Ectopic Pregnancy

Introduction

Ectopic Pregnancy is one in which the conceptus implants either outside the uterus (fallopian tube, ovary or abdominal cavity) or in an abnormal position within the uterus (cornua, cervix, angular and rudimentary horn).
It is the most common surgical emergency in women in many developing countries.
A substantial cause of maternal mortality:

  • Rapidity with which haemorrhage and shock occur
  • Pre-rupture diagnosis is elusive, with consequent delay in surgical
    management.

Symptoms and clinical features ectopic pregnancy

The clinical subsets include:

  • Acute ectopic gestation – 25% or less of cases
  • Sub-acute ectopic gestation -75% of cases
  • “Silent” ectopic/chronic ectopic gestation

Acute Ectopic Gestation

Amenorrhoea

  • Features of acute abdomen particularly lower abdominal pain, vaginal bleeding or brownish discharge, severe pallor, shoulder tip pain.
  • Difficulty with sitting on hard surfaces.
  • Features of shock with cardiovascular collapse:
    • hypotension and tachycardia
  • The uterus is slightly enlarged with
    tenderness on one side
  • Some advice that examination should be avoided if there is a strong suspicion of an ectopic pregnancy
  • Positive cervical excitation tenderness

Sub-acute Ectopic Gestation

  • Slow-leaking ectopic prior to rupture, with most of the signs and symptoms of acute ectopic gestation present but in the mildest form.

“Silent” vs. “Chronic” Ectopic Gestation

  • Asymptomatic
  • May just be picked up during a pelvic examination in the course of booking orbantenatal clinic, or found on ultrasound for another pelvic pathology

Complications of ectopic pregnancy

  1. Shock
  2. Sterility (with the loss of both tubes).
  3. Often requires blood transfusion (with its attendant cost and risk of blood-borne infections)
  4. 5 – 20% risk of having another ectopic gestation
  5. Fatality

Diagnosis

Requires a high index of suspicion
particularly in the case of atypical, slow
leaking or chronic ectopic gestation where diagnosis could be difficult

Differential diagnoses

For unruptured ectopic pregnancy:

  • Acute pelvic inflammatory disease
  • Adnexal torsion
  • Incomplete abortion
  • Endometriosis
  • Degenerating uterine fibroid
  • Acute appendicitis
  • Accidented ovarian cysts

Investigations

  • Haemoglobin concentration/packed cell volume
  • Blood grouping and cross matching
  • Urinalysis
  • Ultrasound scan of the pelvis (preferably trans-vaginal);
  • Serum B-hCG (where available) especially in silent cases
  • Laparoscopy may be necessary when still in doubt, but the availability of trans-vaginal ultrasound scan may obviate this
  • Final arbiter when the diagnosis is in doubt is exploratory laparotomy

Treatment for ectopic pregnancy

Treatment objectives

This depends on the clinical subset.
The objective is to preserve maternal life

1. Acute ectopic

  1. Immediate resuscitation (fluids/blood).
  2. Stop haemorrhage by emergency surgery.
  3. Replace lost blood.

General principles and treatment modalities

Surgery

  • Salpingectomy (total or partial) for
    ruptured ectopic pregnancy
  • Partial salpingectomy if the remaining segment of the tube is about 4 cm long; this could be used for reconstructive surgery subsequently
  • Salpingostomy for unruptured cases.

Non-surgical options

Used in unruptured cases: expectant management and medical agents

Expectant management

  • Monitor pregnancy by-hCG levels
  • Vaginal scans: spontaneous resorption can occur provided gestation sac is <4 cm and hCG is <1,500 IU

Medical treatment

Methotrexate

  • Administered systemically or locally to induce dissolution of trophoblastic tissue (Ru 486)
  • Hyperosmolar glucose solution, potassium chloride andbprostaglandins can also been used

Auto transfusion

  • During surgery for ectopic gestation; very important in developing countries with inadequate blood banking services
  • The risks of transfusion with donated blood are avoided
  • Use only fresh blood.

On discharge:

  • Counsel for contraception and advise to report immediately to the hospital if a pregnancy is suspected so that its site can be confirmed