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Ectopic Pregnancy
Xiaofang Yi, M.D.
Hospital of OB/GYN, Fudan University
Email: [email protected]
Mobile: 15026585241
Abbreviations• STD: sexually transmitted disease
• ART: assisted reproductive technique
• hCG: human chorionic gonadotropin
• TVS: transvaginal sonography
• MTX: methotrexate
Contents1. Definition
2. Classification
3. Epidemiology
5. Tubal Pregnancy
4. Risk Factors
6. Other Site of Ectopic Pregnancy
Definition
• “ektopos”=out of place• Implantation of blastocyst not in the endometrial lining of the uterine
cavity
Classification
• Ovarian ~
• Cornual ~
• Cervical ~
• Abdominal ~
• Ceasarean scar ~
• Heterotopic ~, etc.
Tubal pregnancy (95 % )
Epidemiology
• 2% of all early pregnancies
• 10% of repeat ectopic pregnancy
• 6% of all pregnancy-related deaths
• Mortality ratio in black 18 times higher than in
white women
Endings of tubal pregnancy
Rupture : Isthmic, 12 ~ 16
wks
Abortion : Ampullary, 8 ~ 12
wks
Secondary abdominal
pregnancy
Broad ligament pregnancy
Persistent ectopic
pregnancy
Clinical Manifestations Delayed menstruation
Vaginal bleeding or spotting
Abdominal & pelvic pain
Sharp, stabbing, or tearing
With vasomotor disturbance: vertigo to syncope
Tenderness
Pelvic mass: tender, boggy
Diaphragmatic irritation: pain in neck or shoulder
Symptoms and Signs Pain: 95%
Abnormal bleeding: 60-80%
Abdominal & pelvic tenderness
Uterine changes: pushed to one side,
enlarged
Vital signs: BP will fall, P will rise only
when hypovolemia
Laboratory Tests hCG: the rise over 48 hours ﹤ 66 %
Progesterone: 5-10-25 ng/ml
Hemogram: decrease in hemoglobin or hematocrit
Sonography : TVS
Culdocentesis
Uterine currettage
Laparoscopy / laparotomy
Laboratory Tests hCG: the rise over 48 hours 66﹤ %
Progesterone: 5-10-25 ng/ml
Hemogram: decrease in hemoglobin or hematocrit
Sonography : TVS
Culdocentesis
Uterine currettage
Laparoscopy / laparotomy
TVS Findings• Endometrial cavity
– Pseudogestational sac– Decidual cyst
• Adnexa– Extrauterine yolk sac or embryo: 15-30%– Adnexal mass: PPV 96%, NPV 95%
• Rectouterine cul-de-sac– Free peritoneal fluid
Caution in diagnosing an intrauterine pregnancy in the absence of definite yolk sac or embryo
Discriminatory hCG
• Empty uterus w/ hCG > 1500 mIU/mL
– Ectopic pregnancy
– Nonliving uterine pregnancy
– Early multifetal gestation
• Serial assays of hCG, w/ serial TVS evaluation
– <66% increase within 48hr
– Empty uterus
Differential Diagnosis
Abortion
Pelvic inflammation disease
Appendicities
Rupture of corpus luteum
Torsion of ovarian cyst
Early diagnosis
allows definitive surgical or medical management
Treatment before rupture
Less morbidity, mortality, better prognosis for fertility
Surgical Management (1/3)
– Tubal patency following salpingostomy
– Subsequent uterine pregnancies
– Subsequent ectopic pregnancies
– Safety & cost: operative time, blood loss, analgesic
requirements, hospital stays
Laparoscopy vs Laparotomy
Longer OP time
Limitaion inManipulation
2-DimensionalImage
Expensive Eye-HandDiscrepancy
Less PainEarly recovery Smaller Scar Less Bleeding
Early return to work Less adhesionShort
Hospital Stay
Magnification of OP field
Advantage in Immunology
Surgical Management (2/3)
– Subsequent uterine pregnancies
– Persistent ectopic pregnancies
Indications for conservative surgery
< 3 cm in length
Unruptured
hCG < 3000 mIU/mL
Hemodynamically stable
Surgical Management (3/3)
– Salpingostomy
