CHAPTER 8 ECTOPIC PREGNANCY AND MULTIPLE GESTATION

SECTION 1: ECTOPIC PREGNANCY

1. Risk factors

1.1 History of tubal infection

1.2 Tubal Surgery

1.3 Prior ectopic pregnancy

1.4 Pregnancy with current IUD, depot medroxyproges-terone acetate, or emergency contraceptive pill use

1.5 Use of assisted reproductive technology （ART）

2. Pathological pattern

2.1 Tubal abortion: Tubal abortion is predominantly common in ampullary implantation. The ovum is separated from its attachment leading to haemorrhage into the choriocapsularis space. Muscular contraction enhances further separation of the ovum and facilitates its expulsion through the abdominal ostium.

2.2 Tubal rupture: Tubal rupture is predominantly common in isthmic and interstitial implantation. Commonly, the ovum is partly expelled out through the rent in the tube so that the bleeding is heavy and continuous. Isthmic rupture usually occurs at 6-8 weeks and the interstitial one at about 4 months.

2.3 Old ectopic pregnancy: Repeated small haemorrhages occur in the chorio-capsularis space, separating the villi from their attachments. The products thus form a mole which either ends up in complete absorption or expulsion through the abdominal ostium.

2.4 Secondary abdominal pregnancy: The embryo is expelled into the peritoneal cavity and continue to survice. The placenta gets attached to the neighbouring structures and new vascular connections are established to the surrounding structures. This is a very rare outcome.

3. Diagnosis of ectopic pregnancy

3.1 Clinical Manifestations

3.1.1 Symptoms:The classic triad of symptoms of disturbed tubal pregnancy are amenorrhoea followed by abdominal pain and lastly, appearance of vaginal bleeding.

3.1.2 Examinations: （1）Features of shock are evidenced by the rapid and feeble pulse, fall of the blood pressure and cold and clammy extremities with pallor. （2）Abdominal examination reveals a tense, tumid and tender abdomen. Shifting dullness may be elicited. （3）Bimanual examination: Extreme tenderness on fornix palpation or on excitation of the cervix （4）If there is plenty of blood in the peritoneal cavity the uterus floats as if in water.

3.2 Investigations

（1）Blood examination

（2）Estimation of β- hCG

（3）Sonography

（4）Culdocentesis

（5）Laparoscopy

4. Differential diagnosis of ectopic pregnancy

4.1 Threatened or incomplete abortion

4.2 Ruptured corpus luteum cyst

4.3 Acute pelvic inflammatory disease

4.4 Adnexal torsion

4.5 Acute appendicitis

5. Treatment of ectopic pregnancy

5.1 Expectant management

In hemodynamically stable patients without active bleeding and hemoperitoneum.

（1）They must be carefully followed with serial hCG testing and monitoring

（2）Unruptured mass ＜3cm at its greatest dimension

（3）hCG＜ 1000 mIU/mL）

5.2 Medical management with MTX

（1）Hemodynamically stable without active bleeding or signs of hemoperitoneum

（2）Unruptured mass ≤4cm at its greatest dimension

（3）No fetal cardiac motion detected （4）hCG ＜2000 mIU/mL）

5.3. Surgical management: Laparoscopy or Laparotomy

（1）Salpingectomy

（2）Partial salpingectomy: The remnants of the tube may be reapproximated in the future.

（3）Salpingotomy and Salpingostomy: There is a 10% to 20% risk of residual trophoblastic tissue whenever the products of conception are separated from the tube. If repeat hCG titers fail to decline appropriately, methotrexate （MTX）therapy can be started.

（丁芳）