Ectopic pregnancy

1. ECTOPIC PREGNANCY
Maj Sapna Jaggi
Gd Spl (Obst Gynae)

2. ECTOPIC PREGNANCY
 Definition
 Sites
 Frequency
 Etiology
 Clinical feature
 Diagnosis
 D/D
 Management

3. Definition
When the fertilized ovum is implanted and
develops outside the normal endometrial
cavity

5. Incidence
 1:150 – 1:200 pregnancies
 Incidence is showing an increasing trend over the
years
 leading cause of life-threatening first-trimester
morbidity
 However mortality due to ectopic pregnancy has
decreased
 Recurrence rate - 15% after 1st, 25% after 2
ectopics

6. Etiology
 Any factor that causes delayed transport of
the fertilised ovum through the tube.
 Fallopian tube favours implantation in the
tubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.
 These factors may be Congenital or
Acquired.

7. CONGENITAL
 Tubal Hypoplasia
 Tortuosity
 Congenital diverticuli
 Accessory ostia
 Partial stenosis
 Elongation
 Intamural polyp
 Entrap the ovum on its way.

8. ACQUIRED CAUSES
 INCREASING AGE
 PID(6 TO 10 TIMES )(chlamydia infection mc)
 TUBAL LIGATION (40%) – depend on technique and age of pt
Bipolar cautery – 65%
Unipolar cautery – 17%
 CONTRACEPTION FAILURE
- CuT 4%
- Progestasert 17%
- Minipill 4-10%
- Norplant 30%

9. ACQUIRED CAUSES
 PREVIOUS ECTOPIC PREGNANCY
 TUBAL RECONSTRUCTIVE SURGERY
(4-5 times)depends on method of sterilisation, site of
tubal occlusion
- reanastomosis of cauterised tube 15%
- reanastomosis of pomeroy <3%
 ART In infertility pts 4-7%

10.  PREVIOUS ABORTIONS
 TUBAL ENDOMETRIOSIS.
 CIGARETTE SMOKING
 DES EXPOSURE
 FUNDAL FIBROIDS AND ADENOMYOSIS
 TRANS PERITONEAL MIGRATION OF OVUM.

13. CLINICAL PRESENTATION
 Ectopic Pregnancy remains asymptotic
until it ruptures when it can present in two
variations - Acute &. Chronic
29/08/2022 15:20 Ectopic Pregnancy 13

15. Clinical features ( Acute / Subacute)
 Classical triad
 Pain abdomen (100%)
 Amenorrhea (75%)
 Bleeding PV (70%)
 Shock and haemodynamic instability
present in acute cases
 Vomiting, Shoulder pain & Syncope may
be present in patients with
haemoperitoneum

16. Clinical features ( Acute / Subacute)
 Physical examination
 Pallor
 Tachycardia
 Hypotension
 Cold, clammy skin in patients with shock
 Lower abdominal tenderness
 Features of haemoperitoneum
 Uterine enlargement
 Cervical motion tenderness ( Rocking pain)
 Tenderness elicited through fornices

17. Differential Diagnosis
 Inevitable / Incomplete/ Missed abortion
 Rupture of corpus luteal cyst in pregnancy
 Normal pregnancy with pain abdomen
 Ruptured endometrioma ovary
 Torsion ovarian cyst
 Torsion of pedunculated fibroid
 Acute appendicitis

18. 7
CHRONIC ECTOPIC PREGNANCY
 Patient would have recovered from
previous attack of acute pain.
 Pt may present with amenorrhoea, dull
aching lower abdominal pain, vaginal
bleeding, dysuria, frequency of micturation
or retention of urine and rectal tenesmus.

19. Clinical features ( Chronic Ectopic)
 Variable period of amenorrhoea
 Irregular vaginal bleeding
 Lower abdominal pain
 Tender adnexal mass

21. INVESTIGATION
 BLOOD INVESTIGATION.
  HCG.
SPECIAL INVESTIGATIONS
 ULTRASOUND.
 LAPAROSCOPY
 LAPAROTOMY
 DILATATION & CURETTAGE
 CULDOCENTESIS
 MAGNETIC RESONANCE
 IMAGING

29. MANAGEMENT
 Individualised and depends more on
clinical presentation

31. UNRUPTURED ECTOPIC
PREGNANCY
 Expectant
where only observation is done hoping spontaneous resolution
INDICATIONS
- Initia; serum Hcg level <1000iu/ml and subsequent levels are falling
- Gestation sac <4 cm
-NO FCA on TVS
- No evidence of bleeding and rupture
 Conservative
- Medical
- Surgical

33. Treatment
 Medical treatment of unruptured ectopic
pregnancy
 Patient selection
 Unruptured ectopic
 Hemodynamically stable
 Gestation sac size < 4 cm
 No fetal cardiac activity visualized on USG
examination
 Serum ß hCG < 10,000 mIU/ml
 Methotrexate 50 mg/ sq m I/M single dose

34. METHOTREXATE REGIMES
 Single dose regimen
 2 Dose regimen
 Multiple dose regimen

35. SUMMARY
 Any reproductive age group women presenting
with pain abdomen, always be ectopic minded
 Diagnosis of ruptured ectopic pregnancy is
always clinical.
 It presents as an acute abdomen and
haemodynamic instability due to rapidly
developing haemoperitoneum.
 It requires urgent surgical intervention
(Laparotomy).
 Don’t waste time on unnecessary investigations
with such a presentation

49. Thank you