– Salpingotomy: suture the tubal incision
– Salpingectomy
– Cornual resection
Persistent Ectopic Pregnancy• Post-op day 1: hCG > 50% of the pre-op value
• Post-op day 12: hCG > 10% of the pre-op value
• Risk factors
– Small pregnancies: < 2 cm
– Early therapy: before 42 menstrual days
– hCG > 3000 mIU/mL
– Implantation medial to the salpingostomy site
• Additional surgical or medical therapy is necessary
Medical Management
• Indications
– Asymptomatic,
motivated,
compliant
– Mass ≤ 3.5 cm
– hCG < 2000
mIU/mL
Contraindication Active intra-abdominal
hemorrhge
Intrauterine pregnancy
Breast feeding
Immunodeficiency,
alcoholism
Chronic hepatic, renal, or
pulmonary disease
Blood dyscrasias
Peptic ulcer disease
Methotrexate (MTX)
• Folic acid
antagonist
• Dose &
administration
Toxicity Liver: 12%
Stomatitis: 6%
Gastroenteritis: 1%
Failure rate: 1.5% (hCG <1000 mIU/mL)
14.3% (hCG > 5000 mIU/mL)
Monitoring Efficacy of Therapy• “15%, day 4 and 7 rule”• Weekly serum hCG determination until
undetectable• Resolution time
– Salpingostomy: 20 days– Single-dose MTX: 27-34 days
• Rupture of persistent ectopic pregnancy: 5-10%
The longest resolution time: 109 days
Tubal rupture can occur in the face of declining hCG.
Schematic of comparative patterns of serum-hCG level decline after single-dose methotrexate treatment or laparoscopic salpingostomy for unruptured ectopic pregnancy.
• Indications
– Tubal ectopic pregnancies only
– Decreasing serial hCG levels
– Mass ≤ 3.5 cm
– TVS: no intra-abdominal bleeding or rupture
Expectant treatment
Resolution rate:
hCG < 1000 mIU/mL: 50-
73%
hCG < 200 mIU/mL: 88%
Abdominal Pregnancy• Incidence: 1 in 85,000• Symptoms: vague,
nonspecific• Sonography, MRI: might
be helpful• Life threatening• Pre-op angiographic
embolization• Surgical termination
Ovarian Pregnancy• Symptoms: Mimic tubal pregnancy or a bleeding
corpus luteum
• Surgery:
– Ovarian wedge resection
– Cystectomy
– Ovariectomy
• MTX: if unruptured
Cervical Pregnancy
Incidence: 1 in 18,000 Clinical feature : painless vaginal bleeding Treatment:
Cerclage Curretage and tamponade Arterial embolization
Laparoscopically assisted uterine artery ligation followed by hysteroscopic endocervial resection
MTX: 50-75 mg/m2
Sonographically guided fetal intracardiac injection of 2 mL KCl was added when needed
Intracervical Foley catheter was placed for 3 days
A. TVS of a cervical pregnancy. (1) an hourglass uterine shape and ballooned cervical canal; (2) gestational tissue at the level of the cervix (black arrow); (3) absent intrauterine gestational tissue (white arrows); (4) a portion of the endocervical canal seen interposed between the gestation and the
endometrial canal. B. In a transverse view of the cervical pregnancy, Doppler color flow shows abundant
vascularization. (From Dr. Elysia Moschos.)
Cesearean Scar Pregnancy Incidence: 1 in 2,000 Clinical presentation :
Pain & bleeding Asymptomatic: 40%
Treatment: MTX Curretage Hysteroscopic resection Uterine-preserving rection Hysterectomy
A. TVS shows a uterus with CSP. An empty uterine cavity appearing as a bright hyperechoic endometrial stripe (long, white arrow); an empty cervical canal (short, white arrow); and an intracavitary mass seen in the anterior wall of the uterine isthmus (red arrows). (From Dr. Elysia Moschos.)
B. This hysterectomy specimen with a CSP is transversely sectioned at the level of the uterine isthmus and through the gestational sac.
