Transcript Ectopic ppt - Ipswich-Year2-Med-PBL-Gp-2

Reproduction week 3
‘My period is 2 weeks late, I am
bleeding and in pain’
• In this case Mel, a 21-year old woman, presents to the
emergency department of her local hospital complaining of
vaginal bleeding and left lower abdominal pain. Her
symptoms have come on within the last 24 hours.
– Mel was perfectly well until about 18 hours prior to presenting to the
emergency department.
– At that time she noted that she had developed some vaginal spotting
and had some crampy, non-radiating, left lower quadrant abdominal
pain.
– As she was a couple of weeks late for her period, she assumed that it
was beginning.
– However, over the ensuing 12-18 hours, the pain became worse than
her usual menses, while the bleeding remained spotting.
– She feels slightly nauseous, but has not vomited;
– she has no fever or chills,
– no bowel symptoms
– no dysuria.
What are the differential diagnoses?
What diagnosis must be excluded in this patient?
Murtagh’s – Lower abdominal and pelvic pain in women
Probability diagnosis
Primary dysmenorrhoea
Mittelschmerz
Pelvic/abdominal adhesions
Endometriosis
Serious disorders not to be missed
Ectopic pregnancy
Neoplasia
• ovary
• uterus
• other pelvic structures
Severe infections
• PID
Acute appendicitis
Pitfalls (often missed)
Endometriosis/adenomyosis
Torsion of ovary or pedunculated fibroid
Constipation
Pelvic congestion syndrome
Referred pain (to pelvis)
• appendicitis
• cholecystitis
• diverticulitis
• urinary tract infection
Seven masquerades checklist
Depression ✔
Diabetes Drugs ✔
Anaemia Thyroid disorder Spinal dysfunction ✔
UTI ✔
Extra history/examinations
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Past medical history: None
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Examination
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Family history: a number of family members have been
diagnosed with type-2 diabetes including a maternal
grandfather. Her parents and siblings are all fit and well
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Medications: None
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Afebrile
b/p =110/58
P = 76
RR = 16
O2 sat. = 98%
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Allergies: None known
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Abdomen:
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Past obstetric and gynaecological history:
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Menarche at age 13 years
Regular menses, every 28 days until this cycle.
Currently sexually active in a monogamous relationship
Uses condoms for birth control
Normal Pap smear 7 months ago
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Pelvic/ speculum examination:
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Soft with mild tenderness in lower left quadrant,
no peritoneal signs, no distension
Cervix closed, small amount of old blood visible
in vault
Bimanual examination:
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Uterus anteverted, slightly enlarged and slightly
tender.
Cervical motion tenderness is present.
No palpable adnexal masses, but some mild left
adnexal tenderness
Social history: University student
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Half-pack a day cigarette smoker
Social drinker. Does not use any other recreational drugs
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Urine pregnancy test: Positive
Probability diagnosis
Primary dysmenorrhoea
Mittelschmerz
Pelvic/abdominal adhesions
Endometriosis
Serious disorders not to be missed
Ectopic pregnancy
Neoplasia
• ovary
• uterus
• other pelvic structures
Severe infections
• PID
Acute appendicitis
Pitfalls (often missed)
Endometriosis/adenomyosis
Torsion of ovary or pedunculated fibroid
Constipation
Pelvic congestion syndrome
Referred pain (to pelvis)
• appendicitis
• cholecystitis
• diverticulitis
• urinary tract infection
Seven masquerades checklist
Depression ✔
Diabetes Drugs ✔
Anaemia Thyroid disorder Spinal dysfunction ✔
UTI ✔
What questions should you ask a woman who
presents with bleeding in early pregnancy?
• Risk factors in the past history should be
assessed, for example:
– IUCD (salpingitis, ectopic pregnancy)
– infertility (endometriosis, salpingitis)
– tubal surgery (ectopic)
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What is her age?
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What was the first day of last menstrual period (LMP) (with an indication as to the degree of certainty)?
Is the cycle regular?
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Subfertility is associated with an increased risk of ectopic pregnancy
Is there any history of gynaecological disease — endometriosis, pelvic infection (associated with
increased risk of ectopic pregnancy)?
What is the pattern of bleeding?
