8. Mechanical factors
Congenital: long narrow tube, diverticulae and
accessory ostia.
Traumatic: operation on the tube as salpingoplasty
and tubal reversal following ligation.
Inflammatory: Chronic salpingitis
Neoplastic: Narrowing of the tube by a fibroid or a
broad ligament tumor.
Functional: As tubal spasm or antiperistaltic
contractions.
endometriosis in the tube. encourages embedding
of the fertilized ovum.
9. RISK FACTORS
Hz of tubal surgery
Hx of STD’s (such as chlamydia)
Hx of ART
Hx of ectopic (esp if conservatively
managed without surgery)
Smoking
IUD in place at time of conception
17. •Extraperitoneal rupture (rupture through floor of the tube)
•may lead to broad ligament hematoma with death of the
ovum, or intraligamentary pregnancy.
17
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20. Symptoms & Signs:
In a woman of child bearing age with
pelvi-abdominal pain and/ or vaginal
bleeding …… ALWAYS….think
21.
Clinical Finding: Undistrubed ectopic
Amenorrhoea
A dull aching pain is usually present in
one iliac fossa. It is due to distension of the
tube and stretching of its peritoneal coat.
Classic signs –
adnexal or cervical motion
tenderness.
22. Signs:
Abdominal examination: Tenderness in one
iliac fossa.
Vaginal examination:
(cervical motion tenderness or jumping sign)
The cervix is soft and severe pain occurs
when it is moved from side to side
A mass may be felt to one side of the uterus.
It is very tender, soft and may be pulsating.
23. Subacute type:Symptoms:
Short period of amenorrhea in (25%) no history
of amenorrhea due to occurrence of post
conceptional bleeding that mistaken as a true
menstrual period
Pain: It is felt in one iliac fossa. It may be dull
aching or sharp stabbing or colicky
Fainting attacks or even shock
Vaginal bleeding occurs after pain
24. With ruptured ectopic pregnancy
abdominal guarding and rigidity,
shoulder pain
fainting attacks
and shock.
25. When a woman presents with an
early pregnancy…
Ask yourself two questions…
Where is this pregnancy?
Is it viable?
26. Where is this pregnancy?
In a woman with an early pregnancy you
must determine if the pregnancy is
intrauterine or an ectopic, because her
life could depend on it!
27. How to you determine location of
the pregnancy?
First determine dating by LMP
Then perform ultrasound
If you can see location of the pregnancy, you
are done!
If you cannot…it becomes more
complicated…
28. β-hCG discriminatory value (or zone)
It is the lower limit of hCG at which an
examiner can reliably visualize pregnancy
on ultrasound. It is 1000-2000 IU/L with
vaginal ultrasound and 5000-6000 IU/L
with abdominal ultrasound.
29. If β-hCG levels above the
discriminatory value
The absence of uterine pregnancy
signifies an abnormal pregnancy; ectopic,
incomplete abortion
If β-hCG levels are still below the
discriminatory value, serial β-hCG and
ultrasound should be done.
30. Doubling sign:
In normal pregnancy a 66% or greater increase
in serum β-hCG levels should be observed
every 48 hours (nearly doubles).
Inappropriately rising serum β-hCG levels
suggest (but do not diagnose) an abnormal
pregnancy including ectopic, however, they do
not identify its location.
33. Early pregnancy with unknown
location
Check a serum BHCG
If it is above the discriminatory zone (DZ)an
intrauterine pregnancy should be seen
Then do an ultrasound to see if you see the
pregnancy
35. Treatment of tubal pregnancy
If the patient is shocked: antishock measures.
If the patient is Rh negative and not sensitized
anti-D serum is given.
Medical therapy:
methotrexate (a folic acid antagonist).
IM methotrexate given as a single dose.
36.
The best candidate is the woman who is
asymptomatic, compliant with follow-up, with
an initial serum value <5000 IU/L.
Contraindications:
Breastfeeding
Immunodeficiency / active infection
Chronic liver disease
Active pulmonary disease
Active peptic ulcer or colitis
Blood disorder
Hepatic, Renal or Haematological
dysfunction
37. Signs and Treatment failure and tubal
rupture:
Significantly worsening abdominal pain,
Haemodynamic instability
Level of HCG do not decline by at least 15%
between Day 4 & 7 post treatment
or plateauing HCG level after first week of
treatment
38.
Follow-Up:
If the β-hCG level does not decline (plateau or
increase), the patient may require either a
second dose of methotrexate or surgery.
