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‫بسم ال الرحمن الرحیم‬

‫اخلق طبا بت بال ترین اخلق در اجتماع‬


‫‪.‬میباشد‬
SURGICAL
MANAGEMENT OF
ECTOPIC
PREGNANCY
Ectopic Pregnancy

Definition:
Ectopic pregnancy occurs
when the fertilised egg is
implanted outside the
womb.
Female Pelvic Anatomy
Risk Factors

High:
Tubal surgery, tubal sterilization, previous
ectopic, PID, IUD, tubal pathology
Moderate:
Infertility, previous genital infection, IVF.
Slight:
Previous pelvic/abdominal surgery, smoking,
douching,intercourse prior to 18 years of age
Types of Ectopic
Pregnancy Interstitial: gestation
implants in the interstitial
portion of the fallopian
tube.

Cervical
Vaginal
Broad ligament

Abdominal (0.1%) Angular: A gestation that


implantation within the extends beyond the interstitium
peritoneal cavity (can occur into the adjacent uterine cavity
secondary to tubal pregnancy)
Epidemiology
 2% of all pregnancies each year in the Unites State

 Commonest cause of maternal mortality within the 1st trimester

 Overall incidence in non-white women is 1.4 times higher than in white


women
Sites
 Ampulla (95%)
 Isthmus (8%)
 Cornua (< 2%)
 Ovary (< 2%)
 Abdomen (< 2%)
 Cervix (< 2%)
SITES OF ECTOPIC PREGNANCY

Ampulla (>85%) Abdomen (< 2%)


Isthmus (8%)

Cornual (< 2%)


Ovary (< 2%)
Cervix (< 2%)

1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian


6)Cervical 7)Cornual-Rudimentary horn 8)Secondary
abdominal 9)Broad ligament 10)Primary abdominal
Evaluation and Diagnosis
 History and Physical Exam
 CBC,
 ß-hCG Level
 Ultrasound
 Progesterone Level?
 Culdocentesis
 Laparoscopy
Tubal Pregnancy
Symptoms:
 Amenorrhea
 Abdominal Pains
 Vaginal Bleeding
 Syncope
 Pelvic Mass

Common associated findings:


 Adnexal tenderness (54%) ,
Amenorrhea
 Early pregnancy symptoms
 Nausea, vomiting, diarrhea, dizziness
Other Signs:
 Tachycardia, Low grade fever
 Chadwick’s sign (cervix and vaginal cyanosis)
 Hegar’s sign (softened uterine isthmus)
 Hypoactive bowel sounds
 Cervical Motion Tenderness
 Enlarged uterus
 Tender pelvic or adnexal mass
 Cul-de-sac fullness

Signs suggestive of ruptured ectopic pregnancy:


 Usually between 6 and 12 weeks gestation
 Severe abdominal tenderness with rebound, guarding
 Orthostatic hypotension
Differential Diagnosis
 Appendicitis
 Threatened Miscarriage
 Ruptured ovarian cyst
 PID
 Salpingitis
 Endometritis
 Nephrolithiasis
 Ovarian torsion
 Intrauterine pregnancy
Pathology of Ectopic
Pregnancy

 Fertilized ovum borrows through the epithelium


 Zygote reaches the muscular wall
 Trophoblastic cells at zygote periphery proliferate, invade, and erode adjacent
muscularis
 Maternal blood vessels disrupted leading to hemorrhage
 Outcome: tubal abortion or rupture with hemorrhage
Initial Investigations
Monitor βhCG levels
 βhCG- hormone produced by the placenta (and fetal kidney)
 Detectable in plasma and urine following blastocyst implantation
 Blood levels rise rapidly, doubling every 2d and plateaus at 8-10
weeks gestation
 Serum βHCG levels correlate with the size and gestational age in
normal embryonic growth

• βHCG with inadequate increase may suggest ectopic pregnancy

**βhCG level does not predict ruptured ectopic,


ruptured ectopic may occur at any βHCG level
Serum βhCG Levels
1000

900

800

700
LOW!!!!!
600
BhCG (U/L)

500

400

300

200

100

0
12/23/2005 12/25/2005 12/27/2005 12/30/2005 1/4/2006 1/6/2006 1/9/2006
DATE
Other Labs:
 Complete blood count
 Leukocytosis

 Urinalysis with microscopic exam

 Blood Type and Rhesus


 A negative
• Therefore, must give anti-D (RhoGAM) prior to surgery
Imaging Studies
 US imaging confirms the clinical diagnosis
of suspected ectopic, location, and size
Findings suggestive of ectopic pregnancy:

