G-Y in Gynaecology: Ectopic Pregnancy – themedideas Facts & Figures

  • Saturday, August 10th, 2013

Updated on 01/11/2016

Evidence Based unbiased information

33 Right unruptured ectopic pregnancy 

Ectopic pregnancy is the implantation and development of fertilized ovum outside the normal uterine cavity. The incidence is about 1% of pregnancies. It is a life-threatening condition and often the diagnosis is delayed. The best way to avoid missing an ectopic is to consider abdominal pain in all women of reproductive age as ectopic.

This article has included the majority of the information required in the exams and clinical practice in an objective style comprehensively.

Word count = 3353

 Ectopic Pregnancy

Definition

Ectopic pregnancy is the implantation and development of fertilised ovum outside the normal uterine cavity.

Incidence

About 1% of pregnancies

Sites

* Fallopian tubes (commonest, 95%)

* Angular (cornu of the uterus)

* Cornual (rudimentary horn of the bicornuate uterus)

* Ovaries

* Cervix

* Abdominal cavity

* Broad ligament

* Caesarean section scar

* Myometrium

Heterotopic ectopic pregnancy

* One of the multiple pregnancy lies outside the normal uterine cavity.

* The incidence is 1:4000 to 1:3000 pregnancies.

* In women receiving in vitro fertilization and embryo transfer, the incidence is 1% to 3%.

Ectopic pregnancy following hysterectomy

* It has been reported in the literature.

* As long as the ovaries are present, ectopic pregnancy is possible.

* Only 56 cases of ectopic pregnancies after hysterectomy have been reported. Thirty-one of such cases were diagnosed and treated in the immediate period after hysterectomy (“early presentation“) and were pregnancies presumed to have been present at the time the hysterectomy was performed. Twenty-five cases of “late presentation” ectopic pregnancy after hysterectomy have been reported.

* Presumably, the sperm enters the tube through tubo-vaginal fistula or prolapse of the fallopian tubes through the vaginal vault. The risk increases if pelvic peritoneum is not closed during hysterectomy.

* Sometimes the diagnosis is not even suspected until laparotomy.

* Every woman with intact ovaries, despite previous hysterectomy, who presents with abdominal pain, should be screened for pregnancy.

* “Early presentation” ectopic pregnancies can be prevented with adequate contraception before hysterectomy or by avoiding operating in the periovulatory or luteal phase of the menstrual cycle.

* “Late presentation” ectopic pregnancies after hysterectomy are likely to be dependent on the type of hysterectomy performed and the presence of a residual cervix.

Tubal pregnancy

Sites

* Ampulla (commonest, 55%)

* Isthmus (25%)

* Infundibulum (18%)

* Iinterstitial (2%)

Causes and risk factors

* Chronic salpingitis (commonest)

* Tubal adhesions

* Previous ectopic pregnancy (x10)

* Failed tubal sterilisation (x9)

* Previous tubal surgery (x4.5)

* H/O PID (x4)

* Progestogen only pill

* Ovulation induction with clomiphene

* Tubal kinking due to fibroid or broad ligament cyst

* Developmentally defective tube (elongation, accessory ostia, diverticula etc)

* Transperitoneal migration of ovum (contralateral corpus luteum in 10% cases)

* Early degeneration of the zona pellucida

* Enhanced decidual reaction

* In-utero exposure to diethylstilboestrol etc.

IUCD use and ectopic

* IUCD usage reduces the incidence of intrauterine pregnancy by about 99.5%

* IUCD usage reduces the incidence of tubal pregnancy by about 95%

* IUCD usage does not reduce the incidence of ovarian pregnancy

* So, if pregnancy occurs during IUCD usage, the ratio of tubal:intrauterine pregnancy would be about 7 times higher (more with conventional progesterone releasing IUCD, not with levonorgestrel-releasing IUS) but the absolute number of ectopic pregnancies would be lower than that of non-contraceptive users. Therefore, if a woman does not use any contraceptive she would have greater risk of ectopic pregnancy than her risk of having that if she was using IUCD.

