Jasmine shiju Asst Prof Obstetrics Gynecology Department Implantation

Jasmine shiju Asst. Prof Obstetrics & Gynecology Department

– Implantation outside uterine cavity – Most common site is within fallopian tube 98%, in the distal ampulla than in the proximal isthmus, followed by corneal 2% and abdominal 1. 4%, ovarian 0. 15% and cervical os 0. 15% Incidence: I in 100 of all pregnancies and to 1 in 30 in high risk population arising in the west in parallel with number of cases of chlamydia infection

“ Any pregnancy occurring outside the uterus” Incidence: Increasing due to P. I. D. / infertility 1 -2% of all births 9% after IVF-ET Site of implantation:

Ectopic pregnancy is one in which the fertilized ovum implanted and develops outside the uterine cavity.

10/2/2020 A Amani Abd elgader 5

SITES OF ECTOPIC PREGNANCY Abdomen (< 2%) Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Cervix (< 2%) 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

• MODE OF TERMINATION

10/2/2020 A Amani Abd elgader 9

10/2/2020 A Amani Abd elgader 10

10/2/2020 A Amani Abd elgader 11

10/2/2020 A Amani Abd elgader 12

10/2/2020 A Amani Abd elgader 13

10/2/2020 A Amani Abd elgader 14

Risk Factor for Ectopic Pregnancy • Any factor that leads, directly or indirectly, to a reduction in tubal motility increases the risk for tubal pregnancy • Previous PID – chlamydia infection • Previous ectopic pregnancy • Tubal ligation • Previous tubal surgery • Intrauterine device • Prolonged infertility • Multiple sexual partners

Risk factors:

Pathology of Ectopic Pregnancy • Fertilized ovum borrows through the epithelium • Zygote reaches the muscular wall • Trophoblastic cells at zygote periphery proliferate, invade, and erode adjacent muscularis • Maternal blood vessels disrupted leading to hemorrhage

• THE OUTCOME OF ECTOPIC PREGNANCY – The muscle wall of the tube has not the capacity of uterine muscles for hypertrophy and distention and tubal pregnancy nearly always end in rupture and the death of the ovum. – Tubal abortion – usually in ampullary about 8 weeks – forming pelvic haematocele – Rupture into the peritoneal cavity • Occur mainly from the narrow isthmus before 8 weeks or later from the interstitial portion of the tube. Haemorrhage is likely to be severe. • Sometimes rupture is extraperitoneal between the leaves of the broad ligament – Broad ligament haematoma. Haemorrhage is likely to be controlled

Other Signs: • Tachycardia, Low grade fever • Chadwick’s sign (cervix and vaginal cyanosis) • Hegar’s sign (softened uterine isthmus) • Hypoactive bowel sounds • Cervical Motion Tenderness • Enlarged uterus • Tender pelvic or adnexal mass • Cul-de-sac fullness • Decidual cast (Passage of decidua in one piece) Signs suggestive of ruptured ectopic pregnancy: • Usually between 6 and 12 weeks gestation • Severe abdominal tenderness with rebound, guarding • Orthostatic hypotension

Diagnosis: -ultrasound - the most reliable method of verification of ectopic pregnancy -levels of β-h. CG - more often levels are lower than in normal pregnancy -laparascopy -laparatomy -culdocentesis (a less commonly performed test that may be used to look for internal bleeding)

• Differential diagnosis: 1. 2. 3. 4. 5. Salpingitis Abortion Appendecitis Torsion of pedicle of ovarian cyst Rupture of corpus luteum or follicular cyst 6. Perforation of peptic ulcer.

MANAGEMENT Depending on the presentation: v Acute… with ruptured ectopic and intra-abdominal bleeding…. ABC, , , + surgical approach. v Early stages, with intact ectopic: 1. Expectant… decreasing B-h. CG …. Tubal abortion 2. Medical… Depending on size of ectopic and level of B-h. CG…. . Use methotrexate…. . Not common approach 3. Surgical

Surgical Management v Conservative, Open vs laparoscopic…. . Linear salpengotomy vs milking of the tube v Radical, laparoscopic vs open ……. salpengectomy Ø Fertility post ectopic surgery…

SURGICAL TREATMENT OF ECTOPIC PREGNANCY The debate goes on LAPAROTOMY? VS. LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY?

COMPARING LAPAROTOMY Vs LAPAROSCOPY Hospital cost Post operative adhesions Risk of future ectopic Future fertility Experience of Surgeon Instruments L’tomy More? More Same Trained General L’scopy Less? Less Same Special

SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY v The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment v Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.

