ectopic pregnancy

1. Ectopic Pregnancy
Presented By
Dr.ADNAN FAROOQ BHAT
Dr.ASMA MANSOOR
Intern doctor
Department of Gynaecology &Obstetrics;TMMC

2. Introduction
The term “ectopic” means out of place. So its understandable that
“ectopic pregnancy” means a pregnancy where the fetus is
developing in an abnormal place which is anywhere apart from the
uterine cavity.
Ectopic pregnancy is accounted for 2% of all pregnancies, and is the
most common cause of maternal death during the first trimester
(usually 6-8 weeks of pregnancy).
It represents a serious hazard to a woman’s health and reproductive
potential, requiring prompt recognition and early aggressive
intervention.

3. Ectopic Pregnancy Still contributes significantly to the
cause of maternal mortality and morbidity. While
there has been about four-fold increase incidence –
over the couple of decades ,but the mortality has
been slashed down by 80%.

4. Definition
An ectopic pregnancy is one in which fertilized ovum becomes
implanted in a site other than the normal uterine cavity.
Frequency is 3-4% of all pregnancy.
Sites
• Fallopian tube (95-98% Most common) : Also known as tubal
pregnancy.
• Uterine cornue (2-5%).
• Ovary.
• Cervix.
• Round ligament.

5. Fig : Sites of ectopic pregnancy

6. Risk Factors
 Pelvic Inflammatory Disease (PID).
 Use of IUCD.
 Long time OCP use.
 Any surgery in and around the tube (Tubal Reconstructive Surgery).
 H/O previous ectopic pregnancy.
 Artificial Reproductive Technology (ART).
 Smoking.
 Salphingitis.
 Endometriosis.
 Developmental Defect.
 Black people.
 Overdevelopment of ovum.

7. Types
• Acute ectopic pregnancy.
# Ruptured ectopic pregnancy.
# Unruptured ectopic pregnancy.
• Chronic ectopic pregnancy.

8. Sites of tubal pregnancy
 Ampulla (55% most common)
 Isthmus (25% less common)
 Fimbriae (17% unusual)
 Interstitial (3% rare)

9. Symptoms
H/O short period of amenorrhea (6-8 weeks).
Acute lower abdominal pain which is colicky in nature.
Per vaginal bleeding may or may not be present.
Features of shock may be present in ruptured ectopic
pregnancy.
- Hypotension
-Rapid thready pulse
-Sunken eye
 Shoulder tip pain (referred pain from irritation of diaphragm by intraperitoneal bleeding)

10. Signs
Pallor.
Features of shock.
* Rapid thready pulse.
* Cold clammy skin.
* Hypotension.
* Sweating, restlessness.
P/A/E : Tense, tender, rigid & distended.
P/V/E : Usually not done. But if performed then –
# Cervical excitation test positive.
# Boggy feeling in pouch of Douglas.

11. Classical Triad
 It includes –
Amenorrhea :
In 60-80% of Pt there may be delayed period or
slight spotting at the time of expected menses.
Abdominal pain :
most constant feature in 95% Pt which is variable
in severity and nature
Per vaginal bleeding.
 Unfortunately less than 50% of the patient present with
all 3 symptoms.

12. Differential Diagnosis in case of Acute
ectopic pregnancy
 Acute Appendicitis
 Ruptured corpus luteum
 Twisted ovarian tumor
 Ruptured Chocolate Cyst
 Perforated peptic ulcer
 Urinary tract infection.
 Dysfunctional uterine bleeding

13. Outcome / Complication
• Complete absorption.
• Tubal abortion
<1.Complete <2.Incomplete
• Secondary abdominal pregnancy.
• Tubal rupture.
• Tubal mole.
• Chronic ectopic adnexal mass.
• Survival to term.

14. Investigation
CBC.
Blood Grouping & Rh Typing.
Urine for PT : Positive.
Serum β-HCG : In a normal pregnancy, the β-HCG level doubles
every 48-72 hours until it reaches 10,000-20,000mIU/ml. In ectopic
pregnancies, β-HCG levels usually increase less. Mean serum β-
HCG levels are lower in ectopic pregnancies than in healthy
pregnancies. No single serum β-HCG level is diagnostic of an
ectopic pregnancy. Serial serum β-HCG levels are necessary to
differentiate between normal and abnormal pregnancies and to
monitor resolution of ectopic pregnancy once therapy has been
initiated.

