2. 27 yrs. old lady, married 1½ yrs.
presented to OP with
C/o lower abdominal pain and
C/o spotting P/V from day 7 of
the cycle
C/o fever for 10days.
3. MENSTRUAL CYCLE :
• Regular cycles.
• 3/28days cycle.
• Not associated with clots/pains.
MARITAL H/O:
• Married – 1½ yrs.
• Non consanguinous marriage.
4. PAST H/O:
• No h/o DM, HT, BA, Epilepsy, Thyroid.
• No h/o any previous surgeries.
PERSONAL H/O :
• Mixed diet.
• Bowel and bladder habits normal.
FAMILY H/O:
• Nil significant.
5. ON EXAMINATION:
Patient anxious in pain
febrile, hydration fair.
Pallor +, No pedal edema.
BP – 100/60 mm hg
PR – 68/min
CVS – s1s2 +.
RS - NVBS+.
6. P/A : Soft, bs+.
Tenderness in right iliac fossa +.
P/V – cx uterus retroverted
ut normal size
All fornices tender.
Diagnosis - 27yrs old lady
? ectopic pegnancy /?PID.
7. USG ABDOMEN:
• A Heterogenous lesion 5.6×3cm in left adnexa
close to left ovary.
• A ring lesion 2×2cm with thick hyperechoic rim
and showing peripheral vascularity.
Blood Investigation
• β Hcg-672 miu/ml
10. • An ectopic pregnancy is a complication of pregnancy in
which the pregnancy implants outside the uterine cavity.
11.
12.
13. INCIDENCE
• Increased due to PID, use of IUCD, Tubal surgeries,
and Assisted reproductive techniques (ART).
• Ranges from 1:25 to 1:250
• Average range is 1 in 100 normal pregnancies.
• Late marriages and late child bearing -> 2%
• ART -> 5%
• Recurrence rate - 15% after 1st
, 25% after 2 ectopics
14. 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.
15. CONGENITAL
Tubal Hypoplasia
Tortuosity
Congenital diverticuli
Accessory ostia
Partial stenosis
Elongation
Intamural polyp
Entrap the ovum on its way.
16. ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
Contraceptive Faliure
CuT - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%
17. Tubal sterilization faliure -40%
Depends on sterilization technique and age of the patient
Bipolar Cauterisation -65%
Unipolar Cautery -17%
Silicon rubber band -29%
Interval Salpingectomy -43%
Postpartum Salpingectomy -20%
Reversal of sterilisation
- Depends on method of sterilization, Site of
tubal occlusion, residual tubal length.
- Reanastomosis of cauterised tube -15%
- Reversal of Pomeroy’s - < 3%
18. Tubal reconstructive surgery (4-5 times)
Assisted Reproductive technique
- Ovulation induction, IVF-ET and GIFT (4-7%)
- Risk of heterotopic pregnancy(1%)
Previous Ectopic Pregnancy
- 7-15% chances of repeat ectopic pregnancy
19. Other Risk factors
Age 35-45 yrs
Previous induced abortion
Previous pelvic surgeries
Cigarette smoking
DES Exposure in Utero
Infertility
Salpingitis Isthmica Nodosa
Genital Tuberculosis
Fundal Fibroid & Adenomyosis of tube
Transperitoneal migration of ovum
20. Factors facilitating nidation of ovum in tube:
- Premature degeneration of zona pellucida
- Increased decidual reaction
- Tubal endometriosis
21. • The pregnancy is unable to survive owing to its poor
blood supply, thus resulting in a tubal abortion and
resorption, or it is expelled from the fimbriated end
into the abdominal cavity.
• The pregnancy continues to grow until the
overdistended tube ruptures, with resulting profuse
intraperitoneal bleeding.
• Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial
-4 months
• Abortion is common in ampullary pregnancies,
whereas rupture is in isthmic.
22. • In rare instances, a tubal pregnancy will be
expelled from the tube and seed onto sites in the
abdominal cavity (e.g. the omentum, the small or
large bowel, or the parietal peritoneum), and
gives rise to a viable abdominal pregnancy.
