OBSTETRICS 2

1S-2 | CEU-SOM A & B ECTOPIC PREGNANCY

Eleyneth I. Valencia, MD, FPOGS, FPSUOG

OUTLINE CLASSIFICATION INCIDENCE
Ampulla 70%
I. INTRODUCTION
II. OUTCOMES OF ECTOPIC PREGNANCY Isthmic 12%
III. SIGNS AND SYMPTOMS Fimbrial 11%
IV. DIAGNOSIS
V. SONOGRAPHY Interstitial 2%
VI. KEY COMPONENTS IN DIAGNOSIS Non-tubal (ovary, peritoneal cavity, cervix, and 5%
VII. MANAGEMENT previous CS scar)
A. Medical Table 1. Classification and incidence of ectopic pregnancy
B. Surgical
VIII. TYPES OF ECTOPIC PREGNANCY ! Ampullary – most common location in ectopic pregnancy
A. Interstitial and Cornual Pregnancy
! Isthmic – most common type of location that ruptures
B. Caesarian Scar Pregnancy
C. Cervical Pregnancy
D. Abdominal Pregnancy DEGREE OF RISK RISK FACTORS RISK
E. Ovarian Pregnancy HIGH RISK Tubal corrective surgery 21.0
IX. REFERENCES
Tubal sterilization 9.3
Previous EP 8.3
I. INTRODUCTION In utero DES exposure 5.6
ECTOPIC PREGNANCY
IUD 4.2-45
• Located outside the inner lining of the uterus Documented tubal pathology 3.8-21
• Ectopic came from Greek word, ektopos: out of place
• Implantation of a blastocyst other than in the endometrial lining of MODERATE RISK Infertility 2.5-21
the uterine cavity
Previous genital infection 2.5-3.7
! Cornual pregnancy nasa loob pa din siya ng matres pero wala
siya sa endometrial lining Multiple partners 2.1
• 0.5-1.5% of 1st trimester pregnancy
SLIGHT RISK Previous pelvic or abdominal 0.93-3.8
! The fertilized egg after exclusion from the ovaries will meet the
surgery
Smoking 2.3-2.5
sperm along the fallopian tube then after 7 days the blastocyst
implants in the endometrial lining of the uterine cavity. Douching 1.1-3.1
! Early diagnosis of ectopic pregnancy is now common because
of urine/serum bHCG assay and transvaginal ultrasound Intercourse before 18 weeks 1.6
! Patients with ectopic pregnancy aside with vaginal spotting, Table 2. Risk factors of ectopic pregnancy
vaginal bleeding they also present with hypogastric or abdominal
pain (very common) II. OUTCOMES OF ECTOPIC PREGNANCY
! 95% of ectopic pregnancy are tubal in location
! ART (Assisted Reproductive Technique) – even if there is an • Tubal Rupture
intrauterine gestation, if it will not have a high order multifetal - spontaneous
pregnancy, it may have concomitant ectopic pregnancy. It may - after coitus
also have Heterotopic pregnancy (1/30,000) incidence - after bimanual examination

• Tubal Abortion
- common in distal implantations
! fimbrial ectopic pregnancy
- may lead to abdominal pregnancy

• Pregnancy failure with resolution

! Ectopic pregnancy then in succeeding scan nawala na yung
complex mass meron na lang fluid-filled cul de sac but
asymptomatic, no tenderness, no transabdominal surgery,
bumababa na yung bHCG

• Chronic ectopic pregnancy

- complex pelvic mass prompting diagnostic surgery
! (+) complex mass but (-) bHCG or persistent na
mababang mababa pwedeng mag direct laparoscopy to
determine the complex mass

Image 1. Ectopic pregnancy

1S-2 ECTOPIC PREGNANCY ESTUYE • HO • JAVIER • RAMOS • ROCHA

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 WHY PRONE TO RUPTURE? V. SONOGRAPHY
TRANSVAGINAL ULTRASOUND (TVS)

fallopian tube lacks

the fertilized ovum zygote near or within • High resolution transvaginal sonography
promptly burrows the muscularis layer -
mucosal layer • Pseudogestational sac; decidual cast?
through the epithelium invaded by trophoblast

Transvaginal Sonography: ENDOMETRIUM

hemorrhage tubal rupture

III. SIGNS AND SYMPTOMS

CLASSIC TRIAD
• Abdominal pain – some also present with abdominal mass
• Delayed menstruation/ amenorrhea
• Vaginal bleeding/ spotting (60-80%) Figure 2. Normal IUP
! 3 weeks AOG with a (+) pregnancy test: thickened endometrium
SYMPTOMS ! Intrauterine pregnancy: presence of gestational sac around 2mm as
• Abdominal or pelvic pain
early as 4 weeks and 1 day
• Vaginal bleeding or spotting ! 5 – 6 wks: yolk sac appears and a fetal pole with cardiac activity is
• (+) pregnancy test
detected at 5 ½ to 6 weeks; pwede na makadetect ng embryo with fetal
SIGNS uptake
• Abdominal tenderness (direct and rebound)
• Cervical motion tenderness
• Tender adnexal mass
!
! Uterus may be slightly enlarged because of hormonal changes
Referred pain (in shoulder & neck)
– due to diaphragmatic irritation in a massive/sizeable
hemoperitoneum
! - patient can’t tolerate lying in supine
Massive hemoperitoneum
- in bimanual examination, posterior fornix from posterior cul de
Figure 3. Pseudogestational Sac
sac may bulge !
- aside from having pallor/anemia (low hemoglobin & Pseudogestational sac represents fluid collection between the two
hematocrit), unstable vital signs may be present (hypotension, endometrial layers that conforms to the cavity or shape in the
significant bleeding, or vascular disturbances—may have endometrial cavity (irregular shape), echogenicity: maputing maputi,
vertigo, syncope) !walang laman.
Signs of pregnancy:
IV. DIAGNOSIS - common in ectopic pregnancy
1. gestational sac
• Complete clinical history and physical exam 2. yolk sac
• Blood or laboratory tests 3. embryo
o !
BHCG
for reproductive age, there is always a need to
request for pregnancy test or bHCG determination
(quantitative)

o !
Serum progesterone – 10-25 ng/ml EP?
>25 ng/ml – rule out intrauterine ectopic pregnancy

o Basic lab exams: CBC, ABO typing, urinalysis

•
!
Ultrasound
Two common types:
• Transvaginal
- because of high frequency probe it has ! Figure 4. Decidual Cyst
high resolution to better visualize pelvic Decidual cyst/cast is an echoic area lying within the endometrium
structures but remote from the canal usually seen at the endometrial-myometrial
- it should be empty bladder
!border because of the decidual breakdown and precedes decidual cast
- Intrauterine pregnancy: can be formation
recognized as early as 4-5 Between the endometrial junction yung cyst, centrally located
weeks
gestational sac
• Transabdominal - maganda lang kung may
abdominal recession

- it should be full bladder



1S-2 ECTOPIC PREGNANCY ESTUYE • HO • JAVIER • RAMOS • ROCHA
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Transvaginal Sonography: FINDINGS FOR ECTOPIC PREGNANCY

Figure 5. Empty Uterus

Figure 9. Tubal Ring with Embryo (+/-) FHT

! Tubal ring - definitive diagnosis of ectopic pregnancy

! Definitive diagnosis of ectopic pregnancy: presence of adnexal
mass with tubal ring with GS like structure and embryo inside with
fetal heart rate

TRANSABDOMINAL ULTRASOUND (TAS)

• Identification of tubal pregnancy: difficult
Figure 6. Fluid in the Cul De Sac
! • Intrauterine pregnancy usually is not recognized via TAS until 5th-
It can represent hemoperitoneum
6th menstrual weeks or 28 days after timed ovulation
TRANSVAGINAL SONOGRAPHY: ADNEXA
VI. KEY COMPONENTS IN DIAGNOSIS