15. Serum Progesterone : Greater than 20 micrograms/ml indicates
good pregnancy and less than 5 micrograms/ml is a bad indicator
(ectopic or abortion). Anything in between 5-20 microgram/ml is
a grey zone and not indicative of anything definite .
Transvaginal Sonogram : The following are indicative of ectopic
pregnancy
 Absent intrauterine sac and the presence of ectopic sac.
 Complex adnexal mass.
 Free fluid in cul de sac (ruptured ectopic pregnancy).
Laparoscopy.

16. Fig : USG of Ectopic Pregnancy

17. Fig : USG in Ruptured Ectopic Pregnancy

18. Management
The method of management is individualized and depends entirely
on clinical presentation and state of the patient.
Conservative Management
Indicated when -
• The patient is stable without any significant bleeding or pain.
• The site of implantation is the tube.
• Size of gestational sac < 2cm.
• β-HCG < 1000IU/ml.

19. Medical Management
Indicated if -
• The patient is haemodynamically stable.
• No collection in pouch of Douglas.
• Gestational sac size < 4 cm.
• β-HCG < 3000IU/ml.
• No signs and symptoms of early pregnancy
• No fetal cardiac activity.

20. Methotrexate (MTX)
MTX is the drug of choice.
It is given as a single dose of 50 mg/m2, I/M.
Then β-HCG is followed on Day 4 and 7.
A drop in the levels between Day 4 and 7 of about 15% indicates
successful treatment.
Then weekly monitoring of β-HCG until it falls below 10mIU/ml.
If serum levels are in plateau or the drop was less than 15%, a
second dose of MTX should be given at Day 7.

21. Advantages of MTX -
Cheaper.
Less side effect.
Single dose.
Less monitoring required.
Other drug choices include :
• 20% KCl.
• Prostaglandins.
• Mifepristone.
• Hyperosmolar Glucose
• Vasopressin.
• Actinomycin

22. Surgical Management
Indicated when-
• Patient haemodynamically unstable at presentation.
• Cases not fulfilling criteria of medical therapy.
• Failure of medical therapy.
It entails –
< Unilateral Salphingectomy
<Check other side tube:if both tubes are affected
• If Family complete : Ligation
• If Family incomplete : Anastomosis

23. Fig : Laparoscopic Salpingectomy

24. • Intact tube :
 Salpingostomy (incision on the antimesentric
portion of the tube & removal of products of
conception followed by suturing of incision).
 Salpingotomy (the same procedure as
salpingostomy however the incision is not sutured
and is left to heal by secondary intention).

25. Fig :
Laparoscopic
Surgery in
Ectopic
pregnancy

26. Advantages Of Laparoscopy
 It helps in diagnosis, evaluation, and treatment .
 Diagnose other causes of infertility.
 Decreased hospitalization, operative time, recovery
period, analgesic requirement.

27. Step By Step Management Of Ruptured EctopicPregnancy
Hospitalization
Counseling
Clinical assessment (proper History taking and Examination)
Definitive management :
Call for extra help(Expert
Surgeon,Anaesthetics,Sister,Blood Bank)
Open wide bore IV channel.
Catheterization : urine output(Renal Failure)
Quickly do a few investigations –
• Blood grouping & Rh typing.
• Crossmatiching.
• CBC, Hb%.
Arrange 4 unit of whole blood.

28. Laparotomy with Simultaneous Resuscitation.
• Surgical management is as mentioned before.
• Drain tube is placed.
Post OP care–
 NPO.
 IV fluids.
 Antibiotics.
 Analgesics.
 Intake/Output chart.
 Monitoring vitals.
Remove catheter after 24 hr.
Discharge at 4th or 5th POD.
Follow up.

29. Chronic Ectopic Pregnancy
High degree of suspicion & ectopic conscious
clinician can diagnose.
Diagnosed accidentally in Laparoscopy or
Laparotomy.
 C/F –
o Delayed period.
o Spotting with discomfort in lower abdomen.

30.  P/A – Tenderness in lowerabdomen.
 P/V -
o Should be done gently.
o Uterus is normal in size and firm.
o Small tender mass may be felt in the fornix.
 Investigations -
o TVS.
o Serum β-HCG.
o Laparoscopy.

31. D/D Of Chronic Ectopic
 Incomplete Abortion
 Salpingitis
 Sub-serous uterine fibroid.
 Retroverted gravid uterus.
 Appendicular lump.

32. Management Of Chronic Ectopic Pregnancy
 Hospitalization, observation & conservative treatment
is given.
 Prepare patient for Laparotomy.
 Surgical Management :
o Pelvic hematocele is usually found and removed. If
infected then Posterior Colpotomy is done.
o Salpingectomy / Salpingostomy.
 Post operative care.
 Follow up.

33. THANK YOU