This document contains a patient case report for Januka Katuwal, a 32-year-old female presenting with cessation of menstruation for over a month, abdominal pain for 8 hours, and vomiting for 8 hours. Her examination and investigations revealed a ruptured ectopic pregnancy in her right fallopian tube, which was then managed via an emergency laparotomy and right salpingectomy with left tubal ligation. The document also provides definitions, classifications, risk factors, clinical approaches, diagnostic methods, and management options for ectopic pregnancies.

1. .
AMIT JHA
AMIT UPRETI
NILAM RAI

2. Patient’s particulars
•Name: Januka Katuwal
•Age/Sex: 32 yrs/F
•Religion: Hindu
•Occupation: Housewife
•Address: Imadol
•Bed No.: 139
•Inpatient No.:43515
•Date of Admission: 2073/11/11
•Date of discharge: 2073/11/17

3. Chief Complaints :
•Cessation of menstruation for 1
month & 9 days
•Pain abdomen for 8 hours
•Vomiting for 8 hours

4. History Of presenting illness
•Cessation of menstruation for 1 month
and 9 days
LMP- 2073/10/02
Gestational age- 5 weeks and 2 days
•Pain abdomen
sudden onset, right iliac fossa,
intermittent, non radiating ,
no aggravating & relieving factors

5. •Vomiting
4 episodes, containing food particles, not
blood mixed
No history of
P/V bleeding or P/V discharge
fever
burning micturition
fainting attack

6. Obstetric History
•Married for 15 years
•G₂P₁A₀ L₁
14 years, male baby , NVD at home,
no complications

7. Menstrual History
•K=16 yrs
•Cycle: 28-30 days, regular
•Duration of flow : 3-4 days, uses 2-3 pads
per day, no passage of clots
•No intermenstrual or post coital bleeding
•LMP: 2073/10/02

8. Contraceptive History
•Used Depoprovera for 12 yrs after birth of
first child
•Last dose: Chaitra 2071
•discontinued after diagnosed with
hypothyroidism
•Currently, not using any contraceptives

9. Past History
•History of hypothyroidism – 1 yr (under
medication)
•No h/o HTN, DM, TB, Asthma
•No h/o surgical interventions in the past

10. Family History
No h/o HTN, DM, TB, multiple
pregnancy, congenital anomalies
Personal History
non smoker, doesn’t consume alcohol
Treatment History
Tab. Thyronorm 25 mcg OD
•

11. Examination
•General Condition: ill looking
•Cardinal signs
Pallor: present
Icterus: absent
Edema: absent

12. VITALS:
BP: 90/60 mm Hg
Pulse:80 beats/min, feeble
RR: 20 breaths/min
Temperature: 97⁰ F

13. Systemic Examination
Chest: B/L normal vesicular breath sound . No added
sound
CVS: S₁S₂M₀
Thyroid: not enlarged
Per abdomen: soft
tenderness on right and left iliac fossa and
hypogastric region
no organomegaly
bowel sound present

14. P/S: cervix: normal
discharge: present, curdy white, foul smelling
P/V: vulva/ vagina normal
uterus anteverted
uterus size couldn’t be assessed due to pain
cervical motion tenderness: present

15. INVESTIGATIONS
(2073/11/11)
Hb: 12.6 gm/dl
Platelets: 1,99,000/cu mm
TC: 10,000
Neutrophils: 90% , Lymphocyte: 10%
Glucose Random: 124 mg/dl
Se. Urea: 24 mg/dl
Se.Creatinine: 0.55 mg/dl
Sodium: 133 mmol/L
Potassium: 4.7 mmol/L

16. Blood Group: A positive
Serology: non reactive
UPT: positive
Urine R/E:
WBC : 2-4/HPF
RBC: Nil
Epithelial cells: 10-12/HPF
Sugar: +

17. USG abdomen & pelvis (2073/11/11):
Ill defined hypoechoic lesion measuring
8.7×6.4cm in right adnexa with minimal
internal vascularity associated free fluid in HRA
and pelvic cavity

