宫外孕.ppt
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ADVANCES IN THE MANAGEMENT OF ECTOPICPREGNANCY
Prof. Surendra Nath Panda, M.S.
Department of Obst.Gynaec
M.K.C.G.Medical College
Berhampur-760010, Orissa, India
ECTOPIC PREGNANCY
DEFINITION
Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.
INCIDENCE
>1 in 100 pregnancies.
? Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries.
- USA-5 fold
- UK-2 fold
- France 15/1000 pregnancies
- India-1in100 deliveries
? Recurrence rate - 15% after 1st, 25% after 2 ectopics
HISTORY
? Ectopic pregnancy was first described in 963 Ad by Albucasis.
? 1884 -- Robert Lawson Tait of Birmingham prformed the first successful Salpingectomy operation
? 1953 -- Stromme - Conservative surgery ofSalpingostomy
? 1973 -- Shapiro & Adller - Laparoscopic Salpingectomy
? 1991 -- Young et al - Laparoscopic Salpingotomy
AETIOLOGY
? Any factor that causes delayed transport ofthe fertilisedovumthrough the.
? Fallopian tube favours implantation in the tubal mucosa itselfthus giving rise to a tubal ectopic pregnancy.
? These factors may be Congenital or Acquired.
AETIOLOGY
? CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis
? ACQUIRED -
- Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (lntraluminal adhesion)
- Surgical: Tubal reconstructive surgery, Recanalisation of tubes
- Neoplastic: Broad ligament myoma, Ovarian tumour
- Miscellaneous Causes:IUCD , Endometriosis, ART (IVF & & GIFT), Previous ectopic
CLINICAL PRESENTATION
? Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic
? SYMPTOMS-
- Amenorrhea
- Abdominal Pain
- Syncope
- Vaginal Bleeding
- Pelvic Mass
DIAGNOSIS
"Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it."--Mc. Fadyen - 1981
DIAGNOSIS
? In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.
? This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease.
? This has resulted in early diagnosis and effective treatment.
? Now the rate of tubal rupture is as low as 20%.
METHODS OF EARLY DIAGNOSIS
? Immunoassay utilising monoclonal antibodies to beta HCG
? Ultrasound scanning - Abdominal & Vaginal including Colour Doppler
? Laparoscopy
? Serum progesterone estimation not helpful
METHODS OF EARLY DIAGNOSIS
METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5 weeks can be any of the following-
METHODS OF EARLY DIAGNOSIS
? Poorly defined tubal ring possibly containing echogenic structure and POD typically containing fluid or blood.
? Ruptured ectopic with fluid in the POD and an empty uterus.
? In Colour Doppler, the vascular colour in a characteristic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow
MANAGEMENT
? Depends on the stage of the disease and the condition of the patient at diagnosis.
? Options-
- Surgery - Laparoscopy / Laparotomy
- Medical - Administration of drugs at the site / systemically
- Expectant - Observation
MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
? Hospitalisation
? Resuscitation -
- Treatment of shock
- Lie flat with the leg end raised
- Analgesics
- Blood transfusion
MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
Culdocentesis: -
? Most Helpful in Emergent Situations to Confirm Diagnosis
? Highly Specific if performed and Interpreted Correctly: - Presence of Free-Flowing, NON-Clotting Blood
? Negative Tap Inconclusive
? Remains Controversial
MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
? Laparotomy should be done at the earliest.
? Salpingectomy is the definitive treatment.
? No benefit from removing Ovary along with the tube
? If blood is not available, auto-transfusion can be done.
MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
INVESTIGATIONS-
? Laboratory/Chemical test -
- Serial quantitative beta HCG level by RIA
- Serum progesterone level (<5 mg/ml in ectopic pregnancy)
- Low levels of Trophoblastic proteins such as SPI and PAPP-, Placental protein 14 & 12
? USG- usually haematocele is found
? Laparoscopy
MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
TREATMENT - ALWAYS SURGICAL
? Salpingectomy of the offending tube
? If pelvic haematocele is infected, posterior. colpotomy is to be done to drain the pelvic abscess
? Salpingo-oophorectomy
MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY
? SURGICAL-
? SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT
? MEDICAL TREATMENT
? EXPECTANT MANAGEMENT
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
? Carried out either by Laparoscopy / Laparotomy.
? The procedures are: -
- Salpingectomy / Cornual resection / Excision
- Conservativesurgery (in cases of Infertility & desire for pregnancy)
? Linear salpingostomy
? Linear salpingotomy
? Segmental resection andanastomosis
? Milking of the tube
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
? It is carried out by laparoscopic scissors and diathermy or Endo-loop.
? After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch.......（后略) ......
