Ectopic pregnancy

Implantation of the fertilized ovum either outside the uterus or in an abnormal position within the uterus.Sites of ectopic pregnancy:

1. Tubal (commonest 95%) ampullary, isthmus, fimbrial,interstitial2. Ovarian. - direct implantation - reimplantation after tubal

abortion

3. Cervical3. Cervical

4. Abdominal - primary: implants 4. Abdominal - primary: implants initially on abdominal organsinitially on abdominal organs

- secondary: primary - secondary: primary implantation in tubes, ovaries or implantation in tubes, ovaries or uterusuterus

5. Ligamentory5. Ligamentory

6. Cornual6. Cornual

7. Rudimentary horn7. Rudimentary horn

Causes of Ectopic PregnancyCauses of Ectopic Pregnancy

1. Tubal abnomalities impeding the progress of 1. Tubal abnomalities impeding the progress of fertilized ovumfertilized ovum

a. developmental errors: hypoplasia, diverticula, a. developmental errors: hypoplasia, diverticula,

accessory lumina, undue tortuosityaccessory lumina, undue tortuosity b. distortion of the tube: by adjacent large tumors or b. distortion of the tube: by adjacent large tumors or

endometriosisendometriosis c. previous pelvic inflammatory disease:c. previous pelvic inflammatory disease: chronic PID, gonorrhoea, postabortal, chronic PID, gonorrhoea, postabortal,

secondary to pelvic peritonitis, TB, IUCD, infection secondary to pelvic peritonitis, TB, IUCD, infection from adjacent organsfrom adjacent organs

eg: appendicitis, diverticulitiseg: appendicitis, diverticulitis

d. surgical obstruction after partial salpingectomy, tubal ligation

e. tubal surgery:

microsurgery, reversal of sterilization, previous tubal pregnancy

2. Assisted conception: in-vitro fertilization if tubes are damaged but patent

3. Overdevelopment of the ovum: external migration

4. Endometriosis of the tubes and ovaries

Diagnosis of Ectopic Pregnancy Diagnosis of Ectopic Pregnancy

1. Chronic Ectopic Pregnancy1. Chronic Ectopic Pregnancy Symptoms: short period of amenorrhoeaSymptoms: short period of amenorrhoea : pain- aching in one or both iliac fossa: pain- aching in one or both iliac fossa (due to distention or contraction of the (due to distention or contraction of the

tube)tube) - sharp stabbing pain- sharp stabbing pain (bleeding into peritoneal cavity due to (bleeding into peritoneal cavity due to choriodecidual haemorrhage) choriodecidual haemorrhage) - shoulder tip pain or pain in epigastrium- shoulder tip pain or pain in epigastrium (due to diaphragmatic irritation by blood)(due to diaphragmatic irritation by blood)

: slight vaginal bleeding, brownish discharge: slight vaginal bleeding, brownish discharge

: syncope: syncope

: other symptoms of pregnancy: other symptoms of pregnancy

: acute retention of urine due to : acute retention of urine due to large pelvic haematocoelelarge pelvic haematocoele

SignsSigns General : pallor, increase in pulse rate, slight pyrexiaGeneral : pallor, increase in pulse rate, slight pyrexia

Abdomen: distention, tenderness, muscle guardingAbdomen: distention, tenderness, muscle guarding

Cullen`s sign(bluish discolouration around the Cullen`s sign(bluish discolouration around the umbilicus) umbilicus)

Vaginal Examination:Vaginal Examination:

pulsation in the fornix (of the affected side)pulsation in the fornix (of the affected side) irregular tender enlargement of appendageirregular tender enlargement of appendage small tender masssmall tender mass uterus slightly enlargeduterus slightly enlarged cervical excitation +cervical excitation + POD is full and tenderPOD is full and tender brownish discharge PV + brownish discharge PV +

****** If symptoms strongly suggestive of ectopic, VE is If symptoms strongly suggestive of ectopic, VE is not advisable.not advisable.

II. Acute (tubal rupture) II. Acute (tubal rupture) • There can be sudden massive There can be sudden massive

intraperitoneal haemorrhage.intraperitoneal haemorrhage.• Symptoms: short period of Symptoms: short period of

amenorrhoeaamenorrhoea : severe lancinating pain in : severe lancinating pain in

one iliac fossa one iliac fossa or hypogastrium or hypogastrium : immediate profound : immediate profound

collapsecollapse : bleeding or brownish : bleeding or brownish

discharge PVdischarge PV

Signs:Signs:

General - collapse, pale, cold clammy General - collapse, pale, cold clammy extremities,extremities,

low BP, increased PR low BP, increased PR

Abdomen- acutely tender lower abdomenAbdomen- acutely tender lower abdomen distension and free fluid distension and free fluid

Vaginal E- very tender pelvisVaginal E- very tender pelvis cervical excitationcervical excitation tender enlarged adnexatender enlarged adnexa full and tender PODfull and tender POD blood-stained discharge on VE fingerblood-stained discharge on VE finger **** Diagnosis is missed in 20-25% of cases Diagnosis is missed in 20-25% of cases

Think of ECTOPICThink of ECTOPIC

female of reproductive agefemale of reproductive age

unexplained abdominal painunexplained abdominal pain

+ or - vaginal bleeding+ or - vaginal bleeding

InvestigationsInvestigations Clinically stable patientsClinically stable patients a. Pregnancy tests- urine for UCGa. Pregnancy tests- urine for UCG - serum - serum hCG hCG b. Ultrasound - no intrauterine pregnancy b. Ultrasound - no intrauterine pregnancy

- extrauterine pregnancy - extrauterine pregnancy

sac can be seen sac can be seen - transvaginal scan is more - transvaginal scan is more

accurate accurate c. Posterior Colpotomy (POD puncture) c. Posterior Colpotomy (POD puncture)

- non-clottable - non-clottable blood blood

d. Laparoscopy - for definitive diagnosis d. Laparoscopy - for definitive diagnosis - can - can diagnose before diagnose before rupture rupture

Differential diagnosis

1. Threatened or Incomplete abortion - history of amenorrhoea + - bleeding PV - pain varies

2. Bleeding Corpus Luteum - diagnosis difficult - usually no overdue - laparoscopy necessary

3. Accidents to Ovarian Cysts - no overdue

Management of Ectopic Pregnancy

Acute

a. Resuscitation: - keep quiet, flat - injection morphia - IV line - blood rapidly

b. Surgery - immediate laparotomy - autotransfusion - salpingectomy

Chronic Cases

- Admission- operative procedures a. laparoscopic surgery

- unruptured ampullary or infundibular

-pregnancy < 3 cm in diameter

- salpingotomy - intratubal methotrexate injection - salpingectomy

b. laparotomy

- salpingectomy

- salpingotomy

- milking of the tube

Non- operative procedure Puncture and aspiration of gestational sac,

local PG, KCL, hyperosmolar glucose, methotrexate

Expectant management (non interventional )

Cornual pregnancy - diagnosis difficult - can have profuse intraperitoneal

bleeding - hysterectomy may be necessary

THE ENDTHE END