Treatment: -metotrexate (if the mass is less then 3. 5 cm in diametar) -laparascopy, laparatomy (if the mass is greater than 3. 5 cm in diametar, internal bleeding, cardiovascular colapse) SALPINGOSTOMY SALPINGECTOMY

n Treatment: n If haemorrhage and shock present n n n Restore blood volume by the transfusion of red cells or volume expander Proceed with Laparotomy The earlier diagnosis of tubal pregnancy has allowed a more conservative approach to management where the tube is less damage. n n Pregnancy removed from the tube by laparoscopy (salpingostomy) hopefully retaining tubal function. Trophoblast destroyed by chemotherapeutic agent such as methotrexate

• DIAGNOSIS: – BHCG level – TVU • Medical Managment – Methotrexate 1 mg/kg body weight • Indicationss: – Haemodynamically stable, no active bleeding, No haemoperitneum, minimal bleeding and no pain – No contra indication to methotrexate – Able to return for follow up for several weeks – Non laparoscopic diagnosis of ectopic pregnancy – General anaesthesia poses a significant risk – Unruptured adenexal mass < 4 cm in size by scan – No cardiac activity by scan

• HCG does not exceed 5000 IU/L – Contraindications: • Breastfeeding • Immunodeficiency / active infection • Chronic liver disease • Active pulmonary disease • Active peptic ulcer or colitis • Blood disorder • Hepatic, Renal or Haematological dysfunction

• Side Effects: – Nausea & Vomiting – Stomatitis – Diarrhea, abdominal pain – Photosensitivity skin reaction – Impaired liver function, reversible – Pneumonia – Severe neutropenia – Reversible alopecia – Haematosalpinx and haematoceles

• Treatment Effects: – Abdominal pain (2/3 of patient) – HCG during first 3 days of treatment – Vaginal bleeding • Signs and Treatment failure and tubal rupture: – Significantly worsening abdominal pain, regardless of change in serum HCG (Check CBC) – Haemodynamic instability – Level of HCG do not decline by at least 15% between Day 4 & 7 post treatment – or plateauing HCG level after first week of treatment

• Follow-Up: – Repeat HCG on Day 5 post injection if <15 % decrease – consider repeat dose – If BHCG >15 recheck weekly until <25 ul/l – Surgery should also considered in all women presenting with pain in the first few days after methotrexate and careful clinical assessment is required. If these is significant doubt surgery is the safest option SURGICAL MANAGEMENT: » Laparoscopy approach – salpingostomuy » Laprotomy – salpingostomy » salpingectomy

MANAGEMENT OF ECTOPIC PREGNANCY 1. Positive pregnancy test Lowe abdominal pain + Minimal Vaginal bleeding Asymptomatic with factors for ectopic pregnancy Risk factors Previous ectopic pregnancy Previous PID Tubal surgery Tubal Surgery Tubal pathology (PID, endometriosis Infertility, ovarian stimulation IUCD failure Sterilization failure Previous abdominal surgery DES exposure in utero Multiple sexual partners 2. History + clinical examination

If sure of date of LMP and /or Regular cycle, i. e. >6 wks. gestation, Arrange TV ultrasound If unsure of date of LMP and /or irregular cycle, Measure serum h. CG If h. CG <100 (? early Intrauterine/ ? Ectopic pregnancy If Hcg >1000, use protocol for suspected Ectopic pregnancy 3. Empty uterus + free fluid in POD + adnexal + FH serum h. CG > 1000 Meet criteria for Methorexate treatment Use methotrexate protocol Does not meet criteria for methotrexate treatment Laproscopic /salpingotomy/ Salpingectomy ? Proceed to laparotomy OR Laparotomy if haemodynamically unstable

Repeat Ectopic Pregnancy The rate of repeat ectopic pregnancy after a single ectopic pregnancy ranges from 8% to 20%, with a mean of 15%. Only about one of three nulliparous women who have an ectopic pregnancy ever conceives again (35%), and about one third have another ectopic pregnancy (13%). After two ectopic pregnancies, infertility rates as high as 90% have been reported

10/2/2020 A Amani Abd elgader 41

10/2/2020 A Amani Abd elgader 42

10/2/2020 A Amani Abd elgader 43

10/2/2020 A Amani Abd elgader 44

10/2/2020 A Amani Abd elgader 45

10/2/2020 A Amani Abd elgader 46

10/2/2020 47

Ø Ectopic pregnancy is a life threatening condition & on the increase Ø Not all cases present with a classical picture Ø ALWAYS suspect ectopic pregnancy in a woman of a child-bearing age c/o pain and/or p. v. bleeding Ø Early diagnosis and management is feasible {EPAC}, which should be available in referral centers Ø Tailor your management on the patient presentation. +/_ F. up

Thank you for your patience!!

Thanks 10/2/2020 A Amani Abd elgader 51