Ectopic pregnancy by Dr qurat ul ain

1. Ectopic pregnancy

2. • Ectopic pregnancy is an implantation of
fertilized ovum at the site other then uterine
cavity.
• It can be outside the uterus or in abnormal
position within the uterus (cornua, cervix)

3. Sites:
• Fallopian tube (commonest, 95%)
• Ovaries
• Abdominal cavity
• Cervix
• Vagina
• Broad ligament
• Rudimentary horn of uterus

4. Incidence:
• 1 in 200-300 pregnancies or 22 per 1000 live
births
• More prevalent among black races

5. Tubal ectopic pregnancy
Aeitiology:
1. Pelvic inflammatory disease
2. Tubal surgery
3. Tubal disease
4. IUCDs
5. Diethylstilboestrol exposure
6. Termination of pregnancy
7. Assisted reproduction techniques
8. Ovum transmigration

6. Presentation:
1. Acute presentation
2. Subacute/chronic presentation

7. Acute presentation:
Ruptured tubal pregnancy associated with
intraperitoneal hemorrhage leading to acute
abdomen & often presents with hypovolemic
shock.

8. Symptoms:
Characteristic symptoms:
• Amenorrhea
• Abdominal pain
• Vaginal bleeding
Other symptoms:
• Shock
• Subjective
• Syncope
• Shoulder pain

9. • On GPE, patient is sweating, skin is pale, cold,
clammy with low blood pressure and weak pulse.
• On abdominal examination there is occasional
distension, rigidity, rebound tenderness and
diminished or absent bowel sounds.
• On speculum examination small amount of dark
blood may be seen in vagina while on bimanual
exam. Patient complains of severe pain on
moving the cervix or uterus (chandelier sign)

10. Subacute/chronic presentation:
• Seen when intraperitoneal bleeding from the
tube is recurrent & small in amount.
• Symptoms are vague & so diagnosis can easily
be missed if patient is not evaluated
thoroughly.

11. • On examination pulse and BP are normal,
abdomen is soft, tender & rigidity restricted to
iliac fossa.
• On bimanual examination of pelvis, patient
complains of pain, uterus is of normal size or
may be enlarged & affected adnexa is tender.

12. 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

13. Outcome of tubal pregnancy:
• Rupture
• Tubal abortion
• Tubal mole
• Abdominal pregnancy
• Spontaneous regression

14. Investigations:
• Ultrasound
• Serum hcg
• Ultrasound & hcg
• Laparoscopy
• Colpocentesis
• Serum progesterone

15. Treatment:
• Surgical
• Medical
• Conservative

16. Surgical treatment:
• Laparotomy
• Laparoscopy

17. Laparotomy:
Indications for laparotomy:
• Ruptured tubal pregnancy
• Patient is haemodynamically unstable
• Laparoscopy is contra-indicated
• When ectopic pregnancy is in cornua or
rudimentary horn of uterus.
At laparotomy ectopic pregnancy is treated with:
• Salpingectomy
• Tubal repair

18. Laparoscopic surgery:
Pre-requisites are:
• Ectopic pregnancy of <6 cm diameter
• B-hcg <600 iu/l
• Adequate surgical skills
• Proper equipment
• Minimal adhesions in abdomen
• No massive haemperitoneum

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

20. Ovarian pregnancy:
• Symptomatology, clinical findings &
investigations are same as for tubal ectopic
pregnancy.
• Treated with oophorectomy or salpingo-
oophorectomy.

21. Abdominal pregnancy:
• Can be primary or secondary to tubal abortion
or tubal rupture
• Patient gave history of bleeding or pain in
early part of pregnancy
• On clinical examination, uterus is palpable
separate from baby
• Laparotomy is the treatment

22. Cervical pregnancy:
• Extremely rare
• Patients with high parity & history of surgical
manipulations of uterus are at an increased
risk
• Vaginal bleeding is prominent symptom
• Hysterectomy is the treatment of choice.