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Part 2: Ectopic Pregnancy
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Definition Pregnancy occurring outside the uterus
Sites Fallopian tube 93% (ampullary 70%,
isthmic 12%, fimbrial 11.1%) Interstitial 2.4% Ovarian 3.2% Abdominal 1.3% Cervical 1%
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Incidence 1.6% all pregnancies (NSW 1998) Increasing incidence until about 1992
then plateauing/?falling (1970 0.3%, 1992 1.7%)
?decreased rates associated with contraceptive failures versus no decrease with reproductive failure
Similar rates Western countries
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Age 15-24 years: 0.7% 25-34 years: 1.3% 35-44 years: 1.9%
Mortality small but 15% all maternal deaths
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Tubal damage
Change in tubal motility
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Pelvic infection Especially chlamydial 45% of patients have evidence of prior
salpingitis on pathological specimens Laparoscopically-proven PID confers a
risk of 13% after one episode and 35% after two
Treatment of chlamydia decreases rates
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Previous tubal pregnancy 10-25% recurrence after one tubal
ectopic
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Current IUD Excellent contraceptive efficacy but
prevents implantation in uterus more effectively than in the tube
Copper IUD: 4% of contraceptive failures are ectopics
Progesterone IUD: 17% of contraceptive failures are ectopics
No increased risk once removed
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Progesterone hormonal contraceptives(Likely association)Mechanism: changes to muscular activity of
tube progesterone IUD mini-pill (4-10% of contraceptive failures
are ectopics) morning after pill Implants (30% of contraceptive failures
are ectopics)
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Infertility Without treatment – if a woman
conceives after >1 year unprotected intercourse she has 2.6 x increased risk
With treatmentSurgery such as reversal of sterilisation and tuboplastyOvulation induction (likely small increase)IVF - 2-8% all conceptions, 17% increased risk if tubal factor for infertility identified (Why- ?Fluid reflux into tube, ?embryo placed high in uterus)
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Other abdominal surgery Ruptured appendix Other? – not clear
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Smoking > 2 x risk (increased with increased dose) Nicotine affects tubal motility, ciliary
function and blastocyst implantation
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Tubal abnormalities Eg. Salpingitis isthmica nodosa
(diverticulae) – abnormal myometrial electrical activity
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In utero diethylstilboestrol (DES) exposure
4-13%
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Tubal abortionspontaneous resolutionExpulsion from the fimbrial end of the tube
Involution spontaneous resolution Rupture (usually about 8 weeks) Chronic inflammatory mass (uncommon)
hCG may be low or absentFrom bleeding into tubal wallPersistent symptoms, usually requires salpingectomy
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Classic triad (50%) Amenorrhoea Vaginal bleeding Pain
Abnormal menstrual pattern Pain of any sort – unilateral/bilateral,
dull/sharp, upper/lower abdomen
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Vital signs Abdomen
Non-tender to mildly tenderSigns of rupture: distension, decreased bowel sounds, peritonism
Cervical motion tenderness Adnexal mass (50%) – but may be the
corpus luteum
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hCG positive in virtually all ectopics presenting
Positive in unstable patient Not rising appropriately Not falling appropriately Not seeing an intra-uterine pregnancy at
hCG over the discriminatory zone(1000-2000 on transvaginal scanning)
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UltrasoundTransvaginal and transabdominal importantPresence of intrauterine sac virtually excludes
ectopic pregnancy Heterotropic pregnancy 1/30,000 (Increased
with IVF/ovulation induction) Beware pseudogestational sac of ectopic
pregnancy (sac-like fluid lucency, probably from bleeding) – ideal to see cardiac activity – yolk sac – double decidual sac sign (concentric echogenic rings)
Doppler ultrasound improves diagnosis
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Possible Ultrasound Findings Absence of intrauterine pregnancy over the
hCG discriminatory zone Adnexal gestation with fetal pole and
cardiac activity – 10-17% Adnexal rings (fluid sacs with thick
