Ectopic Pregnancy

1. Ectopic Pregnancy By Rohan Kulkarni

2. Defination. • Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity. • 1 in 100 ( from 1:25 to 1:250) normal pregnancies (incidence)

3. Recent evidence shows that the incidence of ectopic pregnancy has been rising in many countries. • USA-5 fold • UK-2 fold • France 15/1000 pregnancies • India-1in100 deliveries • Recurrence rate - 15% after 1st, 25% after 2 ectopics

4. Overview. • Incidence Increasing (Ќ 1:66 Pregnancies) • Mortality Decreasing With Better Detection • Surgical and Medical Treatment Available • Recurrence Rate ~ 15%

5. Aetiology • Any factor that causes delayed transport of the fertilised ovum through the. • Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. • These factors may be Congenital or Acquired. • CONGENITAL - Tubal Hypoplasia, Congenital diverticuli , Accessory ostia , Partial stenosis • Previous Ectopic Pregnancy • PID

6. Migration of the Ova Externa • Pelvic Abnormalities (Fundul Fibroma, adenomiosis of Fallopian Tubes) • Tubal Reconstrustive Surgery • Tubectomy Operation • Infertility • IUD (~4% pregnancies with IUD in Situ are Ectopic, Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy) • IVF • Induction Ovulation with Gonadotropins • Extraneous Factors (Appendicitis, Endometriosis)

7. Sites • Ampulla (78-95%) • Isthmus (8-12%) • Interstitial portion (2%) - very rare form • Cornua (< 2%) or in accessory horn • Ovary (0,5-3%, 20-30% in IUD users) • Abdomen (< 2%): Primary - very rare. Secondary. • Cervix (< 2%) • Combined Uterine Pregnancy and Ectopic Gestation - 1-3% in IVF, 1:4 000 - 1: 30 000

8. 1 - Fimbrial 2 - Ampullary 3 - Isthemic 4 - Interstitial 5) Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament 10) Primary abdominal

9. Tubal Pregnancy at USG • Detailed view of ectopic (thick, brightly echogenic, ringlike structure outside the uterus) • Tubal pregnancy circled in red • 4.5 mm fetal pole (between cursors) in green • Pregnancy yolk sac in blue

10. Tubal Pregnancy After laparoscopic resection of the tube, the tubal stump is seen at S Close view of the same ectopic

11. Tubal Pregnancy Same situation after rupture Right tubal ectopic pregnancy in 11 th week of gestation

12. Ovarian Pregnancy Ovary is the white structure in the middle Pregnancy is implanted on the far right side of the ovary at the "X„ Around the ovary are seen bleeding and clotted blood

13. Symptoms • Amenorrhea in 75% cases • Abdominal Pain - in 95% cases. Shoulder and Epigasrtric Pain • Vaginal Bleeding • Syncope • Pelvic Mass

14. Clinical classification. • Unruptured (Progressive) - without specific sings • Tubal Abortion - minimal sings • Tubal Rupture (into the peritoneal cavity or between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock

15. Diagnosis • History and Physical Exam • Vaginal Examination • Serial Quantitative -hCG (BSU) • Ultrasound TAS & TVS • Progesterone Level? • Culdocentesis • Laparoscopy • D&C

16. -hCG* Levels Double Every 48 Hrs • < 66% Rise / 48 Hrs Consistent With Ectopic Pregnancy • Single Determination Not Helpful • Best If Done Within Same Laboratory • UltrasoundNever May or May Not Be Helpful • Rules Out Ectopic Pregnanc

17. Culdocentesis • Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood • Negative Tap Inconclusive • May Obviate U/S • Most Helpful in Emergent Situations to Confirm Diagnosis, But Remains Controvers

18. Differential diagnosis • Appendicitis (Perforated) , PID • Rupture of Follicle or Corpus Luteum Cyst • Threatened Abortion • Splenic Rupture • Perforated Gastric or Duodenal Ulcer • Acute Pancreatities • Myocardial Infarct • Pyosalpinx • Septic Abortion • Pelvic Abcess • Retroverted Gravid Uterus • Twisted Ovarian Cyst, Rupture of Chocolate cyst

19. Treatment • Observation • Laparoscopy • Laparotomy • MTX (methotrexate) • Hyperosmolar Glucose • KCl • RU-486 • Prostaglandin F2 alfa

20. Laprotomy • Acute Ectopic Gestation • Salpingoectomy • Secondary Abdominal Pregnancy • Interstial Pregnancy • Cornual Pregnancy • Cervical Pregnancy

21. Laparoscopy • Allows Diagnosis and Treatment • Salpingostomy • Salpingectomy (Total / Partial) • Cornual Resection • Minimally Invasive, Unlike Laparotomy • Few Contraindications: Unstable Patient (Possibly)

22. mxt • Toxic to Trophoblast Cells • Minimal Side Effects • May Preserve Fertility in Cases of Cervical Pregnancy • Requires Compliant Patient, Time • Pain Not Uncommon • 25-50 mg into Gestational Sac • Tubal Patency is Restored in 82% cases • Oral - 50-100 mg (toxicity on GIT) • Intramusculary 1 mg/kg

23. Cervical Pregnancy • Incidence 1:1 000 • Profuse painless bleeding following a short period of Amenorrhea • PE: a patulous external os and productsof conception in the cevical canal, internal os is closed and the uterus is firm and normal in size • US helps in the correct diagnisis • Treatment: - Suction Evacuation and Tamponade by inserting a distended Foley Catheter for 24 hours - Hysterectomy - Hysteroscopic Resection using Resectoscope , MTX

24. Outcomes • 15% Repeat Ectopic Rate • Ectopics: 33% Pregnancy Rate 25% Ectopic • No Benefit To Removing Ovary Along With Tube

25. Ectopic Pregnancy is a Common, Treatable Problem • Sensitive -hCG Assays Allow Early Detection • Surgical and Medical Options Exist

26. Thank you for attention.