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Ectopic pregnancy has a 5-15% recurrence rate; recurrent miscarriage increases the risk of repeat miscarriage
Was there any delay to conception?
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This date provides a degree of certainty that the patient was at least four weeks pregnant at that time
What outcomes have occurred from previous pregnancies, including mode of delivery?
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Although pregnancy is uncommon, up to 50% may be ectopic
What was the first date of confirmation of pregnancy (by urine human chorionic gonadotrophin [UhCG]
or other)?
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Ovulation timing cannot be predicted by LMP if this were the case
Is an IUD in situ?
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Standard pregnancy dating wheels assume a 28-day cycle; short cycles have early ovulation before day 14, long cycles have late ovulation
beyond day 14
Were any contraceptive hormones in use at the time of conception?
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Ovulation can be predicted to have occurred 14 days before the first missed cycle
What is the cycle length?
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Miscarriage risk increases with maternal age
Light prolonged spotting suggests ectopic pregnancy; fresh, heavy or clots is more suggestive of miscarriage
Is there associated pain and, if so, what is the nature — crampy, sharp, central, unilateral?
Have any ultrasounds or blood tests already been performed during this pregnancy? What were the
results?
What was the date and result of the last Pap smear?
What is the patient’s blood group?
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Rhesus D-negative women who are not iso-immunised will require prophylactic Rh(D) immunoglobulin (anti-D)
The aetiology of ectopic pregnancy is not always clear but this is a condition
that is often associated with known risk factors. What are some of these risk
factors?
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Pelvic inflammatory disease
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A history of salpingitis increases the risk of ectopic pregnancy 4-fold. The incidence of tubal damage increases after successive episodes of PID (ie, 13% after 1 episode, 35% after 2 episodes,
75% after 3 episodes).
History of prior ectopic pregnancy
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After one ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy. Overall, a patient with prior ectopic pregnancy has a 50-80% chance of
having a subsequent intrauterine gestation, and a 10-25% chance of a future tubal pregnancy.
History of tubal surgery and conception after tubal ligation
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The increased risk depends on the degree of damage and the extent of anatomic alteration. Surgeries carrying higher risk of subsequent ectopic pregnancy include salpingostomy,
neosalpingostomy, fimbrioplasty, tubal reanastomosis, and lysis of peritubal or periovarian adhesions.
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Conception after previous tubal ligation increases a women's risk of developing ectopic pregnancies. Thirty-five to 50% of patients who conceive after a tubal ligation are reported to
experience an ectopic pregnancy. Failure after bipolar tubal cautery is more likely to result in ectopic pregnancy than occlusion using suture, rings, or clips. Failure is attributed to fistula
formation that allows sperm passage. Ectopic pregnancies following tubal sterilizations usually occur 2 or more years after sterilization, rather than immediately after.
Use of fertility drugs or assisted reproductive technology
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Ovulation induction with clomiphene citrate or injectable gonadotropin therapy has been linked with a 4-fold increase in the risk of ectopic pregnancy in a case-control study. This finding
suggests that multiple eggs and high hormone levels may be significant factors.
Use of an intrauterine device
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The presence of an inert copper-containing or progesterone intrauterine device (IUD) traditionally has been thought to be a risk factor for ectopic pregnancy. However, only the progesterone
IUD has a rate of ectopic pregnancy higher than that for women not using any form of contraception. The modern copper IUD does not increase the risk of ectopic pregnancy. Nevertheless, if a
woman ultimately conceives with an IUD in place, it is more likely to be an ectopic pregnancy. The actual incidence of ectopic pregnancies with IUD use is 3-4%.
Increasing age
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The highest rate of ectopic pregnancy occurs in women aged 35-44 years. A 3- to 4-fold increase in the risk for developing an ectopic pregnancy exists compared to women aged 15-24 years.
One proposed explanation involves the myoelectrical activity in the fallopian tube, which is responsible for tubal motility. Aging may result in a progressive loss of myoelectrical activity along
the fallopian tube.
Smoking
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Cigarette smoking has been shown to be a risk factor for developing an ectopic pregnancy. Studies have demonstrated elevated risk ranging from 1.6-3.5 times that of nonsmokers. A doseresponse effect also has been suggested. Based on laboratory studies in humans and animals, researchers have postulated several mechanisms by which cigarette smoking might play a role in
ectopic pregnancies. These mechanisms include one or more of the following: delayed ovulation, altered tubal and uterine motility, or altered immunity. To date, no study has supported a
specific mechanism by which cigarette smoking affects the occurrence of ectopic pregnancy.
