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Ectopic pregnancy
- 1. ANANDU MATHEWS ANTO GOVT.MEDICALCOLLEGE KOTTAYAM
- 2. Account forabout 1-2% of reported pregnancies. Incidence of ectopic pregnancies are increasing now. This can be accounted for by the following reasons i. Greater prevalence of STD s especially chlamydial infections. ii. Development of newer diagnostic tools with improved accuracy iii. Tubal factor infertility . iv. Increasing use of assisted reproductive techniques.
- 3. DEFINITION Ectopic is definedas “ a pregnancy in which the blastocyst implants anywhere other than the endometrial lining of the uterine cavity”
- 4. SITES OF ECTOPICPREGNANCY
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- 6. EXTRATUBAL ECTOPICS INTRALIGAMENTOUS ABDOMINALOVARIAN CERVICAL CESAREAN SCAR
- 7. AETIOLOGY FOR TUBALPREGNANCY Any factor that causes delayed transport of the fertilized ovum through the fallopian tube . Basically causes can be of two types 1. Acquired 2. Congenital
- 8. AETIOLOGY FOR TUBALPREGNANCY Acquired causes Pelvic inflammatory disease. Pelvic TB . Post-abortal or puerperal sepsis. Salpingitis isthmica nodosa. Assisted reproductive techniques.
- 9. Intrauterine contraceptive devices. Cigarette smoking . Previous ectopic Anyprevious surgeries on the tube
- 10. PELVIC INFLAMMATORY DISEASE Subclinicalchlamydial infection usually leads to PID. Single episode PID 12% risk for ectopic .
- 11. PATHOPHYSOLOGY Similar forPID ,Pelvic TB and for Post abortal/puerperal sepsis. 1. 2. 3. PID/TB/SEPSIS ENDOSALPINGITIS AGGLUTINATION OF TUBAL MUCOSAL FOLDS FORMATION OF BLIND POCKETS Entrapment of fertililized ovum in the tube PID/TB/SEPSIS Decreased ciliation Decreased motility of fertilized ovum PID/TB/PUERPERAL SEPSIS PERITUBAL ADHESIONS KINKING AND NARROWING OF THE LUMEN
- 12. Salpingitis isthmica nodosa(SIN) Also known as Perisalpingitis Isthmica Nodosa It refers to nodular scarring of the fallopian tubes . Aetiology is controversial . Prevailing theroes include salpingitis ,congenital causes . Usually it involves the medial two thirds of the fallopian tube . tubal epithelium invades myometrium Forms a diverticulum Ovum entrapment in the diverticulum
- 13. Assisted Reproductive Techniques Procedures that lead to highest rates of ectopic preganacy are Gamete intrafallopian transfer. Cryopreserved embryo transfer. In vitro fertilization. ► In a women undergoing IVF the greatest risk factors for the development of ectopic pregnancy are A)Tubal factor infertility B)hydosalpinges Also the number of ovum being released is increased due to ovulation induction Other ectopics like interstitial ,abdominal, cervical, ovarian and heterotopic are common after ART
- 14. INTRAUTERINE CONTRACEPTIVE DEVICES AnIUCD can prevent an intrauterine pregnancy more effectively than a tubal pregnancy. Hence a conception with an IUCD in place is more often ectopic than a pregnancy without IUCD . IUCDs are associated with an increased incidence of PID leading to an increased incidence of ectopic pregnancies
- 15. Cigarette smoking Riskincreased in women using >20 cigarettes /day(one pack per day) Smoking Nicotine Smooth muscle spasm Defective ciliary function Defective embryo transport
- 16. PREVIOUS SURGERIES ONTHE TUBE PREVIOUS ECTOPICS Procedures like tubal recanalization procedures and tube sterilization . 1/3rd of pregnancies following tube sterilizations turns out to be ectopic pregnancy. Sterilization using electrocautry is associated with highr risk. Recurrence rate is 12% after 1 ectopic and 28% after second ectopic.
- 17. CONGENITAL FACTORS Accesoryostia Diverticula Partial stenosis Tuba tortuosity Aplasia , atresia , hypoplasia
- 18. Mnemonic - ECTOPICS PREVIOUS ECTOPIC CONGENITAL FACTORS ASSISTED REPRODUCTIVE TECHNIQUES O- PID IUCD CIGARETTE SMOKING SALPINGITIS ISTHMCA NODOSA ,PREVIOUS SURGERIES ON THE TUBE E C T O P I C S
- 19. NATURAL HISTORY OF TUBALECTOPIC
- 20. TUBAL ABORTION Tubal abortion Productsof conception expelled through ostia Products of conception remain in the tubal lumen enclosed in clotted blood(tubal mole) Complete abortion Presents as old or chronic abortion
- 21. Tubal rupture Ectopicattached to antimesenteric border trophoblast invades through the peritonel surface sever intaperitonel bleed. if attached caudally , erosion of the trophoblast can lead to a broad ligament haematoma Rupture is an emergency condition.
