Ectopic Pregnancy

By Samia Manzoor 08-165 Batch : J

Objectives :

what is ectopic pregnancy ? what are different sites, high risk groups of

ectopic pregnancy ? Outcomes of tubal pregnancy clinical features, diagnosis and treatment of

ectopic pregnancy.

Ectopic Pregnancy is Implantation of a fertilized ovum at a site other than the normal uterine cavity.

What is Ectopic Pregnancy ?

Sites of Ectopic pregnancy

(95%)

Risk factors of ectopic Pregnancy

Major risk factors• Pelvic inflammatory

disease( > 50%).• Previous tubal surgery.• Previous ectopic

pregnancy.• Intrauterine

contraceptive devices.• Termination of

pregnancy.

Minor risk factors.• Tuberculosis

salpingitis.• Cigarette smoking.• Age over 35 years.• Many sexual partners.• Congenital anomalies of

the fallopian tubes.• Ovum transmigration.

Pelvic inflammatory disease.

• Intrauterine contraceptive devices.• puerperal sepsis.• Post abortal sepsis.• Generalized or pelvic peritonitis.• Gonorrhea.• Past appendicitis.

Clinical features : Symptoms

1. Amenorrhea

2. Abdominal Pain

Dull ache Unruptured tubal pregnancy.

Sharp Colicky pain Ruptured tubal pregnancy .

3.Vaginal Bleeding

• May persist continuously or intermittent spotting.

• Its mainly uterine in origin and partly by ruptured fallopian tube.

• Due to breakdown of decidua after the pregnancy dies and hormones are withdrawn.

4. Others

• shock.• Syncope.• Subjective symptoms of pregnancy.

• Shoulder pain.

Clinical features: Signs

General physical examination

• patient is sweating, • skin is pale, cold, clammy • low blood pressure• weak pulse.

Clinical features : Signs

Abdominal examination.• Abdomen tenderness.• Abdominal distension.• Cullen’s sign (may be

positive )

Clinical features: Signs

Pelvic examination.

• Bluish discoloration of vulua and vagina.

• On bimanual examination: Tenderness on rocking of cervix, most constant sign of ectopic pregnancy ( chandelier sign).

Clinical Presentation

• Acute ectopic pregnancy.• Chronic ectopic pregnancy. Patient presents with vague history,

intermittent pain and irregular bleeding. The diagnosis can easily be missed if patient is not evaluated thoroughly.

Outcomes of ectopic pregnancy

Usually the tubal pregnancy does not proceed beyond 8-10 weeks of gestation due to

Lack of decidual reaction in the tube. The thin wall of the tube The inadequacy of the tube lumen.

Outcomes of ectopic pregnancy

1.

Tubal abortion

• This occurs more if ovum had been implanted in the ampullary portion of the tube

2-

Tubal rupture• More common if implantation occurs in the narrower portion of the tube which is the isthmus.

3.

Tubal mole and pelvic hematoma.

In tubal mole gestational sac is retained in tube and is surrounded by a blood clot.

4.

Secondary abdominal pregnancy.

5-

Spontaneous regression

Differential diagnosis

• Spontaneous abortion• Ovarian pathology• Corpus luteum haemorrhage.• Acute pelvic inflammatory disease• Appendicitis.• Subserous fibroid.• Retroverted gravid uterus.• Perforated pelvic ulcer• UTI• Ureteric colic.

Diagnosis

• History• General physical examination.• Abdominal and pelvic examination.• Investigations.

Investigation

• Most useful is Ultrasonography Empty uterine cavity, and gestational sac on side of the body of uterus.

• Laparoscopy. Most reliable method of making a diagnosis of ectopic pregnancy.

Investigation

• Culdocentisis . Positive only in the case of ruptured ectopic pregnancy.

•Repeated Blood Hemoglobin in case of atypical features.•Total leukocyte count may be raised.• Abnormal levels of b-hcG.

Treatment

• Surgical .• Medical.

Surgical treatment

Laparotomy Indicated for1. Ruptured tubal pregnancy2. Patient is hemodynamically

unstable.3. Laparoscopy is

contraindicated4. Pregnancy is in

rudimentary horn of uterus.

LaparoscopyIndicated for1. Unruptured tubal

pregnancy2. Which cannot be treated

by medical methods.

Salpingectomy Tubal repair

Partial salpingectomy

salpingotomy

Surgical procedures

http://medical-dictionary.thefreedictionary.com/salpingostomy

Salpingotomy

Medical Treatment

Selection criteria Unruptured tubal pregnancy less than 3 cm in

diameter. Absent haemoperitonium Sonographically non viable pregnancy, fetal heart

sound absent. B-hcG less than 2000 IU/L. Minimal symptoms.

Drugs• Methotrexate (50mg with 2ml aqueous sol)• Actinomycin-D• Prostaglandin• Mifepristone• Hyperosmolar glucose.• 20% potassium chloride.

Other ectopic pregnancies

• Ovarian • Abdominal• Cervical• Heterotopic

“Before you were conceived I wanted you. Before you were born I loved you. Before you were here an hour I would die for you. This is the miracle of Mother's Love“ By Maureen Hawkins