uterus • prior abdominal surgery, failure with progestin-only contraception • ruptured appendix.

5. The most common sites for an ectopic pregnancy : • ampullary (mid) portion of the fallopian tube (80-90%), • isthmic (area closer to the uterus) portion of the fallopian tube (5-10%), • fimbrial(distal end away from the uterus) portion of the fallopian tube (about 5%), • cornual (within the uterine muscle) portion of the fallopian tube (1-2%), • abdomen (1-2%), • ovary(less than 1%), or • cervix(less than 1%).

6. Clinical sign: • amenorrhea • vaginal bleeding(40-50%) • Nausea • breast fullness • Fatigue • pain • low abdominal pain • heavy cramping • pelvic tenderness (75%) • enlarged uterus • adnexal mass(50%) • shoulder pain • recent dyspareunia

7. Differential diagnosis: • Appendicitis • salpingitis • ruptured corpus luteum cyst or ovarian follicle • spontaneous abortion or threatened abortion • ovarian torsion • urinary tract disease • intrauterine pregnancies with other abdominal or pelvic problems such as degenerating fibroids

8. Diagnosis of ectopic pregnancy: Blood hCG assays Typically these assays have a sensitivity of 1-5 mIU/mL so they can detect the occurrence of pregnancy (not location) about 7-8 days after fertilization Concentrations of progesterone Generally, a progesterone concentration of greater than 25 ng/mL is highly correlated (greater than 95%) with a normal intrauterine pregnancy while a concentration of less than 5 ng/mL is highly correlated (almost 100%) with an abnormal and nonviable pregnancy

9. Diagnosis of ectopic pregnancy: Serial circulating hCG concentrations If there is a rate of rise of less than 66% in hCG over a 2 day period of time (in early pregnancy) this suggests an abnormally growing intrauterine pregnancy or an ectopic pregnancy. Culdocentesis In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found there likely comes from a ruptured ectopic pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy.

10. Diagnosis of ectopic pregnancy: Transvaginal ultrasonography The absence of a gestational sac with an hCG concentration of greater than 1500 mIU/mL suggests either an abnormally developing intrauterine pregnancy or an ectopic pregnancy . Multiple gestations have two placentae each producing its own hCG so the concentration of 1500 mIU/mL will occur several days prior to a singleton gestation at the same EGA. Also, pregnancies with large placentae may produce hCG concentrations that are greater than expected for their EGA.

11. Ultrasound showing uterus and tubal pregnancy : Uterus outlined in red, uterine lining in green, tubal ectopic pregnancy yellow. Fluid in uterus at blue circle - sometimes called a "pseudosac" - looks like an early pregnancy sac, but is not (usually a small blood collection).

12. Ultrasound showing uterus and tubal pregnancy : Same picture with tubal ectopic pregnancy circled in red, 4.5 mm fetal pole (between cursors) in green, pregnancy yolk sac blue. Same case as above. Detailed close-up of ectopic pregnancy.

13. Nontubal ectopic pregnancy: The placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described . Fetus would have to be delivered by laparotomy . On 19 April 2008 an English woman, Jayne Jones (age 37) who had an ectopic pregnancy attached to the omentum, the fatty covering of her large bowel, gave birth. The baby was delivered by a laparotomy at 28 weeks gestation. The surgery, the first of its kind to be performed in the UK, was successful, and both mother and baby survived. On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via Caesarean section. She had no problems or complications during the 38 week pregnancy.

14. Heterotopic Pregnancy • In rare cases of ectopic pregnancy, there may actually be two fertilized eggs, one outside the uterus and the other inside . • Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful, emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. • The survival rate of the uterine fetus of an ectopic pregnancy is around 70%.

