Ectopic Pregnancy

What Sample is needed to diagnose Ectopic Pregnancy?

1. Patient serum is needed for Beta- HCG level.
2. Biopsy of the fallopian tube or ovarian tissue for surgical pathology will show placental villi and trophoblastic cells.

How will you define  Ectopic Pregnancy?

• This is defined as the product of conception implanted outside the uterine cavity.
  • Or implantation of the fertilized ovum in a location other than the uterus.

What is the Pathophysiology of Ectopic Pregnancy?

1. Ectopic pregnancy is a gynecological issue because of differential diagnosis.
2. This is the implantation of the fetus out of the usual place of the uterine cavity.
3. This may be seen in 1% of pregnancies.
4. The most common site is:
   1. The ampullary part of the fallopian tube is 80%.
   2. The isthmic portion of the fallopian tube is 12%.
   3. The fimbria of the fallopian tube is 5%.
   4. The abdomen is 1.4%.
   5. The ovary is 0.2%.
   6. The cervix is 0.2%.

5. The most common site is the fallopian tubes, also called a tubal pregnancy.
6. There are chances of ectopic pregnancy in 1 out of 50 pregnancies.
7. The hormonal changes are the same as in a normal pregnancy.
   1. There is the cessation of the menstrual cycle.
   2. There is an elevation of the serum and urinary placental hormone.
   3. 50% of the cases show hypersecretory and decidual changes.
8. The surgical biopsy material takes many sections, particularly from the blood clot.
   1. Try to find the placental villi to confirm the ectopic pregnancy.

What is the Pathogenesis of ectopic pregnancy?

1. Ectopic pregnancy is caused by:
   1. Infection or the scar formation of the fallopian tubes, which block the tube, is almost seen in 50% of the cases.
   2. Due to previous surgery, which may cause scarring.
   3. Adhesion due to previous surgery on the fallopian tubes or pelvic area.
   4. Endometriosis may also block the passage of the ovum

Ectopic Pregnancy: Ectopic site’s pathological changes

What are the Predisposing factors for ectopic pregnancy?

1. If there is a previous H/O ectopic pregnancy.
2. Patients with H/O infertility are more prone to ectopic pregnancy.
3. If there is the H/O gonorrhreal  or chlamydial infection.
4. If there is a H/O intrauterine device application.
5. In the case of H/O endometriosis.
6. More chances in cases of in-vitro fertilization pregnancy.
7. If it is tubal damage from infections or disease.
8. In case there is H/O smoking.
9. In the case of a previous H/O miscarriage.

What are the complications of ectopic pregnancy?

1. Intratubal hematoma also called hematosalpinx.
2. There may be an intraperitoneal hemorrhage.
3. Death of the ovum.
4. The tubal rupture and hemorrhage of the ectopic pregnancy lead to a fatal outcome.
   1. There is severe abdominal pain.
   2. The patient may go into shock.
   3. Immediate surgery can save a life.
5. 13% of these ectopic pregnancies may lead to maternal death.
6. If the diagnosis is not made in time, it leads to the fetus’s death and endangers a pregnant lady’s life.

What is the incidence of ectopic pregnancy?

1. Ectopic pregnancy is the most common cause of death in the first trimester of pregnancy.
2. The majority of the cases >95% occur in the fallopian tubes.
3. Rest occurs in the ovary, cornua, and abdomen.

What are the Signs and Symptoms of ectopic pregnancy?

1. Most of the time, its diagnosis is missed.
2. Usually, there is abdominal pain. This may vary and be seen in 97% of the cases.
3. There may be vaginal bleeding (spotting). This abnormal bleeding is seen in 75% of the cases.
4. Menses are delayed in these ladies in 75% of the cases.
5. Adnexal tenderness on palpation is seen in 90% to 95%.
   1. Also, there is unilateral adnexal mass in 50% of the cases.
6. Fever is seen in about 5% of the cases.
7. A hypovolemic shock may be the presenting symptom in 14% of the cases.
8. The following signs and symptoms suggest an emergency surgical procedure:
   1. Severe tenderness.
   2. If there is abdominal rigidity or guarding.
   3. If there is a hypovolemic shock.
9. 25% of ectopic pregnancy patients show three classic presentations:
   1. Lower abdominal pain.
   2. Vaginal bleeding.
   3. Adnexal mass.
10. Sometimes, patients suspicious of ectopic pregnancy have threatened abortion, pelvic inflammatory disease, rupture of corpus luteal cyst, bleeding ovarian cyst, and dysfunctional uterine bleeding.

How will you Diagnose ectopic pregnancy?

1. Three important symptoms are:
   1. Lower abdominal pain.
   2. Vaginal bleeding.
   3. An adnexal mass.
2. Hemoglobin <10 g/dL is reported in about 40% of ectopic pregnancy cases.
   1. There may be increased total white cells (leucocytosis) in about 50% of the cases.
3. The pregnancy test has variable sensitivity. Urine and serum pregnancy tests have 500 to 1000 mIU/mL sensitivity.
   1. A positive pregnancy test is not diagnostic of ectopic pregnancy. It will indicate only a raised level of HCG.
4. Advise beta-HCG to confirm the pregnancy.
   1. β-HCG level varies from undetectable to 200,000 IU/L, depending upon the size and viability of the trophoblastic cell mass.
   2. Follow the normal dynamics of the HCG level. This will be disturbed in the ectopic pregnancy.
   3. Normally, it increases every 48 to 72 hours until it reaches 10,000 to 20,000 IU/mL.
   4. It should be further evaluated if an abnormal rise in the β-HCG level is <66% higher than the original values.
   5. Serial HCG levels are estimated to differentiate ectopic pregnancy from normal.
   6. If the HCG level does not rise at least 66% in 48 hours or the HCG level falls in this period.
   7. If there is a failure to double (increase) the HCG level in 24 hours, at the 4 to 8 weeks of gestation occurs:
      1. In 66% of ectopic pregnancies.
      2. In 85% of the spontaneous abortion.
      3. In 15% of normal pregnancies.
   8. But you can see the rising rate of 15% in ectopic pregnancies.
5. Ultrasound is the most helpful tool.
   1. Transvaginal ultrasound is more sensitive.
6. Progesterone and HCG both predict abnormal pregnancy rather than advising a single test of HCG.
7. Ectopic pregnancy:
   1. 97% of cases have Progesterone <12.6 ng/mL and HCG <3000 IU/L.
   2. Normal pregnancy has progesterone >12.6 ng/mL and HCG >3000 IU/L.
8. Progesterone level > 25 ng/ mL will ensure intrauterine pregnancy without further laboratory tests (nearly 97%).
   1. Progesterone level < 5 ng/mL strongly suggests an abnormal pregnancy.
   2. Progesterone values are limited because, in 85% of the pregnancies, the values are between 5 to 25 ng/mL.
   3. While values between 5 to 25 ng/mL are intermediate.

How will you Treat Ectopic Pregnancy?

1. The first line of management is surgical laparoscopy.
2. Medically gives methotrexate I/M.

How will you do Follow-up of ectopic pregnancy?

1. After removing the ectopic pregnancy, the HCG level remains typically detectable for four weeks.
2. Monitor the HCG level to ensure there is no leftover trophoblastic tissue.

Questions and answers: