Ectopic Pregnancy

Introduction and Facts

Disrupted ectopic pregnancy is a major problem in gynecology in the world, causing high maternal morbidity and mortality. Since the 1970s, the frequency has increased nearly 6-fold in the United States, now accounting for 2% of all pregnancies. Disrupted ectopic pregnancy, which is generally an emergency, is responsible for 9-10% of maternal deaths due to obstetric disease.

Pathophysiology

Some of the things below have to do with the occurrence of an ectopic pregnancy:

a. The influence of mechanical factors. Mechanical factors that cause ectopic pregnancy include: a history of tubal surgery, salpingitis, tubal adhesions due to nongynecological surgeries such as appendectomy, exposure to diethylstilbestrol, salpingitis isthmica nodosum (small protrusions into the tubal lumen resembling diverticula), and intrauterine devices. uterus (IUD). These things generally cause intra- and extraluminal adhesions in the tube, thereby inhibiting the zygote's journey to the uterine cavity. Other mechanical factors are having an ectopic pregnancy, having undergone surgery on the fallopian tubes such as recanalization or partial tubectomy, repeated abortion induction, tumors that disrupt the integrity of the fallopian tubes.

b. The influence of functional factors. Functional factors are changes in tubal motility associated with hormonal factors. In this case the tubal peristalsis movement becomes sluggish, so that implantation of the zygote occurs before the zygote reaches the uterine cavity. Tubal motility disorders can be caused by changes in the balance of serum estrogen and progesterone levels. In this case there is a change in the number and affinity of adrenergic receptors present in the uterus and smooth muscle of the fallopian tubes.

c. Contraceptive failure. Intrauterine contraception has long been considered a cause of ectopic pregnancy. However, it turned out that only the IUD containing progesterone increased the frequency of ectopic pregnancies. The IUD without progesterone does not increase the risk of an ectopic pregnancy, but if a woman has an IUD, it is more likely that it will be an ectopic pregnancy.

d. Increased affinity for the tubal mucosa. In this case, there is an ectopic endometrial element that is able to increase implantation in the tube.

e. Influence of IVF process. Several incidents of ectopic pregnancy have been reported to occur in the process of pregnancy that occurs with the help of assisted reproduction techniques. Tubal pregnancy has been reported to occur in GIFT (gamete intrafallopian transfer), IVF (in vitro fertilization), ovum transfer, and ovulation induction. Induction of ovulation with human pituitary hormone and hCG can cause an ectopic pregnancy if at the time of ovulation there is an increase in urinary estrogen secretion exceeding 200 mg a day.

Symptoms and Complications

Symptoms and signs of an ectopic pregnancy:

a. Painful. Symptoms that arise relate to whether the ectopic pregnancy has ruptured. The most common symptoms experienced are pelvic and abdominal pain. Digestive symptoms and dizziness or lightheadedness are also common, especially after rupture. Pleuritic chest pain may result from irritation of the diaphragm by bleeding.

b. Abnormal Menstruation. Most women report amenorrhea with spotting vaginal bleeding. Uterine bleeding that occurs in tubal pregnancy is often mistaken for true menstruation. This bleeding is usually light, dark brown in color, and may be intermittent or continuous. In tubal pregnancy, heavy vaginal bleeding is rare.

c. Abdominal and Pelvic Pain. Severe pain on abdominal examination and vaginal examination, especially when the cervix is ​​moved, is seen in more than three quarters of women with ruptured tubal pregnancy. However, this tenderness may not be present before rupture occurs.

d. Uterine Changes. In tubal pregnancy, the uterus can grow during the first 3 months due to the influence of placental hormones. Uterine consistency may also be similar to that found in normal pregnancy. The uterus may be pushed aside by an ectopic mass, or if the broad ligament is filled with blood, the uterus may be severely compressed. Uterine decidual cylinders form in 5 to 10 percent of women with ectopic pregnancies. The discharge of these structures may be accompanied by cramping similar to that experienced during spontaneous abortion.

