15b-ectopicpregnancy-090507104012-phpapp02-130825152041-phpapp01

7/27/2019 15b-ectopicpregnancy-090507104012-phpapp02-130825152041-phpapp01

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Ectopic Pregnancy


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An ectopic pregnancy is a gestationthat implants outside of the

endomitrial cavity. It represents a

serious hazard to a womans health

and reproductive potential, requiring

prompt recognition and earlyaggressive intervention.


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More than 95% of ectopic pregnancies

implant in various anatomic segments ofthe fallopian tube, including the

interstitial (1%), isthmic (5%), ampullary

(85%), and infundibular portions (9%).

Other less common sites of ectopic

implantation are the uterine cervix, ovary,

and the peritoneal cavity (Fig. 1).


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Fig. 1. Possible locations of ectopic pregnancy


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Epidemiology

Since the early 1970s, the incidence ofectopic pregnancy has tripled, and

currently this condition represents the

fourth leading cause of maternalmortality overall (4%) and the most

common cause of maternal mortality in

the first trimester. Several factors havebeen implicated as contributing to this

increased incidence:


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Improved technology, which has allowed

for earlier and more complete diagnosisof some patients whose condition wentundetected in the past.

The rising incidence of acute and chronicsalpingitis, induced abortion, tuballigation, tubal reconstructive surgery, and

conservative management of tubalpregnancy, all of which result inhistologic and structural damage to thetubes.


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The use of intrauterine contraceptive

devices (IUDs). Women with IUDs arefour times more likely to suffer from an

ectopic pregnancy. This effect is due to

the better protection afforded by IUDsagainst intrauterine compared with

extrauterine pregnancy and the higher

incidence of pelvic inflammatory diseaseamong IUD users.


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The overall incidence of

ectopic pregnancy is estimated

to be at least one in every 200

pregnancies.


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Etiology Probably as many as 50% of cases result from

alteration of tubal transport mechanismssecondary to damage to the ciliated surface of

the endosalpinx caused by infections such asChlamydia and gonorrhea. Others are theresult of intrinsic abnormalities of the fertilizedovum and possibly transmigration of the

oocyte to the contralateral tube, with resultingdelays in passage.


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Evolution

Tubal pregnancies rapidly invade the

mucosa, feeding from the tubal vessels,

which become enlarged and engorged.The segment of the affected tube is

distended as the pregnancy grows.

Possible outcomes of such abnormalgestations are as follows:


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The pregnancy is unable to survive owing

to its poor blood supply, thus resulting ina tubal abortion and resorption, or it is

expelled from the fimbriated end into the

abdominal cavity. The pregnancy continues to grow until

the overdistended tube ruptures, with

resulting profuse intraperitoneal bleeding.


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In rare instances, a tubal pregnancy will

be expelled from the tube and seed onto

sites in the abdominal cavity (e.g. theomentum, the small or large bowel, or the

parietal peritoneum), and gives rise to a

viable abdominal pregnancy.


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Symptoms and Clinical Diagnosis

High risk factors can be

summarized as follows:


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A history of tubal infection (ectopic rate

of 1 in 24, as opposed to 1 in 200 innoninfected patients)

Prior ectopic pregnancy (15% to 50%increase in incidence of ectopic gestationin subsequent pregnancies)

History of tubal sterilization within thepast 1 to 2 years (higher incidence ifcauterization was used)


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History of tubal reconstructive surgery(tuboplasty or end-to-end reanastomosis

for sterilization reversal)

Pregnancy with an IUD in place or ahistory of IUD use.

Infertility.


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More than one therapeutic abortion

(controversial)

Pregnancy resulting from failed postcoitalcontraception (probably associated with

abnormal tubal transport)


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The classic symptom triad

amenorrhea,vaginal bleeding,

abdominal pain.


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Abdominal pain, usually in the lower abdomen

in early cases, or generalized in rupturedectopics with a hemoperitoneum. Amenorrhea

or a history of an abnormal last menstrual

period is found in 75% to 90% of ectopicpregnancies. Vaginal bleeding, from spotting

to the equivalent of a menstrual period, results

from a low human chorionic gonadotropin(hCG) production by the ectopic trophoblast

and is seen in 50% to 80% of patients.


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Making the diagnosis of an acutely

ruptured ectopic pregnancy is fairlystraightforward. The patient presents with

symptoms of increasing abdominal pain,

abdominal distention, and hypovolemia.The entire abdomen is acutely tender with

guarding and rebound tenderness.


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Physical examination in patients with an unruptured

ectopic pregnancy may be extremely variable. Ninetypercent have abdominal tenderness, but only 45%

have positive rebound tenderness, and only 50 %

have an adnexal mass on pelvic examination. In half

the cases, the mass is contralateral to the ectopicpregnancy and represents the corpus luteum. Twenty

percent present with bilateral adnexal masses owing

to the presence of a contralateral coupus luteum cyst.

The uterus is soft and either of normal size or slightlyenlarged.


