Ectopic pregnancy

JEANNET E. CANDA, RN,MAED

NDDU COLLEGE OF NURSING
Definition
An ectopic pregnancy is one in which the fertilized egg implants in
tissue outside of the uterus and the placenta and fetus begin to
develop there
The most common site of occurrence is within a fallopian tube,
however, ectopic pregnancies can occur in the ovary, the abdomen
and in the lower portion of the uterus (the cervix)
Put very simply, an ectopic pregnancy means "an out-of-place
pregnancy
Ectopic Pregnancy is a common, lifethreatening condition affecting
one in 100 pregnancies
As the pregnancy grows it causes pain and bleeding. If it is not
treated quickly enough it can rupture and cause abdominal bleeding,
which can lead to maternal cardiovascular collapse and death
Ectopic Pregnancy
Ectopics happen in about 0.25-1% of all pregnancies
The mortality rate is about 1 per 1000 ectopics (10% of all
maternal deaths)

Ectopic pregnancy rate increased almost 4 fold (from 4.5 per
1000 pregnancies to 16.8 per 1000 pregnancies since 1970)

Fatality rate from ectopic pregnancies dropped almost 90%
(from 35.5 per 1000 ectopics to 3.8 per 1000 ectopics)

Most ectopic pregnancies occur in women aged 25-34 years

Over 75% of ectopics are diagnosed before 12th week of gestation


Ectopic Pregnancy
The decrease in maternal morbidity is due to:

early detection of pregnancy (hCG assays)
aseptic (sterile) technique
antibiotics
anesthetic agents
availability of blood and transfusions
surgical techniques (salpingectomy & salpingostomy)

Classification
Tubal pregnancy (96-98%)
ampullary (mid) portion of the fallopian tube (80-90%)
isthmic (area closer to uterus) portion of the fallopian tube (5-10%)
fimbrial (distal end away from uterus) portion of the fallopian tube (5%)
cornual (within the uterine muscle) portion of the fallopian tube (1-2%)
Abdominal (1-2%) primary/secondary
(tubo-abdominal/abdomino-ovarian)
Ovarian (0.5-1%)
Cervical (less than 0.5%)
Heterotopic (combination of ectopic + intrauterine pregnancy)
Uncommon Ectopics
Intraligamentous pregnancy (in broad ligament)

Pregnancy in a uterine diverticulum or sacculation

Angular pregnancy (inside the uterotubal attachment)

Pregnancy in a rudimentary horn of uterus

Intraural pregnancy (in myometrium)

Vaginal pregnancy

Multiple tubal pregnancy
Histology & Anatomy
The fallopian tubes (oviducts)
are small, hollow muscular
tubes each about ten cm long
Inside the tube is delicate
mucous membrane that forms
the fimbriae
In the epithelial lining of the
tubes half the cells are mucus-
secreting and half have cilia-
tiny hair like projections which
beat gently to propel these
secretions towards the uterus
The muscular wall of each tube
becomes thicker towards the
uterus, and has a natural
peristaltic action which assists
the movement of mucus
Embryology & Physiology
Risk Factors for Ectopic
Pregnancy
Pelvic inflammatory disease (PID) or Salpingitis 6 -10 times
higher risk. Mainly invasion of gonorrhea or chlamydia from the
cervix up to the uterus and tubes and infection in these tissues
causes an intense inflammatory response and scar tissue
adhesions in the tube and may damage the cilia of the fallopian
tube

Endometriosis

History of IUD use

Progesteroneonly contraceptive pill (minipill) alters tubal
motility

Pregnancy after tubal ligation or coagulation

Previous tubal surgery

Ovulation induction or ovarian stimulation
Risk Factors for Ectopic
Pregnancy
In vitro fertilization 2-5% of pregnancies are conected with IVF

Advancing age

Previous ectopic about 10-20% of women attempting pregnancy
after one ectopic will have another

Salpingitis Isthmica Nodosa uncommon diverticulae in the
proximal (isthmic) portion of the tube that enhance tubal implantation
of the early developing embryo

Pelvic adhesions, pelvic tumors

Atrophic endometrium

Septate uterus

Zygote abnormalities (chromosomal abnormatity, neural tube
defects, abnormal spermatozoa)
Symptoms
One-sided pain in abdomen (can be persistent and severe, but may
not be on the same side as an ectopic pregnancy)
Shoulder-tip pain (due to internal bleeding irritating the diaphragm
when woman breathe in and out)
Bladder or bowel problems (woman feels pain when she has her
bowels open tenesmus, or when she passes water)
Collapse (feeling of light-headed or faint, paleness, increasing pulse
rate, sickness, diarrhoea and falling blood pressure)
Pregnancy test (from urine may be positive but not always hCG
blood tests to confirm)
Amenorrhoea (missed or late period)
Abnormal vaginal bleeding
Symptoms of pregnancy
Fever (unusual, occuring in 2% of pacients)

