Ectopic pregnancy


Fertilized ovum implants in area other than endometrial lining.
Location of ectopic pregnancy is tubal in 95% of cases, and in 5% of the cases in other. This includes cervical, ovarian, abdominal and interstitial (embryo penetrates myometrium).
The causes are not well understood.

ectopic.jpg

Signs and symptoms


Typically bleeding plus pain in a young female.

Symptoms:
  • Pain may be pelvic, abdominal, shoulder tip
  • Bleeding. In 75% cases uterine bleeding
  • History of amenorrhoea
  • Syncope as a sign of advanced intra-abdominal bleeding

Signs:
  • Tenderness may be diffuse or localised abdominal tenderness. Adnexal and/or cervical motion tenderness +ve.
  • Adnexal mass. Unilateral or not always palpable.
  • Uterine changes. Normal pregnancy changes such as softening or slight increase in size.
  • Haemodynamic instability. Vital signs will indicate signs of haemorrhage.


Risk Factors



Risk factors can be classifieid as tubal, ovarian, hormonal, zygote or other.

Tubal factors such as trauma or infection is where there is scar tissue in tubes. This includes salpingitis (increase risk by 5-10 fold), previous ectopic pregnancy (recurrence risk 10-15%), and previous tubal ligation.

Ovarian factors include fertilization of an unextruded ovum, transmigration of ovum into contralateral tube with delayed and faulty implantation, postmidcycle ovulation and fertilization.

Exogenous hormones such as progestin only OCP increases risk, due to progesterone's smooth muscle relaxant effects and subsequent ovum tapping.

Other factors such as IUD (causing trauma), smoking, increased maternal age, previous pelvic surgery (caesarean section, appendicectomy) also increases risk of an ectopic pregnancy.


Time of Rupture



6-8/40: Isthmic pregnancy- due to small diameter of this portion of tube
8-12/40: Ampullary pregnancy
12-16/40: Interstitial pregnancy- myometrium allow more room to grow

Investigations



Beta-hCG
  • Urine (+) This may be intra-uterine pregnancy, ectopic pregnancy, or miscarriage.
  • Qualitative serum (+) This may be intra-uterine pregnancy, ectopic pregnancy, or miscarriage.
  • Quantitative serum (+) Increased beta-HCG, viable pregnancy, miscarriage, ectopic pregnancy. Decreased beta-HCG may mean miscarriage or ectopic pregnancy.

Ultrasound
  • Transvaginal detects earlier pregnancies (1000mlU/mL beta-hCG)
  • Transabdominal detects later pregnancies (1800-3600mlU/mL)
Intrauterine gestational sac is Not seen in ectopic pregnancies.
Ovarian/fallopian mass may be seen
Fluid in POD

Differential Diagnosis



Viable pregnancy,
Ectopic pregnancy
Mmiscarriage
Ruptured ovarian cyst
STI

Medical Management



Methotrexate (MTX- folic acid antagonist)
Inclusion criteria must be used. For women who are:
  • haemodynamically stable,
  • do not have pelvic pain and/or tenderness.
  • Have Beta-hCG <3500 IU/L,
  • on transvaginal US- no fetal heart activity, un-ruptured ecopic mass size <3.5cm and no fluid in the peritoneal cavity or Pouch of Douglas.
  • Agree to use reliable contraceptive for 3-4 months post-treatment.
  • Desire future fertility,
  • have no pre-existing severe medical condition or disorder.
  • Have no abnormality fo LFT, U&E, or FBC (liver, renal or bone marrow impairment).
  • Have no known contraindicatiosn to metrotrexate.
  • are not currently taking non steroidal anti-inflammatory drugs (NSAIDs), diuretics, penicillin and tetracyclin group drugs (not so critical for the single dose methotrexate regime)
  • do not have co-existing intrauterine pregnancy
  • are not breastfeeding
  • will be compliant with regular follow-ups

Misoprostol (Prostaglandin analogue PGE1)
Softens cervix and contracts uterine. This helps to expel products of conception, and is used in conjunction with MTX

Surgical Management



For women who are NOT haemodynamically stable or who cannot be managed as per criteria above:

Salpingostomy (laparoscopic) if <3cm, intact ampullary pregnancy
Salpingectomy (laparoscopic)
Corneal wedge resection + uterine reconstruction for interstitial pregnancy
Oophrectomy +/- salpingectomy for ovarian pregnancy

N.B. Post-op, measure beta-hCG levels to ensure adequate removal of trophoblast

Emergency Management



Resucitate via large bore cannula and fluids
Hx should be for early pregnancy bleeding:
  • Gravidity,
  • Parity,
  • LMP,
  • Past pregnancy Hx
Ex:
  • Pulse,
  • BP,
  • Appearance,
  • Abdominal Ex
Ix:
  • Beta-hCG (quantitative),
  • Blood group and hold or cross match
  • Pelvic US in clinicaly stable
  • Others: FBE, LFT, U&E
Mx:
  • Laparoscopic Salpingectomy = Gold Standard
  • Laparotomy for unstable patient (quicker)
  • Medical Management with Metrotrexate in clinically unstable. If <4cm, Beta-hCG <4000, no foetal heart beat, pain not too great, minimal free pelvic fluid
  • Rh D immunoglobulin to any Rh -ve mother with diagnosis of ectopic pregnancy

Laparotomy- diathermy conservative OR remove uterus
methotrexate (need close monitoring ie close to hospital, English/communication)