15. Treatment: Nonsurgical treatment: Methotrexate inhibits rapidly growing cells such as a pregnancy or some cancer cells. Most side effects seen with low-dose MTX therapy have been mild and transient. Selection criteria for methotrexate: 1. Hemodynamically stable 2. No evidence of tubal rupture or significant intra-abdominal hemorrhage 3. Tube < 3-4 cm diameter 4. No contraindications to MTX 5. Informed consent 6. Patient will be available for protracted follow-up. Good results with very few side effects are seen with use of a single IM dose of 50 mg/square meter. Resolution of the ectopic has been reported in about 70-95% of cases treated. This depends somewhat on selection criteria for the study. Tubal patency rates by hysterosalpingogram have been 70-85% on the same side as the ectopic. Repeat ectopic and pregnancy rates are comparable to those after conservative surgery.

16. Treatment: Surgical treatment: The possible procedures for ectopic pregnancy can all be done by laparoscopy (same day surgery) or by laparotomy (bigger incision). Usually, if the tube is not ruptured it is done by laparoscopy. Cases of rupture with significant hemorrhage into the abdomen are almost always done by laparotomy because it can be done much faster. Procedures: Salpingotomy (or -ostomy): Making an incision on the tube and removing the pregnancy. Salpingectomy: Cutting the tube out. Segmental resection: Cutting out the affected portion of the tube. Fimbrial expression: "Milking" the pregnancy out the end of the tube. In general, the procedure of choice will be salpingectomy if future fertility is of no concern, if the tube is ruptured, if there is significant anatomic distortion, or if there is overt hemorrhage. There is no evidence that suturing the incision on the tube closed or leaving it open is better.

17. Ectopic pregnancy in animals: Primates three cases of tubal pregnancy eight cases of abdominal pregnancy Laboratory animals:Abdominal pregnancies (guinea pigs, rabbits,hamsters) ovarian pregnancies (rat) tubal pregnancies (mouse) Domestic animals: abdominal pregnancies (cats) Farm animals: Abdominal pregnancies tubal pregnancy

18. Ectopic pregnancy in animals: Rabbit doe. Eight different sized fetuses (black asterisks) attached to stomach serosa (white asterisk) and floating free in the abdominal cavity Rabbit doe. Recent abdominal pregnancy secondary to a left horn rupture (arrow). Two fetuses showed placental attachments (asterisks) to different abdominal surfaces.

19. Ectopic pregnancy in animals: Rabbit doe. Secondary abdominal pregnancy. Two mummified fetuses with a well developed osseous structure and markedly autolysed parenchymatous organs. One of them was attached to the serosal surface of the stomach (right) and the other was free in the abdominal cavity (left).

20. Ectopic pregnancy in humans: Ectopic pregnancy. Laparoscopic picture of an unruptured right ampullary tubal pregnancy with bleeding out of the fimbriated end resulting in hemoperitoneum. A 12-week interstitial gestation, which eventually resulted in a hysterectomy.

21. Chances of future pregnancy: • Conservative surgery for small unruptured ectopics restores tubal patency in over 80% of cases. • In general the ratio of intrauterine to recurrent ectopic is about 6:1 but it rises to about 10:1 if the other tube appears normal. After one ectopic and a tubal sparing surgery: • The subsequent delivery rate is about 55-60%. • The recurrent ectopic rate is about 15% (so about 20% of pregnancies are ectopics). • The infertility rate is about 25-30%. • If the other tube is absent or blocked: • The subsequent delivery rate is about 45-50%. The recurrent ectopic rate is about 20% (so about 30% of pregnancies are ectopics). • The infertility rate is about 30-35%.

22. Chances of future pregnancy: After 2 or more ectopics and conservative surgery: • The subsequent delivery rate is about 30%. • The recurrent ectopic rate is about 20-30% (so about 50% of pregnancies are ectopics). • The infertility rate is about 40-50%. • As a woman has more and more ectopics, the chances for a delivery (without treatment) become less and less. • In vitro fertilization (IVF) will be the best option for attaining a successful pregnancy for many women with a history of tubal damage and one or more ectopic pregnancies. 

23. Complications • The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare in women who have access to modern medical facilities. • Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.

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