echogenic rings) – 38% Complex or solid adnexal rings (DDx corpus
luteum, other cysts, pedunculated fibroid) Intra-abdominal free fluid or cul-de-sac fluid
(the latter doesn’t necessarily represent rupture)
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Chorionic villi in saline test Useful to distinguish products of intrauterine
gestation (chorionic villi) from decidual cast of ectopic pregnancy
Chorionic villi have a lacy frond appearance and float in saline
Tissue should also be sent for histopathology to confirm
Suction curettage may be used to diagnose (hCG <2000, indeterminant ultrasound & <50% rise in hCG over 48 hours)
hCG should fall by >15% within 24 hours of evacuation of normal intrauterine pregnancy
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Culdocentesis Aspiration of fluid from cul-de-sac Positive test if non-clotting blood
obtained 70-90% of patients with ectopic
pregnancy have a haemoperitoneum Rarely used now hCG and transvaginal
ultrasound available
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Laparoscopy Gold standard for diagnosis Missed in 3-4% (if very small)
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Surgical Laparoscopy vs Laparotomy Salpingostomy vs Salpingectomy (Salpingo-oophorectomy)
Medical Methotrexate Other (RU-486, KCl, hyperosmolar glucose,
prostaglandins). Salpingocentesis
Remember Anti-D in Rh-ve women
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Laparoscopy Shorter hospital stay Less post-operative pain Less cost Shorter convalescence Less blood loss Less adhesions (but similar tubal patency
rates)
Similar: pregnancy rate, persistent trophoblast rate, operating time
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Laparotomy for Haemodynamic instability Lack of laparoscopic expertise/equipment Cornual/interstitial pregnancy Ovarian/abdominal pregnancy Patient factors eg. Obesity, adhesions
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Salpingectomy vs Salpingostomy Controversial No difference in future intrauterine pregnancy
rates?Some studies suggest differenceNot enough evidence yet
Increase in persistent trophoblast rates (failure to remove all tissue) with salpingostomy
No difference in recurrence of ectopic in future
Milking tubeFimbrial – may be effectiveAmpullary – double recurrence risk
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Salpingo-oophorectomy No evidence of decreased recurrence
rates Improved intrauterine pregnancy rates
with conservation of ovary therefore no longer performed
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Methotrexate Chemotherapeutic agent which prevents
synthesis of DNA (inhibits dehydrofolate reductase)
Much lower doses used for ectopic than malignancy
Use as primary treatment or if plateauing/ inadequately falling hCG after surgical treatment
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Methotrexate Patient Selection Mild/no pain Haemodynamically stable Ectopic pregnancy <3cm? No fetal heart seen hCG < 2000 ?10000 Compliant/understanding patient
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Methotrexate Baseline LFTs/FBE/UEC/hCG Dose 50mg/m2 (calculated from height and
weight) given IM Repeat hCG day 4 Repeat LFTs/FBE/UEC/hCG day 7 hCG should fall at least 15% from day 4 to
7 (normal to rise from days 1-4) Give second dose if inadequate fall Single dose successful in 91-93% of
appropriately chosen patients
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Methotrexate Side Effects <1% Stomatitis, gastritis, photosensitive rash Impaired liver or renal function Pancytopaenia No evidence of increased malignancy in
future (Contraindications: liver disease, blood
dyscrasias, ulcerative colitis, peptic ulcer disease, concomitant infection)
Warn patient re: moderate increase in pain and bleeding first week
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Methotrexate Follow hCG until <2 Surgery if becomes unstable/failed
treatment
Intrauterine pregnancy rates post-methotrexate comparable to surgical treatment
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hCG should be followed weekly to <2 in all patients treated with methotrexate or tube-conserving surgery (salpingostomy). Some would follow patients after salpingectomy also
Patient told no pregnancy 2 months (use barrier method or OC pill). No IUD
Ultrasound at 6 weeks in subsequent pregnancy to ensure intrauterine
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Overall pregnancy rates after one ectopic:
Intrauterine 50-80% Ectopic 10-25% Others infertile
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Pregnancy after hysterectomy is possible (tube, cervix)
ALWAYS DO A hCG ALWAYS THINK OF POSSIBILITY OF
ECTOPIC PREGNANCY