Surgical management:
Laparoscopy approach – salpingostomy
Laprotomy – salpingostomy
salpingectomy
39. Salpingostomy / Salpingotomy is only indicated
when:
1. The patient desires to conserve her fertility
2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 4Cm. In size
5. Contralateral tube is absent
or damaged
42. laparatomy (if the mass is greater than 3.5 cm in
diametar, internal bleeding, cardiovascular colapse)
43. Treatment:
-metotrexate (if the mass is less then 3.5 cm in diametar)
-laparascopy,or Laprotomy
SALPINGOSTOMY
SALPINGECTOMY
intrapertoneal blood then peritoneal toilet.
Removal of any pelvic hematomas or
44. Algorithm for the diagnosis of unruptured ectopic pregnancy
without laparoscopy.
45. Management of ectopic pregnancy
11- Positive pregnancy test
Lowe abdominal pain +
Minimal Vaginal bleeding
Asymptomatic with factors
for ectopic pregnancy
2. History + clinical examination
46. If sure of date of LMP and /or
Regular cycle, i.e.
>6 wks. gestation,
Arrange TV ultrasound
If unsure of date of LMP
and /or irregular cycle,
Measure serum hCG
If hCG <1000
(?early Intrauterine/
? Ectopic pregnancy
If Hcg >1000, use
protocol for
suspected
Ectopic pregnancy
3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000
Meet criteria for
Methorexate treatment
Use methotrexate
protocol
Does not meet criteria
for methotrexate treatment
Laproscopic /salpingotomy/
Salpingectomy ?Proceed to
laparotomy OR Laparotomy if
haemodynamically unstable
First, dose anybody know the meaning of this word, ectopic. Well, most of you look a little bit confused. Actually, this term is derived from Greek word ”ektopos”. It means out of place or misplaced. Knowing this, I think you can figure out the definition.板书 :定义 which means a pregnancy out of place, in other words, a pregnancy in which the embryo is implanted and develops outside the endometrial lining of the uterus .
In the previous slide, the pregancy is implanted in the fallopian tube. As a matter of fact, ectopic pregnancy can also occur at other locations.板书 According to the site of implantation , the ectopic prenancy can be classified as tubal pregnancy, ovarian pregnancy, abdominal pregnancy and cervical pregnancy. 97% of ectopic pregnancies occur in the Fallopian tube. What I would like to point out although interstitial tubal pregnancies , together with ovary, cervix, or abdomen are very rare, they represent nearly 20% of deaths due to ectopic pregnancies. The high morbidity at these locations are due to massive bleeding when they rupture.
The primary risk factor for ectopic pregnancy is a prior history of pelvic inflammatory disease, eg. previous chlamydia or gonorrhoea. It is one of the main causes of the increase seen in ectopic pregnancies in recent years. Risk of an ectopic increases about 7-fold after a woman suffers acute pelvic infection. Infection may lead to :
-destruction of the tubal epithelium with reduction or loss of ciliary current
-intratubal adhesions resulting in partial tubal obstruction
-peritubal adhesions resulting in restricted tubal motility: these figures show the peritubal adhesions that distort the tubal.
All these situations, acting alone or in combination, can slow the passage of the egg which gives it time to implant itself in the tube.
In this short animation, we can see that the sperm enters the follopian tube and meet with the ovum. However, due to some reasons, the fertilized egg is trapped here before it reached the uterus and develops into a misplaced embryo. This misplaced embryo is somewhat like a time bomb because tissues at these abnormal locations for implantation are vulnerable and thin, they cannot support and accommodate the growing embryo. After several weeks , it may rupture and cause massive intraperitoneal bleeding, resulting in a potentially serious situation.
The tubal pregnancy dose not usually proceed beyond 8-10 weeks due to : Lack of decidual reaction in the tube, the thin wall of the tube , the inadequacy of tubal lumen, bleeding in the site of implantation as trophoblast invades
Eventually, tubal pregancy will end up in either one of the following four outcomes.
1. Tubal abortion
-This occurs more if ovum had been implanted in the ampullary portion of the tube
-as shown in this figure, gestational sac is seperated is expelled into the peritoneal cavity through the tubal ostium --if explulsion was complete the bleeding usually ceases but it may continue due to incomplete separation or bleeding from the implantation site.
Tubal rupture
Rupture of tubal pregancy can cause profuse internal bleeding and even death. More common if implantation occurs in the narrower portion of the tube which is the isthmus. Rupture may occur in the anti-mesenteric border of the tube and cause intraperitoneal hemorrhage. Or rupture into the mesenteric border of the tube and develops broad ligament hemotoma .
Secondary abdominal pregnancy
Most abdomianl pregancies occur after the embryo first implants in the follopian tube, after it is aborted from the fimbrial opening of the tube and it is implanted in the abdomen structure and form a secondary abdominal pregnancy. In most cases , the baby will die to but occasionally they may survive.