Ectopics Manifestation
Emergency presentation - Suddenly, without warning a woman
is very unwell, collapses and is taken to hospital in fase of
haematoperitoneum and hemorrhage shock

Subacute presentation - The most common presentation is with
a missed period, positive pregnancy test, some abdominal pain,
and irregular vaginal bleeding

Rrisk pregnancy group - After previous ectopic, tubal surgery
or assisted conception ( IVF) detection rate is high women
are primary observed

Diagnosis
Early diagnosis of an ectopic pregnancy is critically important
There is no uniformly accepted diagnostic protocol
History
Physical examination (pain, adnexal mass, enlarged uterus)
Transvaginal or transabdominal ultrasound
Quantitative hormone tests (HCG, -hCG, progesterone)
Occasionally culdocentesis (thin needle is inserted at the top
of the vagina, between the uterus and the rectum, to check for
blood in CD)
Sometimes dilatation and curettage (exclude intrauterine
pregnancy or incomplete abortion)

Diagnosis
Pseudogestational sac in uterus (is seen in 10-20% of ectopics)

Decidual transformed endometrium (thick & hyperechogenic)

No presence of developing fetus in uterus

Adnexal mass or Tubal ring (gestational sac, yolk sac or fetal pole)

Occasionaly hemosalpinx (tubes fill with blood)

Enlargement of uterus (not appropriate for date)

Fluid in Cul De- Sac
Differential Diagnosis
Abortion (complete,incomplete, inevitable, missed)
Threatened appendicitis
Acute dysmenorrhea
Placenta previa
Shock (hemorrhagic, hypovolemic)
Ruptured corpus luteum cyst
Adnexal torsion
Cornual myoma or abscess
Ovarian tumor
Endometrioma
Cervical cancer
Management
Once an ectopic is diagnosed, there are several different
treatments

It is not possible to take the pregnancy from the tube and put it into
the womb

In all cases, the pregnancy must be terminated

Various forms of management

The appropriate surgery follow up for the patient are serial blood
tests of the pregnancy hormone (-HCG)

Within a few weeks, the pregnancy hormone should not be
measureable
Management (cont)
Expectant management - proportion of all ectopics will not progress to
tubal rupture, but will regress spontaneously and be slowly absorbed
Level of hCG must falling and a woman becomes clincally well.
Situation needs daily hCG, TVS. If hCG increases or sonographic
findings are suspicious active management
Medical treatment (methotrexate,dyktinomycin, hyperosmolar
glucose, potassium chloride, mifepristone)
given by injection in form of systemic or local administration
Laparoscopic surgery - (salpingotomy or salpingectomy).
Open surgery (laparotomy) - involves a 5-8 cm incision at the top of
the pubic hairline
The affected tube is brought out and either salpingotomy or ectomy is
performed
The options are as follows:
Criteria for Expectant
Management
Decreasing hCG titers (less than 1500 mIU/mL )
Tubal location (rather than ovarian, abdominal, cervical)
No evidence of rupture or significant bleeding
Ectopic mass with size less than 4 cm
Highly motivated patient with strong desire to avoid both
surgery and medical management
Hemodynamically stable healthy woman
Absence of fetal heart tones
Methotrexate Treatment
Anti-metabolite drug
Inexpensive, easy to obtain, well tolerated
Mixture containing at least 85% of folic acid antagonist "4-amino-10-
methylfolic acid and 25% of Leucovorum calcium (folic acid agonist)

The initial dose regimen
MTX (1 mg/kg IM ) or single IM dose of 50 mg/square meter
Leukovorum (0.1 mg/kg IM )

Dont exceed 4 doses
70-95% efficiency of cases treated
Methotrexate management takes 4-6 weeks for complete resolution of
the ectopic pregnancy
Complications of
Methotrexate
Bone marrow suppression
Acute and chronic hepatotoxicity transient elevations in serum liver
transaminases
Progressive pulmonary toxicity (pneumonitis and pulmonary fibrosis)
Dermatologic effects (rashes, itch, folliculitis, photosensitivity, pigment
changes, rarely alopecia)
Renal impairment
GI side effects (stomatitis, gastritis, diarrhoea)
Invasive Treatment
The standard aim of care is to control the bleeding and remove the
ectopic pregnancy

Prior to the late 1980's, this was accomplished by first making a large
incision in the woman's abdomen and "looking" to find if there was a
swollen fallopian tube containing the ectopic

With the advent of advanced laparoscopic technique, the ectopic
pregnancy can be identified with only a small incision below the
umbilicus (navel)

Microinvasive technique

Surgical Treatment Forms
Salpingotomy: 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

Usually, if the tube is not ruptured laparoscopy

Cases of rupture with significant hemorrhage into the abdomen
laparotomy
Complications
Hemorrhage and hypovolemic shock
Infection
Loss of reproductive organs following surgery
Infertility, sterility
Urinary and/or intestinal fistulas following complicated surgery
Disseminated intravascular coagulation
Persistent ectopic (complication of conservative surgical
treatment, incomplete removal of trofoblastic tissue)
Rh disease