ADVANCES IN THE MANAGEMENT OF ECTOPICPREGNANCY
Prof. Surendra Nath Panda, M.S.
Department of Obst.Gynaec
M.K.C.G.Medical College
Berhampur-760010, Orissa, India
ECTOPIC PREGNANCY
DEFINITION
Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.
INCIDENCE
>1 in 100 pregnancies.
? Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries.
- USA-5 fold
- UK-2 fold
- France 15/1000 pregnancies
- India-1in100 deliveries
? Recurrence rate - 15% after 1st, 25% after 2 ectopics
HISTORY
? Ectopic pregnancy was first described in 963 Ad by Albucasis.
? 1884 -- Robert Lawson Tait of Birmingham prformed the first successful Salpingectomy operation
? 1953 -- Stromme - Conservative surgery ofSalpingostomy
? 1973 -- Shapiro & Adller - Laparoscopic Salpingectomy
? 1991 -- Young et al - Laparoscopic Salpingotomy
AETIOLOGY
? Any factor that causes delayed transport ofthe fertilisedovumthrough the.
? Fallopian tube favours implantation in the tubal mucosa itselfthus giving rise to a tubal ectopic pregnancy.
? These factors may be Congenital or Acquired.
AETIOLOGY
? CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis
? ACQUIRED -
- Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (lntraluminal adhesion)
- Surgical: Tubal reconstructive surgery, Recanalisation of tubes
- Neoplastic: Broad ligament myoma, Ovarian tumour
- Miscellaneous Causes:IUCD , Endometriosis, ART (IVF & & GIFT), Previous ectopic
CLINICAL PRESENTATION
? Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic
? SYMPTOMS-
- Amenorrhea
- Abdominal Pain
- Syncope
- Vaginal Bleeding
- Pelvic Mass
DIAGNOSIS
"Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it."--Mc. Fadyen - 1981
DIAGNOSIS
? In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.
? This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease.
? This has resulted in early diagnosis and effective treatment.
? Now the rate of tubal rupture is as low as 20%.
METHODS OF EARLY DIAGNOSIS
? Immunoassay utilising monoclonal antibodies to beta HCG
? Ultrasound scanning - Abdominal & Vaginal including Colour Doppler
? Laparoscopy
? Serum progesterone estimation not helpful
METHODS OF EARLY DIAGNOSIS
METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5 weeks can be any of the following-
METHODS OF EARLY DIAGNOSIS
? Poorly defined tubal ring possibly containing echogenic structure and POD typically containing fluid or blood.
? Ruptured ectopic with fluid in the POD and an empty uterus.
? In Colour Doppler, the vascular colour in a characteristic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow
MANAGEMENT
? Depends on the stage of the disease and the condition of the patient at diagnosis.
? Options-
- Surgery - Laparoscopy / Laparotomy
- Medical - Administration of drugs at the site / systemically
- Expectant - Observation
MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
? Hospitalisation
? Resuscitation -
- Treatment of shock
- Lie flat with the leg end raised
- Analgesics
- Blood transfusion
MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
Culdocentesis: -
? Most Helpful in Emergent Situations to Confirm Diagnosis
? Highly Specific if performed and Interpreted Correctly: - Presence of Free-Flowing, NON-Clotting Blood
? Negative Tap Inconclusive
? Remains Controversial
MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
? Laparotomy should be done at the earliest.
? Salpingectomy is the definitive treatment.
? No benefit from removing Ovary along with the tube
? If blood is not available, auto-transfusion can be done.
MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
INVESTIGATIONS-
? Laboratory/Chemical test -
- Serial quantitative beta HCG level by RIA
- Serum progesterone level (<5 mg/ml in ectopic pregnancy)
- Low levels of Trophoblastic proteins such as SPI and PAPP-, Placental protein 14 & 12
? USG- usually haematocele is found
? Laparoscopy
MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
TREATMENT - ALWAYS SURGICAL
? Salpingectomy of the offending tube
? If pelvic haematocele is infected, posterior. colpotomy is to be done to drain the pelvic abscess
? Salpingo-oophorectomy
MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY
? SURGICAL-
? SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT
? MEDICAL TREATMENT
? EXPECTANT MANAGEMENT
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
? Carried out either by Laparoscopy / Laparotomy.
? The procedures are: -
- Salpingectomy / Cornual resection / Excision
- Conservativesurgery (in cases of Infertility & desire for pregnancy)
? Linear salpingostomy
? Linear salpingotomy
? Segmental resection andanastomosis
? Milking of the tube
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
? It is carried out by laparoscopic scissors and diathermy or Endo-loop.
? After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch.......（后略) ......
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