A. Transvaginal sonography (TVS)

B. Serum beta-hCG level: both the initial level and pattern of rise or
decline
C. Serum progesterone level
!sampling
D. Endometrial
E. Laparoscopy - pwedeng diagnostic to check complex mass
then operative laparoscopy if definitive na yung nakita mo
!
Important to determine lalo na kung may PUL: request for serum
bHCG titer (quantitative) para may baseline ka. We must see a
gestational sac by ultrasound at the bHCG level of 1500-2000 mIU/mL
!(cut-off value)
!
Discriminatory zone: bHCG level of 1500-2000 mIU/mL
Figure 7. Color Flow - to detect an intrauterine gestational sac
! Peritrophoblastic flow or ring of fire - so pag ganyan ang level ng bHCG at wala ka pa nakikitang
! Corpus luteum – also have ring of fire but inside the ovarian stroma gestational sac most probably it’s an Ectopic preganancy.
In adnexa, ring of fire is separate from the ovary - doubling time: 53-66% rise after 48hrs. (<53% = probably
ectopic pregnancy)

!
Figure 8. Complex Mass
Complex Mass – distinct and separated from ovary

1S-2 ECTOPIC PREGNANCY ESTUYE • HO • JAVIER • RAMOS • ROCHA

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 SURGICAL MANAGEMENT
Salpingostomy
conservative surgical
! approach
you make an incision, you
! don’t suture

Figure 11. Salpingostomy

Salpingotomy
! conservative surgical
approach
! you make an incision and
do the suture

Figure 10. Algorithm for evaluation of a woman with a suspected ectopic
pregnancy
!
Hindi lahat ng pagbubuntis sa labas ng matres ay inooperahan, Figure 12. Salpingotomy
! can still be subjected to medical treatment
they
Hindi agad nagrerequest ng serum quantitative bHCG, ! Salpingectomy
magrerequest lang if TVS is non-diagnostic radical surgical approach

VII. MANAGEMENT
MEDICAL MANAGEMENT
!
• Methotrexate
chemotherapeutic agent
o Antimetabolite
o Folic acid antagonist
o Arrests DNA, RNA, protein synthesis – highly effective vs
proliferating tissue such as trophoblast
o !Side effects: liver involvement (12%), stomatitis (6%),
gastroenteritis (1%), bone marrow depression
Hepatotoxic; excreted in the urine (check if there’s a renal
impairment before giving the drug)
! Figure 13. Salpingectomy
o Patient Selection and Classic Predictors of Success:
chances of success according to studies: 83-92% SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY
- hemodynamically stable patient with consent
- small ectopic mass size <3.5 cm • all tubal pregnancies can be treated by partial or total salpingectomy
- low serum BHCG concentration <5000 mlU/mL
• salpingostomy / salpingotomy is only indicated when:
- absent fetal cardiac activity
1. The patient desires to conserve her fertility
2. Patient is hemodynamically stable
3. Tubal pregnancy is accessible
4. Unruptured and <5cm in size
5. Contralateral tube is absent or damaged

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 Figure 17. Diagnostic Laparoscopy

Figure 14. Laparotomy

Figure 18. 3D Gyne Sonography

Management:

Figure 15. Laparoscopy

COMPARING LAPAROTOMY LAPAROSCOPY
L’TOMY VS L’SCOPY
(US Setting)
Hospital cost More? Less?
Post-operative adhesions More Less
Risk of future ectopic Same Same
Future infertility Same Same
Experience of surgeon Trained Special Figure 19. Cornual Resection Figure 20. Cornuostomy
Instruments General Special
Table 3. Comparing laparotomy vs laparoscopy in the US setting
CAESARIAN SCAR PREGNANCY
VIII. TYPES OF ECTOPIC PREGNANCY
INTERSTITIAL AND CORNUAL PREGNANCY
• implanted within the proximal intramural portion of the tube within
the muscular uterine wall
• undiagnosed: ruptures at 8-16 weeks amenorrhea
• greater distensibility of the myometrium covering the interstitial
fallopian tube segment
• proximity to uterine/ ovarian A: severe hemorrhage; higher
mortality rate (2.5%)
• risk factors: previous ipsilateral salpingectomy

Criteria for the Diagnosis:

1. Empty uterus
2. GS seen separate from the endometrium
3. GS > 1cm away from the most lateral edge of uterine cavity
4. Thin (<5mm) myometrial mantel surrounding the sac
(Timor-Tritsh, 1992)
Confirmatory:
!
• Implantation within the myometrium of a prior CS delivery scar
• Due to high incidence of CS
due to poor surgical technique: common is placental
accreta (abnormal attachment of the placenta) or Ceasarian
scar pregnancy
Figure 16. MRI