Other facts

*Risk factors are present in 25% to 50% of patients

*The incidence is about 8 times more common in women with history of infertility

*The right side is commonly affected

*The chance of repeat ectopic is about 10%

*The chance of viable pregnancy following ectopic is 40-60%

*Intramuscular implantation occurs in the tube

*The decidua in the uterus contains no chorionic villi

Fate of tubal pregnancy

* Tubal abortion (commonest)

* Tubal mole

* Tubal rupture

* Tubal perforation

* Secondary abdominal or broad ligament pregnancy

* Continuation of the pregnancy in the tube (rarest)

Time of rupture (approximate)

* Isthmus during 6-8 weeks

* Ampulla during 8-12 weeks

* Interstitial around 16 weeks

Causes of vaginal bleeding in disturbed ectopic pregnancy

* Decidual separation

*Bleeding coming through the uterine cornu from tubal abortion in interstitial pregnancy

Arias-Stella reaction

* Adenomatous change of the endometrial glands (intraluminal budding, loss of polarity of cells, hyperchromatic nuclei, vacuolated cytoplasm and occasional mitosis) is associated with ectopic pregnancy in 10-15% (non-specific).

Clinical features of acute ectopic (rupture/tubal abortion)

* Amenorrhoea (about 6-8 weeks, may be absent)

* Lower abdominal pain of acute onset

* Vaginal bleeding (usually preceded by abdominal pain)

* Fainting attacks

* Shoulder tip pain

* The woman lies quiet (cf. acute PID, the woman tosses on the bed)

* Disproportionate pallor and tachycardia

* Hypotension

* Abdomen tender + rebound tenderness + muscle guard

* Extreme tenderness on moving the cervix (cervical excitation) and over the fornix

* Uterus normal sized or slightly bulky

Clinical features of chronic ectopic (tubal mole/abortion)

* Amenorrhoea (about 6-8 weeks)

* Intermittent lower abdominal pain + fainting attacks (more common, in about 70% cases)

* Vaginal bleeding

* Disproportionate pallor and tachycardia

* Lower abdomen tender + muscle guard

* Tender irregular mass in the postero-lateral fornix encroaching the POD

* Normal sized or slightly bulky uterus pushed to the opposite side by the mass

Clinical features of undisturbed ectopic

* Amenorrhoea

* Lower abdominal discomfort

* Tenderness/mass in the fornix

Diagnosis

* History

* Examination

* Investigations (Urinary pregnancy test, Serum βhCG, Pelvic ultrasound scan, Laparoscopy)

− Acute ectopic is suspected/diagnosed by a history of amenorrhoea and acute lower abdominal pain/vaginal bleeding, tachycardia, hypotension, disproportionate pallor, abdominal tenderness, signs of intraperitoneal haemorrhage, positive cervical excitation, tenderness in the fornix, positive pregnancy test etc.

− The majority of the ectopic pregnancies are diagnosed before they present with such acute features.

− Urinary pregnancy test, serum βhCG, pelvic ultrasound scan and laparoscopy are the main modalities in investigating undisturbed/chronic ectopic pregnancies.

− Serum progesterone and inhibin A levels might be useful and the role of estradiol, VEGF-A, placental proteins etc are being investigated.

− Culdocentesis and uterine curettage have limited value.

− The diagnosis is missed in 20-25% (1 in 4-5) cases.

− The presentation to treatment interval is over 48 hours in 40-50% and over 1 week in 20-25% cases.

* Urinary pregnancy test

− The modern tests are very sensitive and a negative test after missed period implies absence of pregnancy.

− The ELISA test becomes positive with a βhCG concentration of 25-50  IU/L (27th day of the cycle, sensitivity 98% to 100%).

* Serum βhCG

– The serum βhCG becomes positive from 5 to 9 days postconception by immunometric radio assays (detection limits <5 IU/L; sensitivity 100%).

− In early pregnancy, the serum βhCG levels double in approximately 48 hours in intrauterine pregnancy and increase by <66% in 48 hours in ectopic pregnancy.

− In about 15% of intrauterine pregnancies and in about 13% of ectopic pregnancies the doubling time is abnormal. It could be inconclusive in cases of miscarriage of intrauterine pregnancies.