e. Blood Pressure and Pulse. Prior to rupture, vital signs were generally normal. The initial response to rupture may range from no change in vital signs to a mild increase in blood pressure, or a vasovagus response with bradycardia and hypotension. Blood pressure will fall and pulse will increase only if bleeding continues and hypovolemia occurs

f. Temperature. After acute bleeding, the temperature may be normal or even low. The temperature can rise to 38°C, but without infection the temperature rarely exceeds this figure.

g. Pelvic Mass. On bimanual examination, a mass can be palpated

Diagnosis

The ways to diagnose an ectopic pregnancy are:

a. analysis. In the history, there is a triad of KET, namely amenorrhoea accompanied by signs of early pregnancy, abdominal pain, shoulder pain, tenesmus and vaginal bleeding.

b. Physical examination. On examination, the patient was found to be in pain, pale, anemic, restless, symptoms of accumulation of blood in the abdominal cavity, bleeding in the abdominal cavity, signs of shock, symptoms of cardiovascular disorders, and symptoms of changes in the respiratory system were found. On internal/gynecological examination, there was tenderness and tenderness in the cervix, the posterior fornix was prominent and painful, the uterus could be felt slightly enlarged, there was a tumor with indistinct borders around the uterus, and the cavity of Douglas was prominent, filled with blood and painful when pressed.

c. Laboratory examination

1. Hemoglobin, Hematocrit, and Leukocyte Count. After bleeding, the reduced blood volume is returned to normal by hemodilution that lasts for a day or so. Therefore, the hemoglobin or hematocrit examination may initially show only a slight decrease. In interrupted ectopic pregnancy, the degree of leukocytosis varies greatly. In about half of women, leukocytosis of up to 30,000/µL can be found.

2. Urine Examination for Pregnancy. The most commonly used urine test is the latex agglutination inhibition test using a slide with a sensitivity for chorionic gonadotropin (hCG) in the range of 500 to 800 mIU/mL. in an ectopic pregnancy, the chance of being positive is only 50 to 60 percent. If a tube is used, the detection of hCG is in the range of 150 to 250 mIU/mL, and the test is positive in 80 to 85 percent of ectopic pregnancies. The assay using an enzyme-linked immunosorbent assay (ELISA) is sensitive to 10 to 50 mIU/mL and positive in 95 percent of ectopic pregnancies.

3. Serum -hCG examination. Radioimmunoassay, with a sensitivity of 5 to 10 mIU/mL, is the most appropriate method for detecting pregnancy. Since a one-time positive serum test result does not rule out an ectopic pregnancy, several methods have been devised that use serial quantitative serum values ​​to establish the diagnosis. This method is often used in conjunction with sonography.

4. Serum Progesterone. One frequent progesterone measurement can be used to confirm a normally developing pregnancy. Values ​​exceeding 25 ng/mL ruled out an ectopic pregnancy with a sensitivity of 97.5 percent. Values ​​less than 5ng/mL indicate that the embryo-fetus has died, but does not indicate its location. Progesterone levels between 5 and 25 ng/mL are inconclusive.

d. Ultrasound Imaging

1. Abdominal Sonography. Pregnancy in the fallopian tube is difficult to identify with abdominal sonography. Sonographic absence of uterine pregnancy, positive pregnancy test, presence of fluid in the cul-de-sac, and presence of an abnormal mass in the pelvis, suggest an ectopic pregnancy. Unfortunately ultrasound may depict intrauterine pregnancy in some cases of ectopic pregnancy when a blood clot or decidual cylinder gives the appearance of a small intrauterine pouch. Importantly, an intrauterine pregnancy is usually not detectable by abdominal ultrasound until 5 or 6 weeks of menstruation or a serum -hCG concentration is more than 6000 mIU/mL.

2. Vaginal Sonography. Sonography with a vaginal transducer can detect uterine pregnancy as early as 1 week after missed menstruation if the serum -hCG level is more than 1500 mIU/mL. An empty uterus with a serum -hCG concentration of 1500 mIU/mL or more is highly accurate for identifying an ectopic pregnancy. Identification of a gestational sac 1 to 3 mm or more in size, located eccentrically in the uterus, and surrounded by a decidual-chorionic reaction suggests intrauterine pregnancy.

