Abstract on Ectopic Pregnancy

Report: Etopic Pregnancy (Causes, Diagnosis, DD, Management) * is a cause of Acute abdomen gyneacology due to blood in peritoneal cavity Def: EP is implantation of fertilized egg out side the uterine cavity, most commonly in fallopian tubes, but can be ovaries, abdominal cavity and cervix as well. Incidence: - Mortality rate 0.05% after surgical procedures were introduced, b/f mortality rate was 60% highest incidence in 25-34 yrs age group frequency 1:200 pregnancies most common cause of maternal mortality in 1st trimester of pregnancy more in blacks Etiology: 1) Tubal factors: (i) Infection - Acute/chronic salpingitis at present/in anamnesis. Changes the structure of fal. tubes. 30-50% of all cases of E.P. (ii) Tubal surgery - Previous tubal ligation correction of cong. Abnormalities tuboplasty end-to-end reanastomosis for sterilization reversal * Anatomy may be improved, but function may not improve very well (iii) Adhesions - Endometriosis, Appendicitis, peritonitis if late operations, adhesions develop and disturb the motility of fal.tubes. 2) Ovarian factors: fertilization of unextruded ovum post midcycle fertilization 3) Influenze of possible contraception surgical contraception : during c-section tubal contraception is made during pregnancy tubes are edematous and big. Therefore A/f coagulation and cutting, recanalisation can occur. Small spermatozoa can pass through this small opening. IUD 4) Hormonal disturbances: if there is Estrogen-Progesteron disturbances with hyper progesterenemia, it ( the peristalsis of tubes. If morning a/f pill and then pregnancy there is x 10 ( risk for E.P Post coital contraception – due to ( peristalsis of tubes and abnormal tubal transport. Stimulation of ovulation by clomiphene usage and IVF Using progesterone only pills ( 5% Using progesterone bearing IUD DES (Diethyl Stilbesterol) exposure – may cause tubal abnormalities. For the female to dev tubal abnormalities she has to be exposed to DES during her intrauterine life. 5) Zygote abnormalities: Chromasomal abnormalities. Neural tube defects Abnormal sperm count Classification: (1) According to site tubes (95%) * interstitial 1% (corneal pregnancy) single tubal E.P * isthmic 5% * ampulary 85% multiple tubal E.P * infundibulum 4% (usually bilateral) abdominal cavity 1.4% - eg placenta on liver, placenta on ren and renal vasculature (delivered through laparotomy) ovaries – 0.5% (ovorectomy, b/c of profuse bleeding) cervix – rane 0.2% (hysterectomy should be done afterwards) combined / heterotropic pregnancy (1:4000) IUP + EUP exist simultaneously in uterus most of the time (2) twins/multiple pregnancy occurs in case of MAR (medical assisted reproduction) . 2-3/100 MAR pregnancies. compound IUP + EUP superposition of IUP on the extrauterine one. (3) According to the Clinic Progressive E.P – signs symptoms are similar to the normal pregnancy. Pregnancy is going on. Goal is to dg them earlier and save the fallopian tubes. Rupture EP ( already the rupture of the fal. tubes has happened. Pulse is gentle. Blood in ab. Cavity. Slight pain can be present (smt w/o severe pain) and this slight pain can appear and disappear. Tubal abortion: When the EP in the f. tubes is thrown into the abdominal cavity by the tubal peristalsis tr ( Laparotomy & evacuation of mass. Clinic: Symptoms: 1. Pain (90-100%) – Slight or severe – Unilateral pelvic pain/crampy/in lower abdomen/generalized in rupture EP smt shoulder pain – due to irritation of phrenic nn from intraperitoneal blood Lack of menstruation – 75-95% Bloody discharge – 50-80% (it can be regular bloody discharge/spotty) Dizziness – 20-35% Signs of pregnancy – 10-25% (breast tenderness, N, V.) Tenesmus – 5-15% Uterine cast passed vaginally 7% Syncope (orthostatic changes sharp pain and loss of consciousness) Fever less specific (5-10%) Signs: 