- 22. Presents withintraabdominal bleed and shock. Symptoms –pale,cold clammy extremities O/E- pallor +,rapid thready pulse , hypotension. P/A- tenderness in RIF/LIF, abdomen distended, guarding+, rigidity+, cullens sign + blood can collect around the rupture site forming a peritubal haematocele or in the pouch of douglas forming a pelvic haematocele(detected by culdocentesis)
- 23. Site of tubalectopic Usual time of rupture Isthmus Early rupture at 6-8wks Ampulla Later that 6-8 wks Interstitial region Late rupture ,may be in the 2nd trimester.But the bleeding from this site is extensive. • Tubal rupture/abortion can give rise to a pelvic haematoma
- 24. Abdominal pregnancy After tubalrupture , fetus may drop into the abdominal cavity If that fetus is still alive secondary abdominal pregnancy or a secondary intraligamentous pregnancy
- 25. Changes in theuterus Uterus becomes slightly enlarged .Why? Due to myohyperplasia and hypertrophy. Arias Stella phenomenon =hyperplasia of glandular cells with hyperchromatic nucei ,cytoplasmic vacuolations and loss of cell polarity Is non specific.
- 26. Absence ofchorionic villi in the endometrial curettings- MOST RELIABLE FINDNG Floatation test Done to differentiate between endometrial curettage with chorionic villi and without chorionic villi .
- 27. Arias stella reaction+ absence of chorionic villi in endometrial curettage = highly suggestive of ectopic pregnancy
- 28. Stroma ofthe uterus shows decidualistaion with large polyhedral cells and hyperchromatc nuclei. Decidual cast: decidua may be passed as a flat reddish brown piece of tissue called decidual cast. Low levels of hormone ± failing pregnancy ILL sustained decidua Decdua may shed intermittently intermittent bleeding PV / Spotting PV in
- 29. Clinical features Case1: A28yr old women married for 2yrs presented with 8 wks amenorrhoea , acute abdominal pain followed by spotting PV and she was UPT positive . Case2: A 25 yr old married lady presented with history of 10 wks amenorrhoea ,acute lower abdominal pain and fainting . On clinical examination , she has tachycardia , hypotension and pelvic tenderness.she was also UPT positive.
- 30. D/D for firsttrimester bleeding pv 1.Ectopic pregnancy 2.Abortions 3.Vesicular mole
- 31. Classical triadof ectopic gestation =amenorrhea + irregular vaginal bleeding + abdominal pain . Presence of amenorrhoea is not essential for the diagnosis of ectopic pregnancy. WHY? LMP Ovulation And fertilization occur Usual time of UPT positivity 0th 2 wks 4 wks
- 32. Profuse bleedingis unlikely in an ectopic and is more in favour of an abortion. IRREGULAR OR ABNORMAL BLEEDING ASSOCIATED WITH ABDOMINAL PAIN IN A SEXUALLY ACTIVE WOMEN - WE SHOULD ALWAYS SUSPECT AN ECTOPIC PREGNANCY UNLESS PROVEN OTHERWISE .
- 33. ABDOMINAL PAIN SHOULDER PAIN –referred pain from irritation of diaphragm by intraperitoneal bleed FAINTING SPELLS
- 34.
Editor's Notes
- #3 Tubal factor infertility 1.Proximal tubal disease like intratubal muvus debri, following pelvic surgry,salpingitis isthmica nodosa, corneal polyps. 2.Distal tubal diseases- PIB ,pelvic TB, postabortal /puerperal sepsis, appendicitis
- #8 1 cell – 3 cell stage – 4 cell stage ,----- finally we gwt a 16 cell stage called morula -----fluid from the uterine cavity pases into te morula and froms a blastocyst. In the blastocyst the cells are divided into two ie inner cell mass and trohoblast. The blastocyst is the stage of implantation . The trophoblasts , in the blastocyst have the capacity to stick to epithelium and have the capacity to eat up other cells . Till the blastocyst stage the developing embryo has zona pellucida .When tubal transport is affected or delayed , the multiplication of the embryo is not delayed and it goes on normally. So at the blastocyst stage the embryo loses its zona pelucida and wherever the be at that point of time, be it the ampulla , the isthmus etc it gets implanted there
- #11 Symptoms of PID- b/l lower abd pain, abnormal vginal discharge , menometrorrhagia, post coital bleeding, fever nausea ,R upper quadrant pain becoz of perihepatitis(fitz- hugh-Curtis syndrome) Signs –high fever tachycardia coated tongue, P/A – tenderness , rigidity Pelvic exam- foul smelling purulent discharge, cervical excitation, tenderness in forncices ender adnexal mass
- #12 Mucosal folds/ plicae are most numerous in ampulla. a previous salpingitis will produce more crypts here . In salpingitis, there is desquamation of epithelial cells lining the mucosal folds . In the process of healing adjacent plicae get adhered together and form a blind alley in which he fertilized ovum get entrapped.