1S-2 ECTOPIC PREGNANCY ESTUYE • HO • JAVIER • RAMOS • ROCHA

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• Presents early with pain and bleeding; 40% asymptomatic ABDOMINAL PREGNANCY

Niche – poorly yield caesarian (defect) where it may implant a product • Undamaged conceptus gets extruded earlier into the peritoneal
!of conception cavity with the placenta attached
10-15% - WHO acceptable rate in primary CS rate most common site: omentum
! It presents early with pain and vaginal bleeding and 40% still •
!
Re-implantation almost anywhere in the abdomen
!
asymptomatic • It is rare; may follow early tubal rupture or abortion with implantation
• Placenta may be partially attached to the uterus or adnexa
Management:
• Hysterectomy Primary Abdominal Pregnancy
o Acceptable initial choice in those desiring - Rare event, first true primary peritoneal pregnancy described by
sterilization (Williams, 25th Ed.) Gallabin, 1903
• Local MTX injection - Must meet the criteria defined by Studdiford in 1942:
o Fertility-preserving options include systemic or 1. Both tubes and ovaries must be in normal condition with no
locally injected methotrexate, either alone or evidence of recent or remote injury.
combined with conservative surgery (Williams, 25th) 2. No evidence of uteroperitoneal fistula should be found.
• Surgical procedures include (these are completed solely, or 3. The pregnancy must be related exclusively to the peritoneal
with adjunctive MTX): surface.
o Suction curettage 4. Early enough to eliminate the possibility that it is a secondary
o Hysteroscopic removal implantation following a primary implantation in the tube.
o Isthmic excision (abdominal/vaginal) o ??? helpful diagnosis or management
o Foley catheter balloon placement
Clinically
CERVICAL PREGNANCY - Abnormal fetal position palpated
- Cervix displaced

Characteristics of Abdominal Pregnancy on Ultrasound

- Presence of a fetus outside the uterus
- Absence of the uterine wall between the bladder and the fetus
- Extrauterine location of the placenta
- Poor visualization of the placenta
- Pseudo-placenta previa appearance
- Oligohydramnios
- Fetal parts adjacent to the mother’s abdominal contents
- Abnormal fetal presentation
- Absence of amniotic fluid between the fetus and placenta

Can abdominal pregnancies be brought to term or viability?

- ! Yes, and no.
Figure 21. Cervical Pregnancy - Hindi ka at fault kapag buhay ang baby at pinili ng nanay na
• an hourglass uterine shape
! maoperahan siya
• ballooned cervical canal - Laging priority ang nanay
• gestational tissue at the level of the cervix (black arrow)
• absent intrauterine gestational tissue (white arrows) - It is generally recommended to perform a laparotomy when the
• portion of the endocervical canal seen interposed between the diagnosis of an abdominal pregnancy is made.
gestation and the endometrial canal - However, if the baby is alive and medical support systems are in
place, careful watching could be considered to bring the baby to
Management: viability. Women with an abdominal pregnancy will not go into labor.

• First line for stable patients: medical treatment with MTX Management:
• Methotrexate combined with uterine artery embolization – • Delivery of the fetus
“chemoembolization” • Careful assessment of the placental implantation
• Foley catheter insertion 30cc balloon intracervically to
tamponade vaginal bleeding OVARIAN PREGNANCY
• Suction curettage
• Hysterectomy • Spiegelberg criteria for diagnosis of ovarian pregnancy:
o the gestational sac is located in the region of the ovary
o the ectopic pregnancy is attached to the uterus by the
ovarian ligament
o ovarian tissue in the wall of the gestational sac is
provided histologically
o the tube on the involved side is intact

Management:
• Ovarian wedge resection
• Cystectomy
• Larger lesions: Oophorectomy

IX. REFERENCES

• Williams Obstetrics, 25th edition (Cunningham et al)

• Dr. Valencia’s PPT Lecture (July 12, 2019)
Figure 22. Cervical Pregnancy treated by Hysterectomy
• Notes and recordings of OB2 Trans Team (July 12, 2019)

1S-2 ECTOPIC PREGNANCY ESTUYE • HO • JAVIER • RAMOS • ROCHA

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