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ECTOPIC PREGNANCY
TUBAL PREGNANCY
CLINICAL MANIFESTATIONS
MULTIMODALITY DIAGNOSIS
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
INTERSTITIAL PREGNANCY
ABDOMINAL PREGNANCY
OVARIAN PREGNANCY
CERVICAL PREGNANCY
CESAREAN SCAR PREGNANCY
ECTOPIC PREGNANCY
The blastocyst normally implants in the endometrial lining of the
uterine cavity
1 to 2 % of all first-trimester pregnancies
6 % of all pregnancy-related deaths
TUBAL PREGNANCY
Risks
Surgeries - prior tubal pregnancy, for fertility restoration, or for
sterilization confer the highest risk
Prior STD/tubal infection
Peritubal adhesions (salpingitis, appendicitis, endometriosis)
Salpingitis isthmica nodosa, -epithelium-lined diverticula extend
into a hypertrophied muscularis layer
TUBAL PREGNANCY
Risks
Congenital fallopian tube anomalies DES exposure
Infertility, as well as the use of ART atypical implantationscornual,
abdominal, cervical, ovarian, and heterotopic pregnancyare more common
following ART
TUBAL PREGNANCY
smoking
contraceptive method failures- tubal sterilization, copper and progestin-
releasing intrauterine devices (IUDs), and progestin-only contraceptives
Evolution and Potential Outcomes
Fallopian tube lacks a submucosal layer, the fertilized ovum
burrows through the epithelium zygote comes to lie near or
within the muscularis (invaded in most cases by rapidly proliferating
trophoblast) the embryo or fetus is often absent or stunted
Evolution and Potential Outcomes
1.tubal rupture
2. tubal abortion
3. pregnancy failure with resolution
Evolution and Potential Outcomes
1.RUPTURE- the invading expanding products of conception and
associated hemorrhage may tear rents in the fallopian tube at any of
several sites
Interstitial portion-- rupture usually occurs later
Hemorrhage disrupts the connection between the placenta and membranes and the tubal wall
1. If placental separation is complete, the entire conceptus fimbriated end into peritoneal
cavity
2. If the fimbriated extremity is occluded, the fallopian tube may gradually become distended by
blood forming a hematosalpinx
Evolution and Potential Outcomes
3. ABSORBED- an unknown number of ectopic pregnancies spontaneously fail
and are reabsorbed
-hCG assays
acute ectopic pregnancy and chronic
ectopic pregnancy
acute ectopic pregnancy
high serum -hCG level
rapid growth
higher risk of tubal rupture
(-)gestational sac
(-) villi
EP
This decidual cast was passed by a patient with a tubal ectopic pregnancy. The cast mirrors the shape of the endometrial cavity, and each arrow marks the portion of decidua that lined the
cornua.
Multimodality Diagnosis
Differential diagnosis
1. Levels above the Discriminatory Zone- -hCG concentration 1500 mIU/, mL 2000
mIU/Ml Diagnosis: failed uterine pregnancy, completed abortion, or an EP; early multifetal
gestation
2. Levels below the Discriminatory Zone- With these PULs, serial - hCG level assays are
done to identify patterns that indicate either a growing or failing uterine pregnancy
Multimodality Diagnosis
Beta Human Chorionic Gonadotropin
3. Levels that rise or fall -increase the concern for EP
-hCG level is below the discriminatory threshold, are seen 2 days later for further evaluation.
no single pattern characterizes EP and that ~ of ectopic pregnancies will show decreasing -hCG
levels, the other will have increasing levels
with a failing IUP, patterned rates of -hCG level decline can also be anticipated.
rates of decline ranging between 21 and 35 % are commonly used
In pregnancies without these expected rises or falls in -hCG levels, distinction between a
nonliving intrauterine and an ectopic pregnancy may be aided by repeat -hCG level
evaluation.
Expected Minimum Percentage Decline of Initial Serum -hCG Levels to Subsequently Drawn Values for Nonliving Pregnancies
Multimodality Diagnosis
Serum Progesterone
A value exceeding 25 ng/mL excludes ectopic pregnancy with
- values below 5 ng/mL are found in only 0.3 percent of normal pregnancies
Transvaginal sonography of a pseudogestational sac within the endometrial cavity. Its cavity-conforming shape and central location are characteristic of these anechoic fluid collections.Distal to
this fluid, the endometrial stripe has a trilaminar pattern, which is a common finding with ectopic pregnancy.
Various transvaginal sonographic findings with ectopic tubal pregnancies. For sonographic diagnosis, an ectopic mass should
be seen in the adnexa separate from the ovary and maybe seen as:
(A) a yolk sac (shown here) and/or fetal pole with or without cardiac activity within an extrauterine sac
(B) an empty extrauterine sac with a hyperechoic ring
(C) an inhomogeneous adnexal mass. In this last image, color Doppler shows a classic ring of fire, which reflects increased
vascularity typical of ectopic pregnancies. LT OV = left ovary; SAG LT AD = sagittal left adnexal; UT = uterus.
Multimodality Diagnosis
Transvaginal Sonography
Hemoperitoneum
1. Sonography- anechoic or hyperechoic fluid
2. Culdocentesis- blood fills the retrouterine cul-de-sac, then additionally surrounds the uterus as
it fills the pelvis.
Fluid containing
fragments of old clots
or bloody fluid that
does not clot.
Techniques to identify hemoperitoneum. A. Transvaginal sonography of an anechoic fluid collection (arrow) in the retrouterine cul-de-sac. B. Culdocentesis: with a 16- to 18-gauge spinal needle
attached to a syringe, the cul-de-sac is entered through the posterior vaginal fornix as upward traction is applied to the cervix with a tenaculum
Multimodality Diagnosis
Laparoscopy
- direct visualization ;offers a reliable diagnosis in most cases of suspected ectopic pregnancy
- also a ready transition to definitive operative therapy
Treatment Options
Medical therapy antimetabolite methotrexate
Surgical -salpingostomy or salpingectomy
Treatment Options
Medical Management
Regimen Options
Methotrexate is a folic acid antagonist-- binds to dihydrofolate reductase, blocking the reduction of dihydrofolate
to tetrahydrofolate- de novo purine and pyrimidine synthesis is halted, which leads to arrested DNA, RNA, and
protein synthesis: highly effective against rapidly proliferating tissue such as trophoblast.
overall ectopic tubal pregnancy resolution rates approximate 90 % with its use
methotrexate embryopathy- notable for craniofacial and skeletal abnormalities and fetal-growth restriction
excreted into breast milk and may accumulate in neonatal tissues and interfere with neonatal cellular metabolism
Treatment Options
Medical Management
Treatment Side Effects
liver involvement12 %
stomatitis6 %
gastroenteritis1 %
bone marrow depression
65 -75 % of women initially given methotrexate will have increasing pain beginning several days
after therapy.
20 % of women given single-dose methotrexate will have significant pain, and 20 % of these will
require laparoscopy.
5 to 14 % of women treated initially with MTX ultimately required surgery,
4 to 20 %of those undergoing laparoscopic resection eventually received MTX for persistent trophoblast
Rupture of persistent ectopic pregnancy is the worst form of primary therapy failure -5 to 10%
Treatment Options
Medical Management
Monitoring Therapy Efficacy
Serum -hCG levels are used to monitor response to both medical and surgical therapy
After linear salpingostomy, serum -hCG levels decline rapidly over days and then more gradually, with a mean
resolution time of ~20 days
After single-dose methotrexate, mean serum - hCG levels increase for the first 4 days, and then gradually decline,
with a mean resolution time of 27 days
Lipscomb and colleagues (1998) used single-dose methotrexate to successfully treat 287
women and reported that the average time to resolutiondefined as a serum -hCG level < 15
mIU/mL, was 34 days
Treatment Options
Medical Management
Patient Selection
asymptomatic, motivated, and compliant
some classic predictors of success
low initial serum -hCG level
small ectopic pregnancy size
absent fetal cardiac activity
initial serum -hCG level is the single best prognostic indicator of successful treatment with single-
doseMTX
Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is
hemodynamically unstable
-conservative salpingostomy
-radical surgery -salpingectomy
Surgical Management
Salpingostomy
standard therapy for this is single-dose methotrexate, 50 mg/m2 body surface area (BSA).