(From Drs. Sunil Balgobin, Manisha Sharma, and Rebecca Stone.)
Heterotopic pregnancy
• A condition in which ectopic and intrauterine
pregnancies coexist.
• Incidence: 1 in 30 000.
Definition
Latin “Aboriri”-”to miscarry”
A pregnancy termination prior to
20 weeks of gestation, or with a
fetus born weighing < 500 g.
China: 28 wks, 1000g
Vary widely.
Type of Abortion
• Spontaneous abortion
Induced abortion
Septic abortion
• Recurrent spontaneous abortion: The loss of
more than three pregnancies before 20 weeks of
gestation
Type of Spontaneous AbortionThreatened ~:Vaginal bleeding before 20 weeks of gestation.
Inevitable ~: Uterine bleeding from a gestation of less than 20 weeks, accompanied by cervical dilation but without expulsion of placental or fetal tissue through the cervix.
Anembryonic gestation: An intrauterine sac without fetal tissue present at more than 7.5 weeks of gestation.
Incomplete ~: Expulsion of some but not all of the products of conception before 20 completed weeks of gestation.
Complete ~: Spontaneous expulsion of all fetal and placental tissue from the uterine cavity before 20 weeks of gestation.
Missed ~
Bleeding Abdominal Pain Tissue Expulsion
Cervical Os Uterus
Threatened Abortion
Inevitable Abortion
Incomplete Abortion
Complete Abortion
Light
Mild to heavy
Light to heavy
Light to none
None/light
Intensified
Relieved
None
None
None
Partial
Complete
Closed
Dilated
Dilated or obstructed
Closed
Normal
Normal or slightly small
Small
Normal or slightly large
Etiology Fetal factors
Maternal factors: Infections Chronic debilitating diseases Endocrine anomalies Uterine defects
Drug use and environmental factors
Paternal factors
Differential Diagnosis• Cervical polyps
• Vaginitis
• Cervical carcinoma
• Gestational trophoblastic disease
• Ectopic pregnancy
• Trauma
• Foreign body
Management
• There is no effective therapy for a threatened
intrauterine pregnancy.
– Bed rest
– Progesterone? sedative?
• All patients with an incomplete abortion should undergo
suction curettage as quickly as possible.
• Genetic consulting
• Cervical cerclage
A Hegar dilator. Note that the fourth and fifth fingers rest against the perineum and buttocks, lateral to the vagina.
A suction curette is simultaneously rotated 360° several times to remove tissue circumferentially from the uterine walls.
A sharp curette is held with the thumb and forefinger. In the upward movement of the curette, only the strength of these two fingers should be used.
Regimens for Medical Termination of Early Pregnancy
aDoses of 200 versus 600 mg similarly effective.bOral route may be less effective and with more nausea and diarrhea. May be given sublingually, or buccally. Postprocedure pelvic infection significantly higher with vaginal versus oral route. Possibly more effective when given at 36-48 hours instead of at 6 hours.cEfficacy similar for routes of administration.dSimilar efficacy when given on day 3 versus day 5.
References• Williams Obstetrics, 23rd Edition
– Chapter 10. Ectopic Pregnancy
• Berek & Novak’s Gynecology, 14th Edition
• Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage. National Institute for Health and Clinical Excellence: Guidance. Editors: National Collaborating Centre for Women's and Children's Health (UK). Source: London: RCOG; 2012 Dec.
•
Quizs If a patient has documented cardiac activity in the ectopic, what
should be initiated, MTX or surgery ? How to monitor hCG levels and evaluate transvaginal
ultrasound while instituting MTX ? Does surgical management and medical therapy appear to be
equivalent ? Summarize the management strategies for tubal pregnancy and
its indications. What conditions should be differentiated from abortion?
Which statement about ectopic pregnancy is true?
• Implantation of the fertilized egg outside the uterine cavity
• Rarely involves the fallopian tubes
• Usually associated with cervical carcinoma
• The most common site of involvement is the ovary
• Rarely a surgical emergency
THANK YOUXiaofang Yi, M.D.
Hospital of OB/GYN, Fudan
University
Email: [email protected]
Mobile: 15026585241