1. gyneacological examination: -painful gyneacological palpation 75-90% - enlarged uterus 20-30% (( 6 ges wk.) - adnexal mass - adnexal tenderness 2. diffuse or localized ab. tenderness 3. signs of peritoneal irritation Diagnosis: 1. absolute hCG values if pregnancy in uterus it should x 2 in 2 days if it does not double abortion/E.P. 2. progesterone level is high w/normal pregnancy 25 ng/ml w/EP >25 ng/ml 3. US can confirm E.P. (100%) 4. Cul-de-sae puncture if rupture EP non clotting blood in cul-de-sac blood Hct >15% 5. Laparoscopy – only done if rupture EP is suspected DD 1. Abortion (threatened/incomplete) 2. Rupture of corpus luteum cyst 3. Ovarian Apoplexy (rupture of the ovari) 4. Dysfunctional uterine bleeding 5. Endometriosis 6. Pelvic inflamatory disease 7. Degeneration of myoma uteri 8. Acute Appendicitis 9. Acute pyelopephritis non-gynecological 10.A. pancreatitis Management: 1st to detect EP activity evaluate the level of hCG & progesterone US diameter of EP EP Activity Non-Activity Active if progesterone level is low rising of hCG and progesterone HCG is lowering Expectant Management 1) Medical tr. (b/c in most of the cases spon. abortion through the interstitial part of the tubes and no bad consequences) 2) Surgical tr. 3) Combination of medical and surgical treatment. Local methotrexate, prostaglandin RU 486, high concentrated Glucose. 1) Medical tr. Systemic Methotrexate Criteria for systemic Methotrexate (folic acid inhibitor blocks nucleic ( acid synthesis in trophoblastic cells). - EP ( <3cm Unruptured No fetal cardiac activity C/I if maternal hepatic/renal disease Leukopenia Thrombocytopenia Dose 50 mg/m2 i/m if in serum hCG is not satisfactory 2nd dose in 1 wks time ( local tr injection of methotrexate, prostaglandin RU 486, high concentration glucose into the EP 2) Surgical treatment Laparoscopic ( of EP <3.5cm, unruptured, hemodynamically stable p’t. Approach Laparotomic hemodynamic shock EP ( >3.5cm, extensive pelvic adhesion Approach (5-10%) Conservative surgical tr. Linear salpingostomy ● salpingotomy Procedures Radical surgical tr. Salpingectomy total partial ( Conservative surgical treatment Linear salpingostomy done when middle part is involved opening of fal.tube removal of EP tubal incision is left open for spon. closure. Salpingotomy incision and suturing Management * do follow-up hCG it should be <10 u/l if not declinging give systemic methotrexate * for contraception IUD not recommended * next pregnancy confirm the location w/US check serum hCG ( Radical surgical treatment Total salpingectomy removal of the whole fal. Tube. Partial ” excision of a segment and (segmental resection) end-to-end anastomosis and suturing Indications for salpingectomy Recurrence of E.P. Badly ruptured EP No plans for future pregnancy 3) Combined Surgical and Medical tr local injection of methotrexate, prostaglandin RU 480, high concentrated glucose into the ectopic pregnancy. systemic methorexate dose of 50mg / m2, i/m given a/f conservative surgical tr. Complications: 1) Rh isosensibilisation if a female is Rh – (Anti D immunoglobulin should be given) 2) Recurrence of EP 5-10% a/f conservative surgical tr. The 2nd EP occur in the same tube To this risk bilateral salpingectomy should be done b/f IVF 3) Infertility ( 40% 4) Spon. Abortion in next pregnancy ( 15-20% 5) Maternal death 1:1000 (mainly due to hemorage) 6) Intestinal obstruction and fistula may dev a/f hemoperitoneum and peritonitis Advantages of Lap. Surgery short operative time post operative course shorten hospital stay early normal function of the patient Report on Etopic Pregnancy (Causes, Diagnosis, DD, Management) Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom.2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia.3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania. Contact: publications [at] infekcijas.eu (6)