•Absence of gestational sac at βHCG 1800


IU/L
•Free fluid present (71% likelihood of ectopic)
•Echogenic mass at adnexa (85% likelihood)
•Echogenic mass with free fluid (100% likelihood)

Transvaginal vs. Transabdominal


Transabdominal Ultrasound
(on admission)
 Empty Uterus
 Free fluid
 Distended portion of left
Fallopian tube
 No evidence of rupture
 Adenexal mass:
 1.7 x 1.6cm adjacent
and anterior to left
ovary
 Cervical excitation
 Tenderness over left iliac
fossa on deep palpation
with the probe
Management Options
 Medical
Management:
Methotrexate (anti-metabolite)
 Stable vital signs with normal LFTs, CBC, platelets
 Unruptured ectopic pregnancy without cardiac
activity
 Ectopic mass <4 cm
 βHCG <5000 IU/L
 Surgical Management Indications

Failed or contraindicated non-surgical management

Nondiagnostic Transvaginal US and βHCG >1500

Hemoperitoneum

Diagnosis unclear

Unstable vital signs
Radical vs. Conservative
Surgery
Salpingostomy (Conservative)
 Small pregnancy (<2cm) located in distal
fallopian tube
 Maximizes preservation of affected tube
 Associated with a 5% risk or recurrence
 Risk of tubal scarring due to incision
Salpingotomy
 Same as above only incision is sutured
closed

Salpingectomy (Radical)
 Tubal resection

Segmental resection and anastomosis


Surgical Options

1. Laparoscopy
• “Key hole” surgery
• Recommended approach

Advantages:
Less blood loss, decreased number of transfusions, less recovery time, less post-op
analgesia, cost effective

Contraindications:
ruptured EP, haemodynamic instability, surgeon’s lack of experien
Surgical options (cont’d)

2. Laparotomy

 Surgical incision
through the abdominal
wall

Pfannensteil incision

Mainly used for cases
involving
haemodynamic
instability
Pre-Operative Work-Up
1. Full blood count (leukocytosis)
2. Blood group serology
3. Coagulation workup
4. Vital signs → stable for surgery
5. Review tests
• βhCG- ectopic still present
• US imaging- location, size
1. Medications:
• NKDA, GA (no allergy)
Patient Preparation
7. Pre-op nutrition- fasting (unless emergency)
8. Bowel prep- enema
9. Shave suprapubic hair
10. Patient information
• Risks and complications
• Risks of conversion to laparotomy
• Risks of salpingectomy
Surgical Complications

The patient MUST be made aware of these risks when


informed consent is obtained:

 Hemorrhage and hypovolemic shock


 Infection
 Loss of reproductive organs following surgery
 Infertility ***
 Urinary and/or intestinal fistulas following complicated
surgery
 Disseminated intravascular coagulation (rare)
Prognosis for Future Conception

 Conception rate post-ectopic: 77%

 Recurrent ectopic pregnancy risk:


 After 1st ectopic: 5-20% risk
 After 2nd ectopic: 32% risk
Equipment

Laparoscopic Tools

Video monitor
1. Bipolar grasper
2. Atraumatic grasper
3. Grasping forceps
4. Toothed forceps
5. Sharp-tipped monopolar
device
6. 5-10mm suction-irrigation
device
7. Scissors
Anatomical Review

1. Medial tubal A.
2. Lateral tubal A.
3. Uterine A.
4. Ovarian A.
Laparoscopic Salpingectomy

Main Risk: devascularization of the ovary


 Operate close to the tube, away from ovarian
vessels and suspensory ligament
2. Mesosalpinx Division
 Divide the mesosalpinx
with scissors

 Cauterize and divide the


infundibulo-ovarian
ligaments and the lateral
tubal A.
3. Extraction of the tube
 Remove tube through an
extraction bag
 Verification of hemostasis
 Careful lavage
 Removal of equipment
 Suture/ Steri-strip laparoscopic
incisions

Caution:
• Endometriosis
• Utero-peritoneal fistula
Post-operative Plan
 Remove urinary catheter and NG tube
 Observation and analgesia
 Remove IV on the evening of the procedure
 Food on evening of procedure
 Discharge following day
 Discuss use of contraceptives
 Pregnancy 2-3 months post-op (2-3 cycles)
 Information regarding the risk of ectopic recurrence
The End