Emotions Changes
Ectopic pregnancy can be a devastating experience
(loss of baby, loss of part of fertility, recovery from surgery)

Postsurgery depression

Sudden end to pregnancy hormonal disarray

Distress and disruption of family life
Prognosis
The prognosis with an ectopic pregnancy is good for
patients with an early diagnosis

Good when fertility is preserved (as much as possible)

Patients with a previous ectopic pregnancy should be
educated regarding the potential increased risk for
another ectopic pregnancy
The Future Pregnancy
If one of the tubes was removed, woman ovulate as before,
but chances of conceiving will be reduced to about 50%

Woman can still become pregnant and have a successful
pregnancy with one intact tube

Overall chances of a repeat ectopic are between 710%
and depends on the type of surgery

If infertility occurs, fertility treatment techniques can still help
a woman achieve pregnancy (IVF)
Tubal Pregnancy
Is a pregnancy that grows in
the fallopian tube, not the
uterus

If the pregnancy continues
and the tube ruptures, there
may be life-threatening
intraabdominal bleeding

Even with the modern
practice of medicine, the
rupture of the tubal ectopic
pregnancy is still one of the
leading causes of
gynecological deaths
Tubal Pregnancy
Findings
Acute tubal rupture (40% of tubal pregnancies)
Chronic tubal rupture (60% of tubal pregnancies)
Early unruptured tubal pregnancy
Tubal abortion
Tubal Pregnancy at USG
Ultrasound showing uterus
and tubal pregnancy
2D scan
Uterus outlined in red
Uterine lining in green
Ectopic pregnancy yellow
Fluid in uterus at blue
circle is called a
"pseudogestational sac"
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
Tubal Pregnancy
A right tubal ectopic pregnancy seen at laparoscopy
The swollen right tube containing the ectopic pregnancy is on the
right at E
The stump of the left tube is seen at L - this woman had a previous
tubal ligation
Tubal Pregnancy
Close view of the
same ectopic
After laparoscopic resection
of the tube, the tubal stump
is seen at S
Tubal Pregnancy
Right tubal ectopic
pregnancy in 11 th
week of gestation
Same situation after rupture
Tubal Pregnancy
Laparoscopist must try to remove the ectopic pregnancy, preserve
the fallopian tube, and early send the patient home
Diagnostic LSK picture below
DIAGNOSIS & TREATMENT OPERATIVE
LAPAROSCOPIC SURGERY
Tubal Pregnancy
The first step of this technique involves making a linear slit into the
fallopian tube over the ectopic with a monopolar needle tip.
Tubal Pregnancy
The second step involves teasing out the ectopic pregnancy intact, and
then irrigating the incision to make sure it is free of any ectopic tissue
LAPAROSCOPIC SALPINGECTOMY
FOR ECTOPIC PREGNANCY

Laparoscopic left salpingectomy
after attempted salpingostomy
for a left tubal ectopic pregnancy
in a 32-year-old gravida 3 para 2
Because patient wished to retain
her fertility, salpingostomy was
initially attempted to save the tube,
but hemorrhage and retained
trophoblastic tissue dictated a
partial salpingectomy (removal of
part of the tube)
The ectopic pregnacy is visualized
in the ampullary region of the left
fallopian tube
CASE REPORT
LSC salpingectomy (cont)
Salpingostomy on the anti-mesenteric
border. Is perfomed to allow withdraw
of the products of conception and
preservation of the tube
After the tube is opened, a
grasper is used to remove
the products of conception
LSC salpingectomy (cont)
Bleeding occuring after removal
of the products of conception

Electrocoagulation is used to
achieve hemostasis
Electrocoagulation has achieved
hemostasis
The tube was partially removed due
to the retained trophoblastic tissue
LSC salpingectomy (cont)
Successive electocoagulation of
the mesosalpinx and subsequent
sharp dissection allows partial
salpingectomy
The distal tube has been
removed through the port
LSC salpingectomy (cont)
Once hemostasis is
assured, the hemo-
peritoneum is evacuated

A single follow up -
HCG should be examine
for 2-3 weeks post
operation

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
Abdominal Pregnancy
Incidence of 1 in 8000 births

Mostly secondary form of abdominal pregnancy

Predominant symptom si pain with hemorrhage

Genitourinary symptoms discomfort

Immediate surgical removal of the fetus

Retain attached placenta in site and start with MTX treatment

High maternal & fetal mortality rate

Keep in Mind
If the ectopic doesnt die, the thin wall of the tube will
stretch and cause pain, discomfort in the lower abdomen
There may be some vaginal bleeding at this time
As the pregnancy grows, the tube may rupture, causing
severe abdominal bleeding, pain, collapse and if not
recognized death
Even if woman has ectopic, first urine pregnancy test-may
be negative !
Why is ectopic pregnancy
so dangerous?
End with Funny
Thanks for your attention
!