Ectopic pregnancy pt.3 Flashcards by George Rotterdam

When is surgical management of EP considered?

In case of:
• contraindications to medical treatment
• hemodynamic compromise or other clinical signs of ruptured EP (pain or
intra-abdominal bleeding)
• patient preference

How well did you know this?

Not at all

Perfectly

What surgery is performed for EP?

Laparoscopic approach

in which a salpingectomy or salpingostomy/salpingotomy is chosen

How well did you know this?

Not at all

Perfectly

What is salpingectomy?

Removal of the fallopian tube

How well did you know this?

Not at all

Perfectly

What is salpingostomy?

Removal of the EP through a tubal incision while the tube in sity

How well did you know this?

Not at all

Perfectly

When is salpingectomy recommended over salpingostomy?

Salpingectomy is recommended in cases of extensive tubal damage and/or rupture, uncontrolled bleeding, or a large tubal EP (5 cm or more).

How well did you know this?

Not at all

Perfectly

What is the surgical approach determined by?

Status of the patient’s
contralateral fallopian tube, the patient’s plans for future fertility, and surgeon
preference.

How well did you know this?

Not at all

Perfectly

How long should a person wait after methotrexate treatment before being pregnant again?

Regardless of ectopic location, conception

is not recommended for 3 months after exposure to MTX (a known teratogen)

How well did you know this?

Not at all

Perfectly

WHat is the risk of recurrence of tubal EP?

The risk of recurrence of tubal EP ranges from 5 to 25 %.
The risk of recurrent EP is not affected by treatment
modality—medical or surgical—or surgical procedure

How well did you know this?

Not at all

Perfectly

What can surgical approach to tubal ectopic pregnancy surgery be divided into?

CONSERVATIVE TREATMENTS:
- Fimbrial expression
- Salpingotomy
- Salpingostomy
DEMOLITIVE TREATMENT:
- Salpingectomy

How well did you know this?

Not at all

Perfectly

What is fimbrial expression?

This is the only site where it is not necessary to incise the tube.
The trophoblast is aspirated.
The infundibulum of the uterine tube is washed; hemostasis is often useful.

How well did you know this?

Not at all

Perfectly

When is linear salpingostomy prefered over salpingectomy?

In the presence of contralateral tubal disease, a laparoscopic salpingostomy should be considered if future fertility is desired

How well did you know this?

Not at all

Perfectly

When is salpingectomy prefered over salpingectomy?

If the contralateral tube is healthy, the preferred option is salpingectomy, where the entire Fallopian tube, or the affected segment containing the ectopic gestation, is removed

How well did you know this?

Not at all

Perfectly

How does a salpingostomy vs salpingectomy differ when it comes to fertility prospects?

In women with a tubal pregnancy and a healthy contralateral tube, salpingotomy does not significantly improve fertility prospects compared with salpingectomy
The fertility prospects will not be improved via salpingotomy
compared with salpingectomy, moreover, salpingotomy can be
complicated by persistent ectopic pregnancy.
Suggested that salpingectomy should be chosen for women with a
tubal pregnancy if the contralateral tube appears healthy.

How well did you know this?

Not at all

Perfectly

What is a significant difference between salpingostomy vs salpingectomy?

Marked difference in persistent ectopic pregnancy with 11% in salpingotomy vs 0% in salpingectomy

How well did you know this?

Not at all

Perfectly

What is cervical pregnancy?

It is a rare form of ectopic pregnancy in which the pregnancy implants in the lining of the endocervical canal

How well did you know this?

Not at all

Perfectly

How much of ectopic pregnancies do cervical pregnancies account for?

Less than 1 percent of ectopic pregnancies (less than 0.05% of total pregnancies)

What is cervical pregnancy associated with?

• More common in pregnancies achieved
through ART
• Apparent association with a prior history of
curettage or cesarean delivery

What are symptoms of cervical pregnancy?

The most common symptom is vaginal bleeding, which is often
profuse and painless.
Lower abdominal pain occurs in fewer than one-third of patients.

What are some principles to follow in the management of cervical pregnancy?

General principles in the management of cervical
pregnancy should include:
1) minimize the risk of hemorrhage;
2) eliminate the gestational cervical product;
3) spare fertility

How can one reduce the risk of blood loss in cervical ectopic pregnancy surgery?

To reduce the risk of massive blood loss, angiographic

embolization of uterine arteries can be performed before evacuation and curettage of the cervical canal.

