Ectopic pregnancy

Extract

[...] Incidence Increasing in most countries Increase incidence of PID Better diagnostic modalities Use of ART Popularity of contraception Ranges between 1.5 - of all pregnancies Higher risk for women in 35-44yr age group Accounts for 10-15% of maternal death in the 1st trimester (Am Fam Physician 2000) Sites of ectopic pregnancy Fallopian tube > 95% Ampullary segment- 80% Isthmic segment- 12% Fimbrial end- Interstitial-2% Abdominal Ovarian Cervical Sites of ectopic pregnancy Risk factors High risk Previous tubal surgery Tubal sterilization Previous ectopic pregnancy IUCD Tubal pathology Slight risk Smoking Moderate risk Infertility Previous genital infection Multiple partners Natural progression Spontaneous resolution Conceptus dies early Tubal abortion Complete-extruded via fimbria when placental separation is complete Incomplete-partial expulsion Tubal rupture Uncontrolled invasion of trophoblast More often in antimesenteric border Tubal mole or carneous mole Recurrent choriodecidual haemorrhage Lithopedion Fetus dies but too large to be absorbed so lies within body and calcifies Time of rupture at various sites Isthmic-narrow,less distensible 6 8 weeks Ampullary-wide 8 12 weeks Interstitial-can hypertrophy 12 14 weeks Symptoms CLASSICAL TRIAD -lower abdominal pain -amenorrhoea -irregular vaginal bleeding May be asymptomatic in unruptured ectopic Symptoms Abdominal pain 85 Generalized- rupture, haemorrhage Localized- distension Radiating- shoulder Sudden or progressive & continuous or intermittent Symptoms Amenorrhoea and abnormal bleeding Amenorrhoea [...]

[...] DISCRIMINATORY ZONE Transvaginal USG (intrauterine pregnancy identified) hCG 1500- 1800 mIU/ml Transabdominal USG (intrauterine pregnancy identified) hCG 6000-6500 mIU/ml SERUM PROGESTERONE ASSAY Adjuvant to serum β HCG assay Serum progesterone 25 ng/ml viable intrauterine pregnancy Progesterone > 20 ng/ml rarely associated with ectopic pregnancy Sensitivity low SONOGRAPHIC FINDINGS INTRAUTERINE PREGNANCY Gestational sac with echogenic thick endometrium and fetal pole and yolk sac Double decidual sac sign Yolk sac earliest embryonic landmark SONOGRAPHIC FINDINGS EXTRAUTERINE PREGNANCY Gestational sac with thick bright echogenic ringlike structure outside the uterus with fetal pole and yolk sac Pseudogestational sac (20 Noncystic adnexal mass Extrauterine cardiac activity Tubal ring earliest evidence Free fluid in cul-de sac Hematosalpinx PSEUDOGESTATIONAL SAC LAPAROSCOPY Gold standard for detecting ectopic pregnancy Useful when inconclusive findings in USG and serial β HCG Diagnostic and therapeutic use To know the condition of unaffected fallopian tube Disadvantages invasive procedure, cost LAPAROSCOPY CULDOCENTESIS Diagnostic tool for identifying intraperitoneal bleeding Cannot differentiate between ruptured ectopic and other causes of intraperitoneal bleeding Significant when USG facilities not available COLOR FLOW DOPPLER Adenxal mass with peritrophoblastic flow Tubal blood flow 20 - increased over the ectopic site Adenxal ring sign and a “ring of fire” sign Absence of low resistance endometrial blood flow intrauterine pregnancy Management of unruptured ectopic Medical METHOTREXATE - Folic acid antagonist - Chemotherapeutic agent of choice in trophoblastic disease - Deactivates DHFR -reduces THF [cofactor for DNA and RNA synthesis] Criteria for methotrexate Hemodynamic stability Pretreatment HCG ectopic CONSERVATIVE SURGICAL TREATMENT Linear salpingostomy Linear salpingotomy Segmental resection RADICAL TREATMENT Total salpingectomy Segmental resection Preferable in isthmic pregnancy Conservative approach 1. [...]