34) Ectopic Pregnancy - Types. Tubal Pregnancy - Causes, Sx, DDx, Management

Question 1

What is the definition of "”Ectopic Pregnancy”?

Answer 1

-Where the blastocyst implants anywhere other than the endometrial lining of the uterine cavity

• Can potentially lead to Tubal Rupture or Abortion, or Massive Intra-abdominal Hemorrhage, or Death!

Question 2

What are the Types?

Answer 2

1) Tubal = Ampulla, Isthmus, Fimbria {MOST COMMON}

2) Ovarian

3) Abdominal

4) Cervical

Question 3

What are the Risk Factors?

Answer 3

• Pelvic Inflammatory Disease
• STI
• Use of IUD
• Congenital Malformation of the Uterus
• Fibroids
• Smoking
• Hx of Ectopic Pregnancy
• Tubal Occlusion
• 3 or More Spontaneous Abortions
• Multiple Sex Partners
• Older than 40 Y.o

Question 4

What’s the Pathophysiology of Ectopic Pregnancy?

Answer 4

Occurs within the Fallopian Tube

• Absence of Submucosal Layer, thereby allowing ovum to penetrate the epithelium + implant into muscular wall
• Trophoblast Invasion = Where Trophoblasts (form placenta) invade the muscular layer, causing maternal blood to enter spaces surrounding tissue
• Inflammatory Diseases such as Chronic Salpingitis can lead to Tubal Damage
• Chlamydial Infection can cause Tubal Scarring + Obstruction

Question 5

Explain the Development of Tubal Pregnancy

Answer 5

1) Normal Early Pregnancy Changes (post-implantation in fallopian tube) = Corpus Luteum Gravidarum develops in ovary ; Production of Chorionic Gonadotropin; early sx (nausea + appetite changes)

2) Development of Chorionic Villi = Due to implantation in lining of FT, causing CV to grow into deep muscle layers

3) Tubal Stretching –> Destruction = As the ovum grows, the FT stretches, and the CV destroys Tubal Wall –> Fibrinoid Necrosis

4) Interruption of Pregnancy, at 8th GW = Due to (a) Tubal Rupture or (b) Tubal Abortion (ovum’s expelled from fimbrinated end of FT)

Question 6

What are the Symptoms / Signs of Tubal Pregnancy?

Answer 6

• Acute Abdomen (Marked / Rebound Tenderness)
• Hemodynamic Shock
• TRIAD = Abdo Pain / Amenorrhea / Vaginal Bleeding (1st trim)
• Pain irradiates to shoulder due to diaphragmatic irritation of intra-abdominal blood
• Breast Tenderness, Nausea, Urinary Frequency, Dizziness, Syncope + Palpitations
• Cervical Motion Tenderness

Question 7

What’s the Diagnosis / Differential?

Answer 7

• Lower hCG levels than normal, in Urine Pregnancy Test
• Trans-Vaginal Ultrasound
• Culdocentesis = Shows Ruptured Form (Acute Abdomen, Hemorrhage, Hypo-TN, Tachycardia)

DIFFERENTIAL DDX

• Spontaneous Abortion
• Adnexal Torsion
• Appendicitis
• PID
• Endometriosis
• Ovarian Cysts

Question 8

What is the Treatment?

Answer 8

• If UNRUPTURED (Non-Specific Pain, Palpable Mass) = Give Methotrexate
• Surgical = Laparoscopic, Larapotomy