Salpingitis isthmica nodosum
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Salpingitis isthmica nodosum is defined as the microscopic presence of tubal epithelium in the myosalpinx or beneath the tubal serosa. These pockets of epithelium protrude through the tube,
similar to small diverticula. Studies of serial histopathological sections of the fallopian tube have revealed that approximately 50% of patients treated with salpingectomy for ectopic pregnancy
have evidence of salpingitis isthmica nodosum. The etiology of salpingitis isthmica nodosum is unclear
Other
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Other risk factors associated with increased incidence of ectopic pregnancy include previous diethylstilbestrol (DES) exposure, a T-shaped uterus, prior abdominal surgery, failure with
progestin-only contraception, and ruptured appendix.
What features on examination are suggestive
of an ectopic pregnancy?
• [From history: The classic clinical triad of ectopic pregnancy is pain,
amenorrhea, and vaginal bleeding. (only 50% of patients present typically)]
• On Examination:
– Vital signs may reveal orthostatic changes and, occasionally, low grade fever.
– Findings on physical examination may include:
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adnexal, cervical motion, and/or abdominal tenderness
an adnexal mass
mild uterine enlargement
– However, the physical examination is often unremarkable in a woman with a small,
unruptured ectopic pregnancy.
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(Numerous conditions may have a presentation similar to an extrauterine pregnancy. The most common of these are
appendicitis, salpingitis, ruptured corpus luteum cyst or ovarian follicle, spontaneous abortion or threatened abortion,
ovarian torsion, and urinary tract disease. Intrauterine pregnancies with other abdominal or pelvic problems such as
dgenerating fibroids must also be included in the differential diagnosis)
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What investigations would be useful in helping to
confirm a diagnosis of ectopic pregnancy?
Trans-vaginal Ultrasound/ Sonography (TVS) in combination with quantitative b-hCG level if clinically suspected ectopic pregnancy.
An ectopic pregnancy can be diagnosed if the serum hCG concentration is increasing or plateaued. Treatment can be instituted.
Can use TVS alone if diagnostic if a yolk sac, embryo, or embryonic cardiac activity is demonstrated.
Some studies recommend that a gestational sac should be visualized by 5.5 weeks' gestation; a gestational sac should be visualized
with an hCG level of 1500-2400 mIU/mL for transvaginal ultrasound or with an hCG level over 3000 mIU/mL for a transabdominal
ultrasound. If the hCG level is higher than the discriminatory zone and no gestational sac is visualized in the uterus, then consider that
an ectopic pregnancy may be present
If TVS does not reveal an intrauterine pregnancy and shows a complex adnexal mass, an extrauterine pregnancy is almost certain.
Embryonic cardiac activity or a gestational sac with a definite yolk sac or embryo at an extrauterine location is certain evidence of an
ectopic gestation. Treatment of ectopic pregnancy should be instituted.
The diagnosis of ectopic pregnancy is less certain if no complex adnexal mass can be visualized, since there is variability in the level of
expertise among ultrasonographers. Furthermore, a serum hCG greater than 1500 IU/L without visualization of intrauterine or
extrauterine pathology may represent a multiple gestation, since there is no proven discriminatory level for multiple gestations. For
these reasons, our next step in this setting is to repeat the TVS examination and hCG concentration two days later. If an intrauterine
pregnancy is still not observed on TVS, then the pregnancy is abnormal.
The rate of fall is slower with an ectopic pregnancy than with a complete abortion or failed pregnancy (arrested pregnancy, blighted
ovum, tubal abortion, spontaneously resolving ectopic pregnancy). Weekly hCG concentrations should be monitored until the result is
negative for pregnancy.
TVS is not sensitive for determining the location of the pregnancy when the hCG level is below the discriminatory zone. A serum hCG
concentration less than 1500 IU/L should be followed by repetition of hCG in three days to follow the rate of rise. HCG concentrations
usually double every 1.4 to two days until six to seven weeks of gestation in normal pregnancies (and in some ectopic gestations). We
find that measurement every 72 hours is more practical than every 48 hours, and allowing 72 hours for doubling helps to avoid
misclassifying those viable pregnancies with slower than average doubling times.