3. Pulsed and Color Doppler Ultrasound. This technique identifies the location of the intra- or extrauterine vascular color in a characteristic shape called a ring-of-fire pattern and a low-impedance high-velocity flow pattern that corresponds to placental perfusion. If this pattern is seen outside the uterine cavity, then an ectopic pregnancy is diagnosed.

Management and Care

The treatment for an ectopic pregnancy is usually a laparotomy. In such an action, several things need to be considered and considered, namely: the patient's condition at the time, the patient's desire for reproductive function, the location of the ectopic pregnancy, the anatomical condition of the pelvic organs, the operator's microsurgical technique ability, and the local in vitro feltilization technology. The results of these considerations determine whether a salpingectomy is necessary in tubal pregnancy, or conservative surgery in the sense that only a salpingostomy or tubal reanastomosis is performed. If the patient's condition is bad, for example in a state of shock, it is better to do a salpingectomy.

In the case of an ectopic pregnancy in the ampullary part of the unruptured fallopian tube, it has been tried to be treated using chemotherapy to avoid surgery. The criteria for cases treated in this way are:

1. Pregnancy in the ampullary tube has not ruptured.

2. Diameter of gestational sac = 4cm

3. Bleeding in the abdominal cavity less than 100 ml.

4. Vital signs are good and stable.

As for the contraindications are:

1. Presence of intrauterine pregnancy

2. Immunodeficiency

3. Moderate to severe anemia, leukopenia, or thrombocytopenia

4. Sensitivity to methotrexate

5. Peptic ulcer disease

6. Breastfeeding

7. Kidney dysfunction and liver disease

8. Evidence of tubal rupture

Surgery

Laparoscopy is recommended over laparotomy unless the woman in question is unstable. Although reproductive outcomes, including rates of uterine pregnancy and recurrence of ectopic pregnancy are equivalent, laparoscopy is more cost effective and results in shorter healing time. Tubal surgery for ectopic pregnancy is considered conservative if the tube is saved. Examples are salpingostomy, salpingotomy, and expression of ectopic pregnancy through the fimbria. Radical surgery is performed if a salpingectomy is required.

a. Curettage. In most cases, incomplete abortion and tubal pregnancy can be distinguished by curettage. Curettage is recommended if the serum progesterone level is less than 5 ng/mL or -hCG is abnormally elevated.

b. Salpingostomy. This procedure is used to expel small pregnancies that are usually less than 2 cm long and are located in the distal third of the fallopian tube. A straight incision is made, 10 to 15 mm or less in length, at the antimesenteric margin just above the ectopic pregnancy. The product will usually pop out of the incision and can be carefully removed or rinsed. Minor bleeding sites are treated with electrocautery or laser, and the incision is left unstitched for secondary healing. This procedure can be performed via a laparoscope and is currently the gold standard surgical method for an undisturbed ectopic pregnancy.

c. Salpingotomy. This procedure is the same as for a salpingostomy except the incision is closed with 7-0 Vicryl sutures or equivalent. There was no difference in prognosis with or without sutures.

d. Salpingectomy. Tubal resection can be performed via an operative laparoscope and can be used in either interrupted or unruptured ectopic pregnancies. When removing the fallopian tubes, it is recommended to make wedge incisions not exceeding the outer third of the tubal interstitium. Cornual resection is done in an effort to minimize the possibility (although rarely) of recurrence of pregnancy in the fallopian tube.

e. Segmental resection and anastomosis. Resection of the mass and tubal anastomosis is sometimes performed for unruptured isthmic pregnancies. This approach is used to avoid scar tissue formation and narrowing caused by salpingostomy. After the tubal segment is exposed, the mesosalpinx below the tube is incised, and the isthmus of the tube containing the ectopic mass is resected. The mesosalpinx is sutured so that the fallopian tube fuses together. The tubal segments were then sutured layer by layer with Vicryl 7-0 interrupted. This procedure is best performed with microsurgical techniques and enlargement of the operating field.

Reference:

Tarigan GY. Karakteristik pasien kehamilan ektopik terganggu di RSUP H. Adam Malik periode tahun 2012-2015. [Internet]. [Cited 26/8/2021]. Available from: http://repositori.usu.ac.id/bitstream/handle/123456789/19922/130100373.pdf?sequence=1&isAllowed=y