* Pelvic ultrasound scan

– The transvaginal scan is more sensitive than a transabdominal scan and the diagnosis of normal or abnormal pregnancy can be made one week earlier than is possible using the latter. It can detect an intrauterine gestational sac at 4 weeks and 2 days amenorrhoea, the double decidual sign at 5 weeks, the yolk sac and an embryo at 5-6 weeks and fetal heart beat by 6 weeks of gestation.

− On transvaginal ultrasound a gestational sac can be seen with the serum βhCG concentration of 1000-1500 IU/L (6000-6500 IU/L for transabdominal ultrasound). This has a diagnostic sensitivity of 95-99% and a specificity of 95-100% for ectopic pregnancy. Absence of an intrauterine gestational sac with such concentration of serum βhCG implies an ectopic pregnancy or a recent complete miscarriage. In multiple pregnancy the levels of serum βhCG would be slightly higher and would take another 2-3 days for a sac to be detected. In case of ectopic pregnancy, a pseudo-sac (single ring image, due to decidual reaction in the endometrium) may give a false impression of an intrauterine pregnancy. However, presence of a viable intrauterine pregnancy does not exclude the possibility of heterotopic pregnancy. The ultrasonic findings suggestive of ectopic pregnancy include – empty uterus, intrauterine pseudo-sac (single ring image, double ring is found in intrauterine pregnancy due to decidua capsularis and parietalis), a tubal ring (doughnut or bagel sign) with a fetal heart beat, adnexal mass, ill-defined tubal ring with fluid in the pouch of Douglas etc.

− If ultrasound alone is used about 25% of ectopic pregnancies would be missed.

− Colour Doppler has been used to investigate establishment of uteroplacental circulation in early pregnancy and for the early recognition of normal and abnormal intrauterine pregnancy and ectopic pregnancy. In case of difficulty, colour and pulsed Doppler increases the sensitivity of transvaginal ultrasound.

* Laparoscopy

– It establishes the diagnosis in suspected cases (false negatives 3-4%; false positives about 5%).

Differentiating features from D/D                                                                               

* Inevitable/incomplete miscarriage

– Vaginal bleeding usually precedes abdominal pain

− General condition proportionate with visible blood loss

− Absence of signs of intraperitoneal bleeding

− Absence of cervical excitation

− Products of conception may be seen at external os

− Intrauterine gestational sac or products of conception in scan

* Complete miscarriage

– Vaginal bleeding usually precedes abdominal pain

− History of presence of intrauterine pregnancy in scan

− General condition proportionate with visible blood loss

− Absence of signs of intraperitoneal bleeding

− Absence of cervical excitation

* Urinary tract infection in pregnancy

– Increased frequency of micturition

– Dysuria, urgency

– Loin/suprapubic pain/ tenderness

– Absence of signs of intraperitoneal bleeding

– Evidence of infection in urine sample

– Intrauterine pregnancy in scan

* Salpingitis

– Absence of amenorrhoea

− Bilateral lower abdominal pain

− Absence of vaginal bleeding

− Presence of vaginal discharge

− The woman tosses on the bed (remains quiet in ectopic)

− Absence of pallor, rather looks flushed

− Raised temperature

− No signs of intraperitoneal bleeding

− Bilateral tenderness in the fornices (usually)

− Negative pregnancy test

− Absence of pregnancy in the scan

− Raised white cell count and CRP

− Positive high vaginal and intracervical swabs

* Twisted ovarian cyst

– History of presence of ovarian cyst

− Nausea, vomiting

− Absence of amenorrhoea

− Absence of pallor

− Absence of signs of intraperitoneal bleeding

− Negative pregnancy test

− Ovarian cyst in scan

* Ruptured corpus luteal cyst

– Absence of amenorrhoea

− Negative pregnancy test

− Absence of pregnancy in scan

* Ruptured endometrioma

– Absence of amenorrhoea

− History of endometrioma

− Negative pregnancy test

− Absence of pregnancy + endometrioma in scan

* Acute appendicitis

– Absence of amenorrhoea and vaginal bleeding

− No history of appendicectomy

− Pain, vomiting and temperature (usually appear in that order)