MEDICAL VS SURGICAL
Women who are hemodynamically stable and in whom there is a small tubal diameter, no fetal
cardiac activity, and serum -hCG concentrations < 5000 mIU/mL have similar outcomes with
medical or surgical management
Expectant Management
Stovall and Ling (1992a) restrict expectant management to women with
MANAGEMENT:
Surgical management with either cornual resection or cornuostomy may be
performed via laparotomy or laparoscopy,
INTERSTITIAL PREGNANCY
During cornual resection, the pregnancy, surrounding myometrium, and ipsilateral fallopian tube are excised en bloc.
ABDOMINAL PREGNANCY
an implantation in the peritoneal cavity exclusive of tubal, ovarian, or intraligamentous
implantations
incidence of 1 in 10,000 to 25,000 live births
most are thought to follow early tubal rupture or abortion with reimplantation
ABDOMINAL PREGNANCY
Studdiford Criteria
the tubes and ovaries must be normal, with no evidence of recent or past injury
there must be no evidence of uteroplacental fistula
the pregnancy must be related only to the peritoneal surface and early enough in gestation to
eliminate the possibility of secondary implantation after primary tubal nidation
ABDOMINAL PREGNANCY
Management
Termination generally is indicated when the diagnosis is made. Certainly, before 24 weeks, conservative
treatment rarely is justified
Preoperative options
angiographic embolization
catheters placed in the uterine arteries
insertion of ureteral catheters
Bowel preparation
The principal surgical objectives involve delivery of the fetus and careful assessment of placental
implantation without provoking hemorrhage.
Cervical pregnancy. Transvaginal sonographic findings may include: (1) an hourglass uterine shape and ballooned
cervical canal; (2) gestational tissue at the level of the cervixblack arrow); (3) absent intrauterine gestational tissue
(white arrows); and (4) a portion of the endocervical canal seen interposed between the gestation and the
endometrial canal.
CERVICAL PREGNANCY
RUBIN CRITERIA
1. Cervical glands must be present opposite to the placental attachment
2. Attachment of placenta to the cervix must be intimate
3. The placenta must be below the entrance of the uterine vessels or below
the reflection of the anteroposterior surface of the uterus
CERVICAL PREGNANCY
Management
methotrexate has become the first-line therapy in stable women also can be injected directly into
the gestational sac, alone or with systemic doses
If -hCG levels do not decline more than 15 percent after 1 week, a second dose of methotrexate
can be given
CERVICAL PREGNANCY
Hung and colleagues (1996) noted higher risks of systemic methotrexate treatment failure
WITH:
o gestational age > 9 weeks
o -hCG levels > 10,000 mIU/mL,
o crown-rump length > 10 mm
o fetal cardiac activity
many induce fetal death with intracardiac or intrathoracic injection of potassium chloride
Hysterectomy
Fertility preserving options- locally/systemic MTX injection
Suction curettage/ transvaginal aspiration
Hysteroscopic removal
CESAREAN SCAR PREGNANCY
Godin
An empty uterine cavity is
identified by a bright
hyperechoic endometrial
stripe (long, white arrow).
An empty cervical canal is
similarly identified (short,
white arrow)
Last, an intrauterine mass is
seen in the anterior part of
the uterine isthmus (red
arrows).
B. Hysterectomy specimen containing a cesarean scar pregnancy. C. This same hysterectomy specimen is transversely
sectioned at the level of the uterine isthmus and through the gestational sac.