Transcript Ch.10 ECTOPIC PREGNANCY 부산백병원 산부인과 R2 서영진 Implantation anywhere (normally, endometrial lining of the uterine cavity) 2% in U.S.A >95% : involve oviduct Risk of death.

Ch.10 ECTOPIC PREGNANCY
부산백병원 산부인과
R2 서영진
Implantation anywhere
(normally, endometrial lining of the uterine cavity)
2% in U.S.A
>95% : involve oviduct
Risk of death ↑, subsequent successful pregnancy↓
 but, with earlier diagnosis,
maternal survival ↓, reproductive capacity ↓
GENERAL CONSIDERATIONS
Risk factors
- prev. tubal surgery
- prev. ectopic pregnancy
- PID, endometriosis
- prev. c/sec
- assisted reproduction: GIFT, IVF
- failed contraception
EPIDEMIOLOGY
- increase fourfold in the U.S.A from 1970 to 1992
- nonwhite, older age
- increasing causes
1. Increase STD
2. Earlier diagnosis (before resorb spontaneously)
3. Contraception (failed)
4. Tubal sterilization techniques
5. Assisted reproductive techniques
6. Tubal surgery
Mortality
- markly decreased
- improved diagnosis
& management
- but, most common
cause of the
maternal death in
first trimester
of the U.S.A
PATHOGENESIS OF ECTOPIC PREGNANCIES
Tubal pregnancy
- ampullary > isthmic > interstitial
- secondary, tubo-ovarian, tubo-abdiminal,
broad-ligament pregnancies develop
- fertilized ovum burrows through the epithelium
(because, tube lacks a submocosal layer)
 zygote comes to lie within the muscular wall
 rapidly proliferating trophoblast invades the
subjacent muscuralis
 maternal blood vessels are opened
Tubal abortion
- common in ampulla
but rupture is usual in isthmus
- if placetal separated completely, all tissues
extruded into the pelvic cavity
 disappear hemorrhage and symptoms
- some bleeding: remain the oviduct & PCDS
or forming a hematosalpinx
Tubal rupture
- the invading, expanding products of conception
may rupture the oviduct at any sites
- occur in the first few weeks in first trimester
(but, interstitial pregnancy usually occur later)
- usually, spontaneously rupture
(sometimes coitus or bimanual examination)
- rarely, undamaged conceptus into the peritoneal
cavity  lithopedion
# abdominal pregnancy
- if the greater portion of the placenta retains its
tubal attachment, further development is possible
# broad-ligament pregnancy
- into a space formed between the folds of the
broad ligament
# interstitial pregnancy (cornual pregnancy)
- 3% of all tubal pregnancy
- rupture may not occur until up to 16 weeks
- severe hemorrhage (because the inplantation site
is located between the ovarian & uterine arteries)
Multifetal ectopic pregnancy
# heterotypic ectopic pregnancy
- tubal pregnancy + uterine pregnancy
- 1/30,000  1/7,000 (assisted reproduction)
 1/900 (ovulation induction)
- after assisted reproductive technique
persistent gonadotropin level after D&C or abortion
fundus is larger than menstrual dates
more than one corpus luteum
ectopic pregnancy without vaginal bleeding
USG evidence of intra- and extrauterine pregnancy
# Multifetal tubal pregnancy
- same tube or in each tube
CLINICAL FEATURES OF ECTOPIC PREGNANCY
- depend on whether rupture has occurred
- usually, not suspect pregnancy
thinks that she has a normal pregnancy
- in contemporary prectice, symptoms and signs
of the ectopic pregnancy are often subtle or
even absent
Symptoms and signs
- pain : most frequently
abdominal and pelvic pain (95%)
G-I symptom (80%)
dizziness or headache (58%)
- abnormal menstruation
: amenorrhea (most common)
bleeding (true menstruation vs. abnormal)
if profused, incomplete abortion > ectopic preg
- abdominal and pelvic tenderness
- uterine change
: be pushed to one side due to ectopic mass
: enlarged uterus (hormonal stimulation)
: endometrium is converted to decidua
(the decidua without trophoblast suggests
ectopic pregnancy but not absolutely)
- blood pressure and pulse
: early – no change or slightly BP↓ , pulse↓
late – hypovolemic shock (BP↓, pulse ↑)
- pelvic mass
: 5-15cm, 20% (bimanual examination)
posterior or lateral of uterus
soft and elastic
: iatrogenic rupture
- culdocentesis
: identify hemoperitoneum simply
: cervix is pulled toward the symphysis pubis
16- or 18- gauze needle
through the posterior fornix into the cul-de-sac
Laboratory tests
- hemogram : Hb↓,Hct↓.WBC↑ (>30,000㎕)
- chorionic gonadotropin assays
: ELISA are sensitive to levels of chorionic
gonadotropin of 10 to 20 mIU/mL
- serum progesterone level
: >25㎍/mL – normal pregnancy (97.5% sensitivity)
but, inconclusive
Ultrasound imaging
- abdominal sonography
: if tubal pregnancy, difficult….
