1. ECTOPIC PREGNANCY ECTOPIC PREGNANCY ASSOCIATE PROFESSOR IOLANDA BLIDARU, MD, PhD

2. 09/06/2015 11:43Ectopic Pregnancy2 ECTOPIC PREGNANCY DEFINITION Any pregnancy where the fertilised ovum gets implanted & develops in a site other than uterine cavity. ectopic / extrauterine heterotopic

3. 09/06/2015 11:43Ectopic Pregnancy3 INCIDENCE >1 in 100 pregnancies. The incidence of ectopic pregnancy has been rising: –USA - 5 fold –UK - 2 fold –France - 15/1000 pregnancies –India - 1/100 deliveries Recurrence rate - 15% after 1, 25% after 2 ectopics

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5. 09/06/2015 11:43Ectopic Pregnancy5 ETIOLOGY Any factor that causes delayed transport of the fertilised ovum through the Fallopian tube (tubal ectopic pregnancy). These factors may be: 1.congenital or acquired; 2.mechanical or functional

6. 09/06/2015 11:43Ectopic Pregnancy6 ETIOLOGY CONGENITAL - tubal hypoplasia, tortuosity, congenital diverticuli, accessory ostia, partial stenosis ACQUIRED –Inflammatory: PID, septic abortion, puerperal sepsis, medical termination → intraluminal / peritubal adhesions –Surgical: tubal reconstructive surgery, recanalisation of tubes –Tumoral: broad ligament myoma, ovarian tumour –Miscellaneous causes: IUD, endometriosis, ART, hormonal perturbations → tubal disfunctions –Previous ectopic pregnancy

7. 09/06/2015 11:43Ectopic Pregnancy7 SITES OF ECTOPIC PREGNANCY 1)Fimbrial 2)Ampullary 3)Isthmic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Abdomen (< 2%) Cervix (< 2%)

8. 09/06/2015 11:43Ectopic Pregnancy8 PATHOLOGIC ANATOMY minimal reaction against trophoblast invasion local hemorrhage → hematoma The uterus - some of the changes associated with normal early pregnancy, (softening of the cervix and isthmus, increase in size). the Arias-Stella reaction in the endometrium – in pregnancy both endocervical gland hyperplasia and hypersecretory appearance

9. 09/06/2015 11:43Ectopic Pregnancy9 EVOLUTION Tubal pregnancy tubal abortion in ampullary pregnancy tubal rupture in isthmic pregnancy, interstitial (cornual) pregnancy hematosalpinx pelvic hematocele Abdominal/ovarian pregnancy (primary/secondary) Broad ligament pregnancy Cervical pregnancy spontaneous regresion

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11. 09/06/2015 11:43Ectopic Pregnancy11 CLINICAL PRESENTATION Ectopic pregnancy remains almost asymptomatic until it ruptures. In contemporary practice, syptoms and signs of ectopic pregnancy are often subtle or even absent. In recent years, in spite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.

12. 09/06/2015 11:43Ectopic Pregnancy12 DIAGNOSIS SYMPTOMS 1.Amenorrhea – abnormal menstruation 2.Abdominal pain – absent / different sites; pain in the neck or shoulder (diaphragmatic irritation); tenderness on bimanual ex. + motion of the cervix 3.Syncope, vaso-vagal response (bradycardia, hypotension) 4.Vaginal bleeding – scanty, dark brown, intermitent / continuous 5.Pelvic mass - lateral or posterior to the uterus, +/- uterine displacement; painful; bulging of Douglas pouch

13. 09/06/2015 11:43Ectopic Pregnancy13 EARLY MULTI-MODAL DIAGNOSIS Vaginal ultrasound scanning (+ colour Doppler) Serum beta HCG level Serum progesterone levels < 5ng/mL Uterine curettage Culdocentesis Hemogram Laparoscopy / laparotomy A combination of these methods may have to be employed, but only to hemdynamically stable women; those with presumed rupture must undergo surgical therapy.

14. 09/06/2015 11:43Ectopic Pregnancy14 METHODS OF EARLY DIAGNOSIS Multi-modality diagnosis results 1.TV – US - Demonstration of the gestational sac with or without an alive embryo outside the uterus. - Ruptured ectopic with fluid in the cul-de- sac and an empty uterus. 2. Culdocentesis - in emergent situations to confirm diagnosis, highly specific if performed and interpreted correctly → presence of free-flowing, NON-clotting blood

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17. 09/06/2015 11:43Ectopic Pregnancy17 DIFFERENTIAL DIAGNOSIS Threatened or incomplete abortion Salpingo-ooforitis Appendicitis Twisted ovarian cyst Rupture of a corpus luteum / follicular cyst Other abdominal conditions

18. 09/06/2015 11:43Ectopic Pregnancy18 MANAGEMENT Depends on the stage of the disease and the condition of the patient at diagnosis. 1.COMPLICATED ECTOPIC PREGNANCY 2.NON-COMPLICATED ECTOPIC PREGNANCY

19. 09/06/2015 11:43Ectopic Pregnancy19 MANAGEMENT OF COMPLICATED ECTOPIC PREGNANCY TREATMENT – ALWAYS SURGICAL Salpingectomy of the offending tube Posterior colpotomy - if pelvic haematocele is infected → to drain the pelvic abscess Salpingo-oophorectomy

20. 09/06/2015 11:43Ectopic Pregnancy20 MANAGEMENT OF NON-COMPLICATED = UNRUPTURED ECTOPIC PREGNANCY SURGICAL MEDICAL TREATMENT EXPECTANT MANAGEMENT OPTIONS

21. 09/06/2015 11:43Ectopic Pregnancy21 SURGICAL TREATMENT OF UNRUPTURED ECTOPIC PREGNANCY Carried out by Laparoscopy / Laparotomy. The procedures are: –Salpingectomy / Cornual resection / Excision –Conservative surgery (in cases of Infertility & desire for pregnancy)

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23. 09/06/2015 11:43Ectopic Pregnancy23 MEDICAL TREATMENT Trophotoxic substance: –Methtrexate - resolution of tubal / abdominal pregnancy by systemic administration –Interferes with the DNA synthesis Ectopic pregnancy size should be < 3.5 cm. IV/IM/Oral, usually along with Folinic acid. Injection into the ectopic pregnancy sac or affected tube

24. CLINICAL FORMS DIAGNOSIS AND MANAGEMENT Tubal pregnancy Abdominal pregnancy - laparatomy Cervical pregnancy - hysterectomy 09/06/2015 11:43Ectopic Pregnancy24