brief explanation on ectopic pregnancy and its treatment

1. ECTOPIC PREGNANCY
Hari Prakash Bharathi
Group 4 Year 6
Department of Surgery
Tbilisi State Medical
University
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2. BACKGROUND
IMPLANTATION OF THE ZYGOTE OUTSIDE UTERUS
>90% IN FALLOPIAN TUBE
LESS COMMON IN OVARIES, CERVIX, ABDOMINAL ORGANS
SEVERE BLEEDING AND ABDOMINAL PAIN
MOST COMMON IN FIRST TRIMESTER
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3. TYPES
Extra uterine
 Fallopian tube, ovaries, abdominal cavity, intraligamentous
Uterine
 cervical, angular, corneal
Heterotrophic (2 fertilized ovum, 1 is ectopic and
other normal)
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7. RISK FACTORS
Any factors that responsible for the delayed transport
of the zygote to the uterus
 Congenital
 Acquired
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8. RISK FACTORS
Congenital
Tubal hypoplasia
Tortuosity
Accessary ostia
Congenital diverticulitis
Partial stenosis
Elongation
Intramural polyps
Acquired
Pelvic inflammatory
disease
Contraceptive failure
Tubal sterilization failure
Sterilization reversal
Tubal reconstructive
surgery
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10. OTHER RISK FACTORS
Age 35 to 45
Previous induced abortions
Genital tuberculosis
Infertility
Smoking
Trans peritoneal migration of ovum
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11. IFFY HYPOTHESIS
“Theory of reflux” menstrual fluid throw matured
ovum into tube
Due to
 Premature degeneration of zona pellucida
 Increased decidual reaction
 Tubal endometriosis
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12. TUBAL PREGNANCY
Implantation of the zygote in the fallopian tube
Ampullary 80%
Ishthmic 10%
Fimbrial 5%
Interstitial 2%
Rudimentary horn of bicorunate uterus 2%
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14. PATHOPHYSIOLOGY
Due to the formation of trophoblast, the zygote
implanted into the tubal wall and began to produce
hCG, which maintains corpus luteum.
Corpus luteum produce estrogen and progesterone
required for the uterus enlargement
Tubal pregnancy does not develop beyond 8 weeks
due to
 Poor vascular supply
 Thin wall
 Narrow lumen
 Lack of decidual reaction in the tube
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16. FATE OF TUBAL PREGNANCY
Tubal mole
Tubal abortion – more common in ampulla
Tubal rupture – more common in isthmus
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18. SYMPTOMS
3As
Abdominal pain,
Amenorrhea and early signs of pregnancy
Abnormal vaginal bleeding
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19. SIGNS
General examination
Weakness
Pallor
Tachycardia, tachypnea
Hypotension
One sided abdominal pain
Vaginal examination
Vaginal spotting
Bluish vagina and cervix
* Do not do bimanual
examination unless
resuscitation is available,
may lead to rupture.
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20. DIAGNOSIS
β-hCG test
Ultrasound
Culdocentasis
Laparoscopy and laparotomy
Transvaginal sonography
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24. TREATMENT FOR UNRUPTURED
ECTOPIC PREGNANCY
Expectant
Medical
Surgical
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25. EXPECTANT
Criteria:
 Asymptomatic
 <100ml of fluid in pouch of
Douglas
 hCG <1000 iu/l
 Mass <3cm
 Declining hCG
Initial follow up
Weekly hCG and transvaginal
ultrasound
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26. MEDICAL
Selection Criteria
 Hemodynamically stable
 No signs of active bleeding
 Absence of fetal heart beat
 Normal FBS, LFT and KFT
Exclusion criteria
 Thrombocytopenia
 Hepatic dysfunction
 Ectopic mass >3.5 cm
 Presence of FHR
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27. MEDICATIONS
Systemic - methotrexate
Local – injections of prostaglandins, hyperosmolar
glucose, local methotrexate, potassium chloride
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28. SURGICAL MANAGEMENT
Salpingectomy
Salpingotomy linear, segmental
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31. OVARIAN PREGNANCY
Very rare in normal conception
IVF shows increasing chances
Symptoms are similar to tubal
Diagnosis mainly by ultrasound
Treatment oophorectomy
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32. INTERSTITIAL PREGNANCY
In the cornual segment of tube and lies within uterine
wall.
Swelling lateral to the implantation in the round
ligament
Progress beyond 15 weeks and may lead to massive
hemorrhage
Treatment hysterectomy
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34. CERVICAL PREGNANCY
Implantation below the level of internal os.
Two diagnostic criteria
 Presence of cervical gland opposite to placental attachment
 Portion of placenta located below the uterine vessels
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35. HETEROTOPIC PREGNANCY
Mostly rare in normal but increased incidence in IVF
Methotrexate is contraindicated
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36. ABDOMINAL PREGNANCY
Due to primary implantation or secondary
implantation after tubal rupture
Physical findings and symptoms vary depends on
gestational age
10 to 20 % fetal survival rate and with deformity
Do not attempt to remove placenta as it cause severe
hemorrhage.
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38. THANK YOU
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