: using abdominal ultrasound until 5 to 6 menstrual
weeks or 28 day after timed ovulation
- vaginal sonography
: earlier and more specific
: as early as a week after missed menses
: when hCG > 1000 , G-sac is seen half the time
: detect adnexal mass, fluid collection of PCDS
DIAGNOSIS OF ECTOPIC PREGNANCY
Multi-modality diagnosis
1. Vaginal sonography
2. Serum -hCG: intiallavel and subsequent level
3. Serum progesterone
4. Uterine curettage
5. Laparoscopy and, less frequently, laparotomy
 only hemodynamically stable women,
with rupture should undergo prompt surgery
# discriminatory -hCG level
- failure to visualize a uterine pregnancy by
transvaginal ultrasound
- empty uterus + >1500 mIU/mL
100% excluding a live uterine pregnancy
- mean doubling time for -hCG : 48 hours
- if the -hCG level rises inappropriately, plateaus,
or exceeds the discriminatory level without evidence
of a uterine pregnancy, a live uterine pregnancy
can be excluded
- biopsy < curettage (sensitivity)
# serum progesterone
- its accuracy is crude
- if < 5 ng/mL or > 25 ng/mL,
neither absolutely refute nor confirm a living
uterine pregnancy
Surgical diagnosis
- laparoscopy
:direct visualization of the fallopian tube, pelvis
- laparotomy
:hemodynamically unstable
TREATMENT AND PROGNOSIS
- importantly, early diagnosis→early medical Tx
(more cost-effective than surgical therapy)
Anti-D immunoglobulin
- D-negative women who are not sensitized Dantigen should be given anti-D immunoglibulin
Surgical management
- laparoscopy > laparotomy (if stable)
- salpingostomy
: < 2cm incision, distal third of tube
small bleeding – electrocautery
incision is left unsutured
- salpingotomy
: incision is closed with Vicryl 7-0
- salpingectomy
: tubal resection (wedge of the outer third of the
interstitial portion)
- segmental resection and anastomosis
: an unruptured isthmic pregnancy
: prevent scarring and narrowing of the small
isthmic lumen
- persistent trophoblast
: increase the risk
1. small preg < 2 cm
2. early preg < 42 menstrual days
3. β-hCG > 3000 mIU/mL
4. implantation medial to the salpingostomy site
: incomplete remove of trophoblast
5~10% of salpigostomies
: post op #1
→ β-hCG value is less than 50% of preop. value
Medical management
# systemic methotrexate
- folic acid antagonist
effective against rapidly proliferating trophoblast
- contraindication
: active bleeding, >4cm, breast feeding, alcoholic,
immunodeficiency, lever or renal ds, peptic ulcer
- success rate ↑
: < GA 6 weeks, <3.5cm, -hCG<15,000 mIU/mL
fetus is dead
<patient selection>
- must be hemodymamically stable
- fails 5~10% ( higher : > 6weeks, >4cm)
require treatment : other medical or surgical
if outpatient, rapid transportation
signs of rupture must be reported promptly
until resolved, sexual intercourse(X), alcohol(X)
folic acid, vitamins (X)
table 10-3
<monitoring toxicity>
- liver involve, stomatitis, gastroenteritis
BM depression, pneumonitis, alopecia
- resolved by 3~4 days after methotrexate was
stop
<monitoring efficacy of therapy>
<persistent ectopic pregnancy>
- requires additional methotrexate or surgery
- separation pain : mild and relieved by nonnarcotic
analgesics
but, worrisome pain : Hb, β-hCG follow up, USG
Other treatment
- direct injection
: various cytotoxic drugs
laparoscopy or transvaginally by culdocentesis
- oral methotrexate therapy
: two devided doses 2 hours apart for total dose
of 60 mg/㎡
: lower success rate
- expectant management