23.
24. CLINICAL APPROACH
• Dignosis can be done by history, detail examination and judicious
use of investigation.
• H/o past PID, tubal surgery,current contraceptive measures should
be asked
• Wide spectrum of clinical presentation from asymtomatic pt to
others with acute abdomen and in shock.
25. ACUTE ECTOPIC PREGNANCY
• Classical triad is present in 50% of pt with
rupture ectopic.
- PAIN:- most constant feature in 95% pt
- variable in severity and nature
- AMENORRHOEA:- 60-80% of pt
- there may be delayed period or slight
spotting at the time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
• Feeling of nausea,vomiting,fainting attack, syncope attack(10%)
due to reflex vasomotor disturbance.
26. CHRONIC ECTOPIC PREGNANCY
• It can be diagnosed by high clinical suspicion.
• Patient had previous attack of acute pain from which she has
recovered.
• She may have amenorrhoea, vaginal bleeding with dull pain in
abdomen,and with bladder and bowel complaints like
dysuria,frequency or retention of urine, rectal tenesmus.
27. • O/E:- patient look ill, varying degree of pallor,
slightly raised temperature. Features of shock
are absent.
• P/A:- Tenderness and muscle guard on the lower
abdomen.
A mass may be felt, irregular and tender.
• P/V:- Vaginal mucosa pale, uterus may be normal
in size or bulky, ill defined boggy tender
mass may be felt in one of the fornix.
28. DIAGNOSIS
• Patient with acute ectopic can be diagnosed clinically.
• Blood should be drawn for Hb gm%, blood grouping and cross
matching, DC and TWBC, BT, CT.
• Should be catheterized to know urine output.
Bed side test:-
1. Urine pregnancy test:- positive in 95% cases.
ELISA is sensitive to 10-50 mlU/ml of β hCG and
can be detected on 24th
day after LMP.
29. 2. Culdocentesis:- (70-90%)
- Can be done with 16-18 G lumbar
puncture needle through posterior fornix
into POD.
- Positive tap is 0.5ml of non clotting blood.
• Other Investigations:-
1. Ultra Sonography-
a) Transvaginal Sonography (TVS):
- Is more sensitive
- It detect intrauterine gestational sac at
4-5wks and at S-β hCG level as low as 1500
IU/L .
30. b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
-Identify the placental shape (ring-
of-fire pattern) and blood flow
outside the uterine cavity.
c) Transabdominal Sonography:
- can identify gestational sac at 5-6 wks
- S-β hCG level at which intrauterine gestational
sac is seen by TAS is 1800 IU/L.
31. 2. β-HCG Assay-
a) Single β-HCG: little value
b) Serial β-HCG: is required when result of
initial USG is confusing.
- When hCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.
-Rise of β-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .
Biochemical pregnancy is applied to those
women who have two β-HCG values >10 IU/L
32. 3. Serum Progesterone –
- level >25 ngm/ml is suggestive of normal
intrauterine pregnancy.
- level <15 ngm/ml is suggestive of ectopic
pregnancy.
- level <5 ngm/ml indicates nonviable
pregnancy, irrespective of its location.
4. Diagnostic Laparoscopy (Gold standard)–
- Can be done only when patient is
haemodynamically stable.
-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.
33. 5. Dilatation & Curettage –
- Is recommended in suspected case of
incomplete abortion vs ectopic pregnancy.
- Identification of decidua without chorionic
villi is suggestive of extra uterine pregnancy.
- “Arias-Stella” endometrial reaction is
suggestive but not diagnostic of ectopic
pregnancy.