− Pain usually starts around the umblicus

− Pain and tenderness settles down to the McBurney’s point (right iliac fossa)

− Absence of cervical excitation and tenderness in the fornices (in case of pelvic appendix the right fornix may be tender)

− Negative pregnancy test

− Absence of pregnancy + suggestive findings in the appendix in scan

− Raised white cell count and CRP

* Irritable bowel syndrome

– Absence of amenorrhoea and vaginal bleeding

– Variable abdominal pain

– Abdominal bloating, dyspepsia

− Absence of cervical excitation (fornices, occasionally, may be tender)

− Negative pregnancy test

− Absence of pregnancy in scan

 

Management

Acute ectopic

* Resuscitation, arrangement for blood (4-6 units) and immediate laparotomy for ipsilateral salpingectomy.

* The ipsilateral ovary is removed only if it is pathological or adherent to the tube/gestational sac to such an extent that removal of the ectopic leaving the ovary would be unsafe.

* In some cases of interstitial rupture with uncontrollable bleeding and poor general condition of the woman, a subtotal hysterectomy may be required.

Chronic or undisturbed ectopic

* Conventionally ipsilateral salpingectomy is performed.

* In women who wish to preserve their fertility a conservative approach would be more appropriate, especially if the other tube is damaged or has been removed before.

* If facilities are available, a laparoscopic approach is preferable to laparotomy as it is associated with shorter hospital stay and postoperative recovery, less postoperative analgesic requirements and reduced costs.

* The reproductive outcome following conservative management with laparoscopy is comparable with that after laparotomy: subsequent intrauterine pregnancy 61% versus 53% and subsequent ectopic pregnancy 14% versus 7%. Subsequent persistent trophoblastic tissue is more common after laparoscopic conservative management compared to laparotomy (8% versus 4%).

Conservative management

Indications

* The woman wants to maintain fertility

* The other tube is damaged or removed

* The affected tube is minimally damaged

Contraindications

* Haemodynamically unstable patient

* Ruptured ectopic pregnancy with severe tubal damage or severe haemorrhage

* Sterilised patient

* Patient does not desire further pregnancy

* Second ectopic pregnancy in a tube previously treated conservatively

* Frozen pelvis with severely damaged tube

Methods

Surgical

* Salpingostomy (ampullary)

* Linear salpingotomy (ampullary)

* Resection and end to end anastomosis (isthmial)

* Milking (infundibular, better avoided as it is associated with higher incidence of postoperative bleeding, persistent trophoblastic tissue and may cause damage to the endosalpinx predisposing to ectopic in future)

* Aspiration of the affected segment

Surgically administered medical (SAM) treatment

* In this technique a trophotoxic substance is injected into the ectopic pregnancy or into the affected tube.

* The aim is to obtain trophoblastic destruction without risk of systemic side effects.

* The trophotoxic substances used include methotrexate (commonest), prostaglandin F2-alpha, hyperosmolar glucose solution (50%) etc.

* The methods of administration include laparoscopy (commonest), transvaginal under sonographic control, transabdominal percutaneous under sonographic control, hysteroscopy and falloposcopy.

* Presence of fetal heart motion is a relative contraindication to methotrexate as the former may persist for 5 to 6 days after methotrexate. In this circumstance potassium chloride can be injected into the fetal heart to stop it, followed by methotrexate.

* Initially the serum bhCG concentration  rises from day 1-4 following methotrexate and becomes undetectable in 4 weeks.

Medical

* Intramuscular methotrexate in a dose of 50 mg/sq m body surface area or 1mg/kg body weight has been used with 0.1 mg/kg oral folinic acid.

* Its successful use was first described by Tanaka et al in 1982.

Expectant management

* Before the advent of salpingectomy in 1884 (Robert Lawson Tait), ectopic pregnancies were treated expectantly with a mortality rate of about 70%, the diagnosis often being made post-mortem.

* Selected women with ectopic pregnancy diagnosed early by scan and serial serum beta-hCG may be managed expectantly, which in the past would have remained undiagnosed and resolved spontaneously.

* The success rate is variable (46-100%).

* It should only be used in suitable women and in units where appropriate monitoring facilities are available.

Contraindications of laparoscopic conservative surgery

Absolute

* Shock

* Haemoperitoneum >2000 ml

* Encysted haematocele

*Haematosalpinx > 6 cm

* Interstitial pregnancy

* In presence of contraindications to laparoscopy

Relative

* Haemoperitoneum >500 ml

* Haematosalpinx >4 cm

* Serum βhCG >20,000 IU/L

* Obesity

* Adhesions

Criteria for non-surgical conservative management

* Haemodynamically stable patient

* No active bleeding into peritoneal cavity

* Unruptured ectopic pregnancy

* Serum βhCG <10,000 IU/L

* Size of the gestation sac <3.5 cm

* Fluid in the pouch of Douglas <100 ml

* Informed consent of the patient

* Facilities of follow up by serum βhCG and ultrasound scan are available

Criteria for expectant management

* Haemodynamically stable patient

* No active bleeding into the peritoneal cavity

* Unruptured ectopic pregnancy

* Serum βhCG <800 IU/L

* Size of the gestational sac <2 cm

* Fluid in the pouch of Douglas <50 ml

* Informed consent of the patient

* Facilities of follow up by serum βhCG and ultrasound scan are available

Advantages of non-surgical over surgical conservative management

* Less hospital stay

* Avoidance of morbidity from surgery and anaesthesia

* Avoidance of peritubal or intra-abdominal adhesions due to surgery

* No scar on the tube

* Reduced cost

Disadvantages of non-surgical compared to surgical conservative management

* Diagnosis depends on ultrasound scan and estimation of serum bhCG

* Treatment may take several days

* Non-response/tubal rupture may occur in 3-4% cases and surgery may be required

* Side effects of drugs used

Follow up of patients after conservative management

* Serum βhCG concentration should be checked weekly.

* If it fails to fall below 2/3rd of its pre-treatment level or persists above 1/3rd of that level, methotrexate or surgery may be used.

Outcome of conservative management

PTT        SIUP       SEP         SIUP: SEP

Salpingectomy                     0%          38%        10%        3.8

Salpingotomy                       11%        60%        15%        4

Methotrexate                        16%        54%        8%          6.75

PTT = Persistent trophoblastic tissue

SIUP = Subsequent intrauterine pregnancy

SEP = Subsequent ectopic pregnancy

SIUP/SEP = Subsequent intrauterine pregnancy: Subsequent ectopic pregnancy ratio

* Important reproductive outcome measures are subsequent intrauterine pregnancy (SIUP) rate, subsequent ectopic pregnancy (SEP) rate and SIUP:SEP ratio

* About 1% of cases treated by salpingotomy require salpingectomy because of persistent trophoblastic tissue

* Percentage of subsequent intrauterine pregnancy after salpingotomy is substantially higher than that following salpingectomy (60% versus 38%) with a similar SIUP:SEP ratio (3.8 versus 4).

* Following salpingectomy, the risk of losing the other tube because of a subsequent ectopic would be 10%, leaving IVF as the only option. The same risk following salpingotomy would be 0.15% (1% of 15%).

* Subsequent intrauterine pregnancy rate following two ectopic pregnancies (at least one tube remaining) is 30%.

RCOG recommendations

* A laparoscopic approach to the surgical management of tubal pregnancy, in the haemodynamically stable patient, is preferable to an open approach (Grade A).

* Management of tubal pregnancy in the presence of haemodynamic instability should be by the most expedient method. In most cases this will be laparotomy (Grade C).

* In the presence of a healthy contralateral tube there is no clear evidence that salpingotomy should be used in preference to salpingectomy (Grade B).

* Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contralateral tubal disease and the desire for future fertility (Grade B).

* Medical therapy should be offered to suitable women, and units should have treatment and follow-up protocols for the use of methotrexate in the treatment of ectopic pregnancy (Grade B).

* Expectant management is an option for clinically stable women with minimal symptoms and a pregnancy of unknown location (Grade C).

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© Dr Sudipta Paul, themedideas.com, 2013

G-Y in Gynaecology: Ectopic Pregnancy – themedideas Facts & Figures
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