: spontaneous resolution
: 1. Decreasing serial -hCG levels
2. Tubal pregnancies only
3. No evidence of bleeding or rupture
4. Ectopic mass < 3.5cm
: more likely if initial -hCG < 1000mlU/mL
ABDOMINAL PREGNANCY
- follow early rupture or abortion of a tubal
pregnancy into the peritoneal cavity
- placenta : after penetrating the oviduct and
maintains its tubal attachment, gradually
encroaches upon and implants in neighboring serosa
fetus : continues to growth within peritoneal cavity
Diagnosis
- difficult , because early rupture or abortion of a
tibal pregnancy is the usual antecedent
- nausea, vomiting, flatulence, constipation,
diarrhea, abdominal pain
- palpable fetal position
: close to the examining fingers (thin, multiparous)
- cervix : usually displaced
- fetal head : vaginal fornix
# laboratory tests
: unexplained transient anemia after initial tubal
rupture or abortion
: unexplained increase AFP value
# sonography
: oligohydramnios is common but nonspecific
: fetal head lie adjacent to maternal bladder
with no interposed uterine tissue
# MRI, CT
Fetal outcome
- surviving fetuses may be abnormal
- fetal deformation : cranial asymmetry
various joint abnormalities
fetal malformation: limb deficiency
CNS anomalies
Management
- risk for sudden and life-threatening bleeding
: in-hospital management
generally, termination
- suppuration, mummification, calcification
adipocere : yellowish, greasy mass
- surgery : bleeding due to the lack of constriction
of vessels after placental separation
(adequate blood supply, monitoring)
laparotomy : vertical midline incision
# management of the placenta
- avoid unnecessary exploration of other organ
must be safety removed
- if possible, blood vessel supplying the placenta
should be ligated first
- if leaving placenta : long-term sequelae (infection)
resorption (>5years)
- methotrexate use is controversal
# arterial catheterization and embolization
- preoperatively
- lifesaving in massive pelvic hemorrhage
# maternal prognosis
- higher than normal pregnancy
- reduced by preoperative planning
OVARIAN PREGNANCY
- rare
- IUD user
- similar to tubal pregnancy
- rupture at early period
Diagnosis
- serious bleeding : 1/3
- vaginal ultrasound
Treatment
- surgical : wedge resection, cystectomy, ovariectomy
- methotrexate in unruptured state
CERVICAL PREGNANCY
- rare form (1 in 18,000 pregnancies)
- increasing : assisted reproduction
(in vitro fertilization, embryo transfer)
- typically, trophoblast erodes endocervix
- 90% : painless bleeding
1/3 : massive bleeding
1/4 : abdominal pain
- identification : clinical suspicion + sonography
Surgical management
- in past : hysterectomy
(but, urinary tract injury↑, because the
enlarged barrel-shaped cervix)
- Cerclage : similar to a McDonald cerclage
Shirodkar cerclage
- Curettage and Tamponade
: hemostatic cervical suture at 3 and 9 o’ clock
suction curettage, then foley catheter(30cc)
vaginal packing tightly
- Arterial embolization
: preoperative arterial embolization
: laparoscopic uterine artery ligation
+ hysteroscopic endocervical resection
Medical management
- to avoid the risk of uncontrolled hemorrhage
- chemotherapy is the first choice in stable women
(methotrexate and other drug)
- other method (not systemically)
: directly into the gestational sac
intra-amnionically
OTHER SITES OF ECTOPIC PREGNANCY
-
Splenic pregnancy
hepatic pregnancy
retroperitoneal pregnancy
diaphragmatic pregnancy
cesarean scar pregnancy