A normally rising hCG concentration should be evaluated with TVS when the hCG reaches the discriminatory zone. At that time, an
intrauterine pregnancy or an ectopic pregnancy can be diagnosed.
If the hCG concentration does not double over 72 hours then the pregnancy is abnormal  If an adnexal mass is visualized on TVS,
then treat for a presumed ectopic pregnancy. If an adnexal mass is not visualized, some clinicians administer methotrexate and others
perform curettage to determine the type of nonviable pregnancy and thereby avoid medical therapy of nonviable intrauterine
pregnancies .
What options are available for the management of ectopic
pregnancy? What might be some of the advantages and
disadvantages of the various options available?
Medical Tx – Administration of Methotrexate (antimetabolite that blocks dihydrofolate reductase,
blocking synthesis of purine nucleotides  disrupted DNA synthesis and cell multiplication)
-Advantages include eliminating morbidity from surgery and general anesthesia, potentially less
tubal damage, and less cost and need for hospitalization. Treatment with methotrexate is an
especially attractive option when the pregnancy is located on the cervix, ovary, or in the
interstitial or the cornual portion of the tube. Surgical treatment in these cases is often
associated with increased risk of hemorrhage, often resulting in hysterectomy or oophorectomy.
-Side effects include a plethora of GIT symptoms and a transient elevation in liver enzymes.
Treatment effects of methotrexate include an increase in abdominal pain (occurring in up to two
thirds of patients), an increase in bhCG levels during first 1-3 days of treatment, and vaginal
bleeding or spotting.
-Contraindications include haemodynamic instability, active bleeding, mental unreliability (for
followup etc), gestation size of more than 3.5cm, fetal cardiac activity, bhCG > 15,000IU/L and
free gluid in the cul-de-sac, breastfeeding, immunodeficiency, liver disease, blood dyscrasias etc
 these require surgical intervention.
A common regime for administration of methotrexate is 1 mg/kg IM on days 0, 2, 4, and 6,
alternated by 4 rescue doses of calcium folinate as 0.1 mg/kg on days 1, 3, 5, and 7 or just once of
dose of methotrexate as 50 mg/m2 IM in a single injection or as a divided dose injected into each
buttock.
What options are available for the management of ectopic
pregnancy? What might be some of the advantages and
disadvantages of the various options available?
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Laparoscopy recommended in most cases (vs Laparotomy)  fewer postoperative adhesions, less blood loss,
reduced analgesia need, reduced cost, hospitalisation and recovery time.
Laparotomy reserved for patients who are hemodynamically unstable or have cornual ectopic pregnancies; also
preferred method for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is
difficult (eg, secondary to the presence of multiple dense adhesions, obesity or massive hemoperitoneum).
Linear salpingostomy is most common procedure, an incision is made along the antimesenteric border to remove
the products of conception is the procedure of choice for unruptured ectopic pregnancies in the ampullary
portion of the tube.
In some cases, resection of the tubal segment containing the gestation or a total salpingectomy is preferred over
salpingostomy. This is true for isthmic pregnancies, where the endosalpinx is usually damaged. These patients do
poorly with linear salpingostomy, with a high rate of recurrent ectopic pregnancy. Delayed microsurgical
reanastomosis can be performed to reestablish tubal patency if enough healthy fallopian tube is present.
Total salpingectomy can be achieved by progressively coagulating and cutting the mesosalpinx, starting from the
fimbriated end and advancing toward the proximal isthmic portion of the tube. At this point, the tube is separated
from the uterus by coagulating and excising with scissors or laser
Indications for surgical treatment of ectopic pregnancy include the following:
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The patient is not a suitable candidate for medical therapy.
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Medical therapy has failed.
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The patient has a heterotopic pregnancy with a viable intrauterine pregnancy.
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The patient is hemodynamically unstable and needs immediate treatment.
The only contraindications to surgical management are the following:
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The patient has a medically treatable ectopic pregnancy.
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The patient has other medical conditions that would make the risks associated with surgery unacceptable.
Linear salpingostomy