Ectopic Pregnancy and Its Diagnosis

Sample

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

Definition

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

pathophysiology

1. This is the implantation of the fetus out of the normal place of the uterine cavity.
2. This may be seen in 1% of pregnancies.
3. 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%.
   1. The fimbria of the fallopian tube is 5%.
   2. The abdominal is 1.4%.
   3. Ovary is 0.2%.
   4. Cervix is 0.2%.

4. The most common site is the fallopian tubes and these are also called a tubal pregnancy.
5. There are chances of ectopic pregnancy 1 out of 50 pregnancies.
6. The hormonal changes are the same as a normal pregnancy.
   1. There is the cessation of the menstrual cycle.
   2. There is the elevation of the serum and urinary placental hormone.
   3. 50% of the cases show hypersecretory and decidual changes.
7. In the surgical biopsy material take many sections particularly from the blood clot.
   1. Try to find the placental villi to confirm the ectopic pregnancy.
8. The ectopic pregnancy is caused by:
   1. Infection or the scar formation of the fallopian tubes which blocks 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 in the pelvic area.
   4. Endometriosis may also block the passage of the ovum.

9. If the diagnosis is not made in time, it leads to the death of the fetus and endangers the life of a pregnant lady.
10. Complications of ectopic pregnancy are:
    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 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.

Incidence

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.

Sign and Symptoms

1. Most of the time its diagnosis is missed.
2. Usually, there is abdominal pain.
3. Or there may be vaginal bleeding (spotting).
4. The following signs and symptom suggest emergency surgical procedure:
   1. Severe tenderness.
   2. If there is abdominal rigidity or guarding.
   3. If there is a hypovolemic shock.
5. 25% of the ectopic pregnancy patients shows three classic presentations:
   1. Lower abdominal pain.
   2. vaginal bleeding.
   3. Adnexal mass.

Diagnosis

1. Advise beta-HCG to confirm the pregnancy.
   1. Follow the normal dynamics of the HCG level. This will be disturbed in the ectopic pregnancy.
   2. Normally it increases every 48 to 72 hours until it reaches 10,000 to 20,000 IU/mL
   3. Serial HCG levels are estimated to differentiate ectopic pregnancy from the normal.
   4. If the HCG level does not rise at least 66% in 48 hours or HCG level falls in this period.
   5. But you can see the normal rate of rising by 15% of the ectopic pregnancy.
2. Ultrasound is the most helpful tool.
3. Progesterone and HCG both predict the abnormal pregnancy than advising a single test of HCG.
4. 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.
5. Progesterone level > 25 ng/ mL, will assure the intrauterine pregnancy and no need for further laboratory tests.
   1. Progesterone level < 5 ng/mL strongly suggest abnormal pregnancy.

Treatment

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

Follow-up

• After removal of the ectopic pregnancy HCG level normally remains a detectable level for 4 weeks.
• Monitor the HCG level to be sure that there is no leftover of trophoblastic tissue.

 

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