Ectopic pregnancy

1. ECTOPIC
PREGNANCY
By :Darayus P.Gazder (DPG)
Roll Number: 18

2. Ectopic Pregnancy
 Definition: It is defined as an implantation of a
conceptus outside the normal uterine cavity
Or
 In theory, any mechanical or functional factors that
prevent or interfere with the passage of the fertilized
egg to the uterine cavity may be aetiological
factors for an ectopic pregnancy.
If not diagnosed on time, it may be life
threatening!!
 Incidence (11.1/1000 pregnancies)

4. Sites of ectopic pregnancy

5. ETIOLOGY ,INCIDENCE
 Mostly unknown
 Premature implantation (infection –damage to tubes-
delay of passage of fertilized ovum along tubes)
 One in 90 pregnancies is ectopic .
 A combined intra uterine and extra uterine pregnancy
is very rare and occurs in 1;40000 spontaneous
pregnancies and 1;1000 IVF pregnancies.
“ Heterotopic pregnancy ”

7. RISK FACTORS
 Congenital anomalies of the fallopian tubes
 Scarring due to a ruptured appendix
 Previous ectopic pregnancy
 Infections of the female genital organs
 History of PID
 Maternal age more than 35 yrs
 IUCD
 IVF- fertility treatment
 Tubal ligation/ reversal of tubal ligation
 Smoking
 Progesterone only contraceptive pills

8. OUTCOME
 Ectopic gestation mostly terminates between 6-10 weeks:
1) TUBAL ABORTION- 65 % of cases, usually in the fimbrial and
ampullary implantations. Repeated small hemorrhages from
the invaded area of the tubal wall detach the ovum, which dies
and :
1. Is absorbed completely
2. Is aborted completely through the tubal ostium into the
peritoneal cavity
3. Is absorbed incompletely with the result that the clot covered
conceptus distends the ostium
4. Forms a tubal blood mole

10. Outcome
2) TUBAL RUPTURE- 35 % of the cases more
common when the implantation is in the
isthmus. This may occur earlier then the 6th
week.
The trophoblast burrows deeply and erodes
the serosal coat of the tube, causing it to break
and rupture.
If this is seen on the mesenteric side of the
tube a broad ligament hematoma will form

12. Outcome
3) SECONDARY ABDOMINAL PREGNANCY
– very rarely the extruded ovum continues to
grow and attaches to the abdominal organs. A
few advance to term, the fetus dies and is
converted to a lithopaedion

13. Clinical Presentation:
 Unruptured ectopic: (TRIAD)
1) Lower abdominal pain, mild vaginal bleeding,
amenorrhea
 Ruptured ectopic:
1. Epigastric pain, severe lower abdominal pain,
shoulder tip pain, shock

14. CLINICAL PATTERNS:
1) Subacute presentation
 Mild lower abdominal pain
 Occasionally sharp pain and faintness
 Slight vaginal bleeding
 On examination lower abdominal tenderness, vaginal
examination may show a tender fornix or vague
mass.
 Acute collapse ( incase of ruptured or incomplete
tubal abortion)
 Cessation of symptoms (incase of complete abortion
with or without a pelvic hematocoele)

15. 2) Acute presentation
 Sudden collapse (especially in isthmal tubal
pregnancy)
 Acute lower abdominal pain
 Fainting
 Signs of Internal haemorrhage (leading to pallor,
collapse, falling blood pressure, rapid weak pulse )
 Pain maybe either epigastric or shoulder tip pain
(referred)
 Abdominal examination may reveal tenderness with
some fullness and muscle guarding.
 Vaginal examination will reveal extreme cervical
tenderness.

