Ectopic Pregnancy

Definition

Is when the conceptus implants either outside the uterus (fallopian tube , ovary or abdominal cavity ) or in an abnormal position within the uterus (cornua , cervix ). Combined tubal and uterine (heterotopic) pregnancies are very rare .

Epidemiology

.The incidence of ectopic pregnancy is 1 in every 150 pregnancies .

95% of ectopic pregnancies occur in the fallopian tube . Over 50 % of tubal pregnancies are situated in the ampulla, 20 % occur in the isthmus, 12 % are fimbrial & 10 % are interstitial .

Risk factors The risk increases with: Maternal age , number of sexual

partners, use of an intrauterine device, after a proven pelvic inflammatory disease (gonorrhoea, Chlamydia ), after pelvic surgery, endometriosis & IVF . Risk of recurrence is high (around 10%).

Mortality rate

. Mortality from ectopic pregnancy remains high , representing 13% of all maternal deaths

Clinical features

There is no pathognomonic pain or findings on clinical examination that are diagnostic of a developing extrauterine pregnancy . Vaginal bleeding (usually old blood in small amounts ) short period of amenorrhea and chronic pelvic pain (iliac fossa , sometimes bilateral ) are the most commonly reported symptoms .

General examination

Pulse rate and blood pressure must be recorded. Low blood pressure, fainting, dizziness and rapid heart rate may be noted . These symptoms are present in about 59 % typical of ruptured ectopic pregnancy (intra – abdominal bleeding ). Note: bimanual examination may provoke the rupture of the tube .

suprapubic tenderness on palpation Free fluid in the abdomen (haemop)

Positive cervical excitation test on P.V exam

Investigation Pregnancy test (positive in 50%) Vaginal U\S Differential diagnosis Threatening abortion Pelvic inflammatory disease Acute appendicitis & other causes of

acute abdomen

hCG and transvaginal ultrasound

hCG levels and ultrasound findings must be interpreted together . A laparoscopy should be considered in women with hCG above the discriminatory level and absence of an intrauterine gestational sac on ultrasound .

Culdocentesis

.To exclude hemoperitoneum in the emergency room for the rule out of ectopic patient .

Laparoscopy sometimes used to establish the diagnosis.

Management . Treatment of ectopic pregnancy has always

been surgical (salpingectomy or salpingotomy ), either by laparotomy or laparoscopy . With the wider use of ultrasound, an early diagnosis is now possible, in many cases, before the onset of symptoms .Others: medical- methotrexate, therapeutic puncture and aspiration of ectopic sac , local injections of prostaglandins, potassium chloride,or hyperosmolar glucose.

Gestational Trophoblastic Diseases

GTDs .(GTD) is a term commonly applied to a

spectrum of inter – related diseases originating from the placental trophoblast.

The main categories of GTD are 1/ complete hydatidiform mole 2/partial hydatidiform mole and

3/choriocarcinoma .

Complete or classical hydatidiform moles: are generalized swelling of the villous tissue,with diffuse trophoblastic hyperplasia and no embryonic or fetal tissue .

Partial hydatidiform mole: is characterized by focal swelling of the villous tissue, focal trophoblastic hyperplasia & embryonic or fetal tissue.

Choriocarcinomas: Are large masses of anaplastic

trophoblast invading muscles & blood vessels with loss of villous patter. Vascular metastases to the lung & vaginal interoitus are common.

. complete mol is 1 per 1500 pregnancies, partial mol 1 per 700 pregnancies while choriocarcinoma 1 in 30000 .

Risk factors

.

Maternal age

Previous molar pregnancy .

Women with blood group A have been shown to have greater risk than blood group O women .

Clinical features .

Vaginal bleeding , uterine enlargement greater than expected for gestational age and an abnormally high level of serum hCG. Pregnancy induced hypertension, hyperthyroidism, hyperemesis G, anaemia & ovarian theca lutein cysts (torsion or rupture of theca lutein cysts) .

Symptoms of choriocarcinoma are: abnormal vaginal bleeding after evacuation or delivery, dyspnoea, nerological symptoms & abdominal pain (few weeks or months and sometimes up to 10 – 15 years after their last pregnancy).

Ultrasound examinationUltrasound examination

. Typically reveals a uterine cavity filled with multiple sonolucent areas of varying size and shape (‘snow storm appearance,) without associated embryonic or fetal structure .

Laboratory examinations

. hCG is important for diagnosis and follow – up of GTD .

Histological examination of the sample confirm the trophoblastic hyperplasia and a chest X – ray to exclude the presence of lung metastasis .

Management

Uterine evacuation (suction Uterine evacuation (suction curretage) under running oxytocin curretage) under running oxytocin infusion & prepared blood (severe infusion & prepared blood (severe bleeding is common).bleeding is common).3% of3% of molar molar pregnancy will develop topregnancy will develop to choriocarcinomachoriocarcinoma. Pulmonary . Pulmonary complications might follow evacuation of complications might follow evacuation of molar pregnancy. Early diagnosis reduces molar pregnancy. Early diagnosis reduces the risk of severe complications. Follow the risk of severe complications. Follow up is very important for detection of up is very important for detection of changes to choriocarcinomachanges to choriocarcinoma

Fallow up:Fallow up: Serial hCG levels is the gold standard for Serial hCG levels is the gold standard for

montioring therapeutic response of GTD montioring therapeutic response of GTD after evacuation of molar pregnancy. The after evacuation of molar pregnancy. The hCG levels should be monitored weekly hCG levels should be monitored weekly until undetectable followed by monthly until undetectable followed by monthly monitoring for 12-24 months .monitoring for 12-24 months .

Indications of chemotherapy Serum hCG level more than

20000iu/L 5wks after evacuation. Rising hCG levels Persistent uterine bleeding &

positive hCG Evidence of choriocarcinoma

(histological) Presence of metastases