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Differential Diagnosis

Many gynecologic and

nongynecologic disorders havesymptoms in common with ectopic

pregnancy. Gynecologic disorders to

be considered include:


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Threatened or incomplete abortion (also

presenting with pain, bleeding, and apositive pregnancy test)

A ruptured corpus luteum cyst

(abdominal pain, moderate to severe, attimes coexisting with a history ofamenorrhea, vaginal spotting, and

presence or absence of pregnancy, andevidence of hemoperitoneum)


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Acute pelvic inflammatory disease with

fever, abdominal pain, leukocytosis, and,

at times, adnexal masses.

Adnexal torsion Degenerating leiomyoma (common in

pregnancy)


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The key to the successful management of

ectopic pregnancy is early diagnosis. Althoughthe number of new cases has increased

threefold, fewer are arriving at the hospital

ruptured, with the patient already in

hemorrhagic shock. This decrease is evidence

that a high index of suspicion and vigorous

efforts at early diagnosis are effective.


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-hCG testing

Human chorionic gonadotropin is consisting of

two linked subunits, and. -hCG is secreted

by both the cytotrophoblast and the

syncytiotrophoblast and has the sole functionof supporting the corpus luteum. Abnormal-

hCG can not provide information on the

location of the pregnancy. Ultrasonographymust be used to locate the gestation.


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The sensitivity of the current methods for

detection of -hCG in the maternal serum

allows the confirmation of pregnancyeven before a missed period.


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Ultrasonography

This field has shown rapid technological

improvements in recent years, and its

application to the diagnosis of ectopic

pregnancy, alone and in combination withhCG testing, is now the standard of care.

Transvaginal ultrasonography has allowed the

detection of an intrauterine gestational sac atas early as 5 weeks of amenorrhea (2 mm

diameter).


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If the sac is not visualized at the uterine

cavity, special attention is needed todifferentiate between a true sac and a

pseudosac, which is a ring-like structure

produced on ultrasound by a prominentdecidual echo. Evidence of

hemoperitoneum may be inferred by the

sonographic description of free fluid inthe cul-de-sac.


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Culdocentesis

Culdocentesis is the technique by which a needle,

attached to a syringe, is inserted transvaginally

through the posterior vaginal fornix into the pouch of

Douglas to detect any fluid within the peritonealcavity (Fig. 2). Although the procedure is simple,

inexpensive, and rapid, it is quite uncomfortable for

the patient and is of limited use in an unruptured

ectopic pregnancy. It is unnecessary when thediagnosis is obvious and has a high false-negative

rate.


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Fig. 2. Technique for culdocentesis


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Management

Emergency treatment

Surgical treatment

Laparotomy

laparoscopy

Medical treatment

Expectant management


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Emergency treatment

Immediate surgery is indicated when the

diagnosis of ectopic pregnancy with

hemorrhage is made. Transfusion withwhole blood or an appropriate blood

component therapy as soon possible is

indicated when the patient is in shock.


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Surgical treatment

Rapid entry into the abdomen should be

accomplished, as control of hemorrhage can be

lifesaving. Careful, fast exploration of the

abdominal cavity should be done at once.Remove products of conception, clots, and free

blood. At operation the damaged tube is

usually removed. This procedure is the mostcommon for ectopic pregnancy.


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The type of procedure performed by either

laparoscopy or laparotomy will be dictated by

local findings at the time of surgery and thedesire of the woman for future fertility. In

patients who with to conserve fertility, a linear

salpingostomyis the treatment of choice inunruptured ampullary pregnancies. In ampullary

pregnancies that have already ruptured, a

segmantal resection or partial salpingectomycan

be offered, which implies the removal of only

the affected segment of tube, leaving the rest

intact.


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Medical treatmentUnruptured ectopic pregnancy

can be treated withMethotrexate (MTX).


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Indications

no contraidications to MTX

type of unruptured or abortion

unruptued mass


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Expectant management

As many as 80% of ectopic pregnancies with

hCG levels of 1000mIU/ml or less will not

ruture spontaneously or bleed profusely but

will undergo spontaneous resolution.Expectant management is generally

reserved for reliable, relatively asymptomatic

patients in whom the hCG titers are


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Treatment of Uncommon Types of

Ectopic Pregnancies

Ectopic pregnancy and tubal pregnancy are

terms used interchangeably because other sites

of ectopic implantation are rare. A pregnancy

can implant on the surface of the ovary. Thetreatment is aimed at removing the pregnancy

and sacrificing as little as possible of the ovarian

tissue.


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Cervical pregnancy usually presents with profuse

vaginal bleeding, and attempts at removal of the

pregnancy are often unsuccessful. Hysterectomy

is frequently indicated and is usually quitedifficult. In more recent years, methotrexate and

arterial embolization have been used to manage

cervical pregnancy.


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All of the following therapeutic procedures are

recommended for ectopic pregnancy EXCEPT:

A salpingectomy

B salpingo-oophorectomy

C partial salpingectomy

D salpingostomy

Likely reasons for the establishment of an ectopic


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Likely reasons for the establishment of an ectopic

tubal pregnancy include all of the following

EXCEPT:

A pelvic infection

B peritubal adhesions

C transmigration of fertilized ovum

D uterine myoma

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