16.  Vitals:
 BP, Pulse, Temperature, R/R
Laboratory Investigations:
 CBC(complete blood count),
 Blood Grouping and Cross Matching
 Beta hCG ( Levels double every 48 hrs a rise <66%=EP )
 Progesterone (Viable Preg: >79nmol/L, EP: <15.9 nmol/L)
 Ultrasound
 TVS (Transvaginal U/S Scan)
• Can detect 75-80% on initial scan and further 25% on follow
up.
• Transabdominal U/S has a limited role.
 Laparoscopy
(Advantage: Diagnostic and Therapeutic)

17. Clinical suspicion of ectopic gestation
Measure B hCG
Negative
Ectopic
gestation
ruled out
Positive
Gestational
sac in uterus
Gestational
sac in tube
Doubtful
Laparotomy/
Laparoscopy/
Medical treatment
Laparoscopy
Laparoscopy/
Laparotomy
US not
available
Ultrasound
D
I
A
G
N
O
S
I
S

20. TREATMENT / ACTION TO BE TAKEN:
 CHECK: Airway, Breathing, Circulation
 In cases of shock maintain I/V line .
 Morphine as a painkiller can be given.
 Ambulatory ultrasound for confirmation of diagnosis if
its an intrauterine or extra uterine pregnancy
 Management may be:
A) Medical
B) Expectant
C) Surgical

21. Medical management
 Methotrexate (Anticancer antifolate drug)
 DOSE: Single intramuscular injection calculated from patients,
body surface area as 50mg/m2 or in 4 doses IM every
alternate day with 7.5mg cover of leucovorin on the other
alternative days
 Investigation
 Renal Function tests
 Liver Function Tests
 Complete blood count
 Contraindication:
 Chronic liver, renal and hematological disorder
 Active infection
 Immunodeficiency/ Breast feeding

22.  Criteria:
 Haemodynamically stable patient, no evidence of
haemoperitoneum on scan, mild or no pain
 Serum βhCG <3000IU/L
 No contraindication to the use of Methotrexate.
 Adnexal mass, <4 cm size on ultrasound.
 No fetal cardiac activity in the ectopic sac.
 Patient compliance with follow up visits.
 Monitoring
 Check serum βhCG levels on days four and seven
 A further dose, if βhCG levels have failed to fall by more
than 15% between day four and day seven.
 Then check weekly till level falls to <5000IU/L
 Active intervention is needed If patient become symptomatic
or Serum βhCG levels rises above (3000 IU/L) or plateau

23. Expectant management
 Based on the assumption of spontaneous resolution of
pregnancy through regression i.e. without treatment:
 CRITERIA:
 Hemodynamically stable and asymptomatic
 Serum βhCG at initial presentation <1000IU/L.
 Adnexal mass <4cm on Transvaginal scan (TVS)
 Less than 100 ml free fluid in pelvis

24.  Women managed expectantly should be followed by:
 Serial βhCG twice weekly measurements (ideally less than
50% of its initial level within seven days)
 Weekly by transvaginal ultrasound (a reduction in the size of
adnexal mass by seven days)
 Transvaginal ultrasound weekly βhCG, until levels are less
than 10IU/L.
 Counsel about the importance of compliance with follow-up
and should be with in easy access to the hospital in question.
 Active intervention is needed:
 If patients become symptomatic
 Serum βhCG rises or levels start to plateau.

25. Surgical management
 If Serum βhCG is >3000IU/L
 Patient is symptomatic(or hemodynamically unstable)
Salpingotomy: Removal of conceptus with conservation of
tubes
Done in women with diseased contralateral tube and fertility
desired
Salpingectomy: Removal of tube in the presence of healthy
contra lateral tube
Can be done by two methods;
 Laparoscopy
 Laparotomy

26. CRITERIA
Laparoscopy
 Pt hemodynamically
stable
 No previous surgeries
 Unruptured ectopic
 Adnexal mass<4cm
Laparotomy
 Hemodynamically
unstable
 Previous surgeries
 Ruptured ectopic
 Expertise for laparoscopy
is not available

27. Prognosis:
 10-20 % are at risk of having a second
gestation with ectopic.
 60 % will become pregnant again with a
normal intrauterine gestation.
 Early careful monitoring is required in women
who become pregnant with previous history
of ectopic gestation. It is recommended to get
a TVS between 6-10 weeks .