34. DIFFERENTIAL DIAGNOSIS
D/D of Acute Ectopic
1. Rupture corpus luteum of pregnancy
2. Rupture of chocolate cyst
3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion
6. Acute Appendicitis
7. Perforated peptic ulcer
8. Renal colic
9. Splenic rupture
36. MANAGEMENT OF RUPTURED ECTOPIC
PRINCIPLE: Resuscitation and Laparotomy
ANTI SHOCK TREATEMENT:
- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching, BT, CT
- Folley’s catheterization done
- Colloids for volume replacement
LAPAROTOMY:
Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given
- Autotransfusion only when donated blood not available.
37. MANAGEMENT:
MEDICAL MANAGEMENT:
• Offer systemic methotrexate as a first-line treatment to women
who are able to return for follow-up and who have all of the
following:
• no significant pain an unruptured ectopic pregnancy
• with an adnexal mass smaller than 35 mm with no visible heartbeat
• a serum hCG level less than 1500 IU/litre no intrauterine
pregnancy (as confirmed on an ultrasound scan).
38. • Offer surgery as a first-line treatment to women
who are unable to return for follow-up after
methotrexate treatment or who have any of the
following:
• an ectopic pregnancy and significant pain
• an ectopic pregnancy with an adnexal mass of
35 mm or larger
• an ectopic pregnancy with a fetal heartbeat
visible on an ultrasound scan
• an ectopic pregnancy and a serum hCG level of
5000 IU/litre or more.
39. • Offer the choice of either methotrexate or
surgical management to women with an ectopic
pregnancy who have a serum hCG level of at
least 1500 IU/litre and less than 5000 IU/litre,
who are able to return for follow-up and who
meet all of the following criteria:
• no significant pain an unruptured ectopic
pregnancy with
• an adnexal mass smaller than 35 mm with no
visible heartbeat
• no intrauterine pregnancy (as confirmed on an
ultrasound scan).
40. • Single dose of methotrexate (MTX) 50 mg/M2
is given intramuscularly.
• Monitoring is done by measuring serum β
hCG on D4 and D7. When the decline in hCG
between
• (i) D4 andD7 is > 15%, patient is followed up
weekly with serum hCG until hCG < 10
mIU/ml.
• If the decline is < 15%, a second dose of MTX
50 mg/M2 is given on D7.
41. Multiple dose regimen:
• 1mg/kg on days 0,2,4,and 6 followed by 4 doses of
leucovorin as 0.1mg/kg on days 1,3,5,7.
• Weekly Beta hCG level till < 2mIU/ml.
42. SURGERY:
• Laparotomy.
• Laparoscopy.
INDICATION:
• Pt not suitable for medical management.
• Medical therapy has failed.
• Pt has a heterotopic pregnancy with a viable intrauterine
pregnancy.
• Pt is hemodynamically unstable and needs immediate
treatment.
46. SALPINGECTOMY AND SALPINGOTOMYSALPINGECTOMY AND SALPINGOTOMY
•Offer a salpingectomy to women undergoing surgery for
an ectopic pregnancy unless they have other risk factors for
infertility.
•Consider salpingotomy as an alternative to salpingectomy
for women with risk factors for infertility such as
contralateral tube damage.
•Inform women having a salpingotomy that up to 1 in 5
women may need further treatment. This treatment may
include methotrexate and/or a salpingectomy.
•For women who have had a salpingotomy, take 1 serum
hCG measurement at 7 days after surgery, then 1 serum
hCG measurement per week until a negative result is
obtained.
47. Anti-D rhesus prophylaxis
•Offer anti-D rhesus prophylaxis at a dose of 250 IU
(50 micrograms) to all rhesus negative women who
have a surgical procedure to manage an ectopic
pregnancy or a miscarriage.
•Do not offer anti-D rhesus prophylaxis to women
who:
• receive solely medical management for an ectopic
pregnancy or miscarriage
• or have a threatened miscarriage
• or have a complete miscarriage
• or have a pregnancy of unknown location.
48. MILKING OR FIMBRIAL EXPRESSION:
THIS IS IDEAL IN DISTAL AMPULLARY OR
INFUNDIBULAR PREGNANCY.
IT HAS GOT INCREASED RISK OF PERSISTENT
ECTOPIC PREGNANCY.