What is the treatment algorithm for conservative management of CEP?

1- Ultrasound diagnosis of CEP made
2- If initial beta-HCG is lower than 34000 mIU/mL give methotrexate/Leu, if higher go to step 3
3- If there is fetal heart activity MTX/Leu +KCI (potassium chloride) +UAE (uterine artery embolization) is given, if fetal heart activity absent MTX/LEU +UAE

How much do interstitial pregnancy contribute to total tubal pregnancies?

Interstitial pregnancies account for only 2-4% of tubal pregnancies or
approximately 1 in 2500-5000 live births.

What is the mortality rate of interstitial pregnancy? Why?

The mortality rate is as
high as 2.5%, a rate that is 7 times greater than that of ectopic pregnancies
Tube has a significantly greater capacity
to expand before rupture than do the distal tubal segments.

What is an interstitial pregnancy?

An interstitial pregnancy refers to an ectopic

location of the gestational sac in the intramyometrial segment of the fallopian tube.

What is angular pregnancy?

The term of ‘angular pregnancy’ refers to an implantation in the lateral angle of the uterine cavity, medial to the internal ostium of the fallopian tube.

What is the clinical significance of angular pregnancies?

- There were no cases of uterine rupture, maternal death, abnormal placentation or hysterectomy. - It was concluded that angular pregnancy is a variation of a normally implanted intrauterine pregnancy, rather than a form of ectopic pregnancy.

What are symptoms of interstitial pregnancy? Significance

- It may remain asymptomatic until 7-16 weeks of gestation in rare cases, at which time rupture can result in catastrophic hemorrhage. - This is accentuated by the rich vascular anastomosis of the uterine and the ovarian arteries in this region - Thus, early detection and a high index of suspicion are crucial to reducing morbidity and mortality

What are treatment options for interstitial pregnancy?

Conservative options include: • methotrexate administration (local and systemic) and • minimally invasive surgical techniques that include resection of the involved tube and pregnancy alone with preservation of the uterine architecture.

How are most ultrasound examinations done in early pregnancy?

Most ultrasound examinations undertaken in early pregnancy are performed using a transvaginal route.

What are the goals of early pregnancy ultrasound examination?

Three main objectives: (i) to confirm the location and number of pregnancies, (ii) to establish whether a normally implanted pregnancy has the potential to develop further beyond the first trimester (iii) to assess the risk to maternal health posed by ectopic pregnancy.

Can other structures in the female reproductive system support embryo growth and development? Why?

- The uterine cavity is the only anatomical structure within the human body able to support normal development of pregnancy until term. - The surrounding uterine muscle has enough elasticity to expand and accommodate a growing pregnancy. In addition, its contractile strength is sufficient to facilitate expulsion of the foetus and placenta and to achieve immediate haemostasis following delivery.

How can one differentiate between an interstitial and angular pregnancy?

- Interstitial pregnancy may often be challenging to differentiate from angular pregnancy. - The differentiating ultrasonographic feature of an interstitial pregnancy is the paucity of myometrium around the superolateral portion of the sac; conversely, the intrauterine angular pregnancy will be surrounded on all sides by at least 5 mm of myometrium.

What is the transport of the oocyte and embryo dependent on?

The transport of an oocyte and embryo through the tube relies on both smooth muscle contraction and ciliary beating, which are affected by several local factors—toxic, infectious, immunologic and hormonal.

How does smoking affect implantation?

Smoking and infection have been shown to decrease cilia density, while ciliary beat frequency has been shown to be responsive to the changing hormonal milieu of the menstrual cycle

What are surgical approaches for interstitial pregnancies?

They include: - Transcervical suction evacuation - Cornuostomy/salpingostomy - Cornual resection (excision) - Cornual wedge resection - Minicornual excision - Hysterectomy

What are the most common surgical approaches in treating interstitial pregnancies?

- Cornual resection: Most common laparoscopic approach for interstitial pregnancies more than 4 cm in diameter - Cornual wedge resection: Most common conservative procedure before widespread use of operative laparoscopy - Cornuostomy/salpingotomy: Best for interstitial pregnancies less than or equal to 4cm in diameter - Minicornual excision: Maximal exposure of the interstitial pregnancy is provided; the uterine architecture and vasculature are preserved - Transcervical suction evacuation: Requires laparoscopic and/or ultrasonographic guidance

When is hysterectomy considered for interstitial pregnancies?

- Most common in the past | - Last resort treatment