18. Diagnosis
G₂P₁A₀L₁ at 5 wks & 2 days of gestation with
right sided ruptured ectopic pregnancy.

19. Management
Emergency laparotomy followed by right
salpingectomy with left sided tubal ligation
OT Findings :
Haemoperitoneum of around ~ 1 lit.
Uterus normal size
Around 3×2 cm mass present in the ampullary
region of right fallopian tube
Right ovary normal
Left tube and ovary normal
Drain kept
Drain: blood stained serosanguinous fluid

20. II pint whole blood transfused(073/11/12)
Post transfusion Hb. 10.4 gm/dl
Drain removed on 5th
post op. day
Inj. IV fluids (RL III pint, DNS III pint over 24
hours)
Inj. Ceftriaxone 1 gm IV BD
Inj. Metronidazole 500 mg IV TDS
Inj. Ketorolac 30 mg IV TDS
Inj. Ranitidine 50 mg IV BD
Inj. Pethidine 50 mg IM SOS
Inj. Phenargan 25 mg IM SOS

21. Tab. Cefixine 200 mg PO BD
Tab. Metronidazole 400 mg PO TDS
Tab. Ketorolac 10 mg PO TDS
Tab. Ranitidine 150 mg PO BD
Tab. Thyronorm 25 mcg PO BD
Tab. Chymoral forte 1 tab. PO TDS
Powder Protinex 2 tsf TDS

22. Discharged on 6th
post op. day with medication:
Tab. Cefixime 200 mg PO OD for 4 days
Tab. Metronidazole 400 mg PO TDS for 4 days
Tab. Thyronorm 25 mcg PO OD
Tab. Chymoral forte 1 tab. PO TDS for 5 days
Tab. Ranitidine 150 mg PO BD for 4 days
Tab. Flexon 1 tab. PO OD for 2 days

23. DEFINITION
“Any pregnancy where the fertilised ovum gets
implanted & develops in a site other than normal
uterine cavity”.
It represents a serious hazard to a woman’s health
and reproductive potential, requiring prompt
recognition and early aggressive intervention.

24. IMPLANTATIONS SITES
EXTRAUTERINE UTERINE
TUBAL 95-96%
-Ampulla 70%
-Isthmus 12%
-Infundibulum 11%
-Interstitial &
cornual 2%
OVARIAN
(1:40,000)
ABDOMINAL
(1:10,000)
-CERVICAL
(1:18,000)
-ANGULAR
-CORNUAL
-CAESAREAN
SCAR (<1)
PRIMARY SECONDARY
Intraperitoneal Extraperitoneal
Broad Ligament
(rare)

26. 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%
•Recurrence rate - 15% after 1st
, 25% after 2
ectopics

27. In KISTMCTH :
•Total gynaecology case in last 1 year = 403
(2072 -11 – 18 to 2073 – 11 – 17 )
•Total ectopic pregnancy in last 1 year = 10
(Till 2072- 11 – 18 to 2073 – 11 - 17 )

28. ETIOLOGY
CONGENITAL
•Tubal Hypoplasia
•Tortuosity
•Congenital diverticuli
•Partial stenosis
•Elongation
•Intramural polyp

29. ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
Contraceptive Faliure
CuT - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%

30. Tubal sterilization failure -40%Tubal sterilization failure -40%
Reversal of sterilisationReversal of sterilisation
Tubal reconstructive surgery (4-5 times)
Assisted Reproductive technique
- Ovulation induction, IVF-ET (4-7%)
- Risk of heterotopic pregnancy(1%)
Previous Ectopic Pregnancy
- 7-15% chances of repeat ectopic pregnancy

31. Other Risk factors
Age 35-45 years
Previous induced abortion
Previous pelvic surgeries
Cigarette smoking
Infertility
Genital Tuberculosis
Fundal Fibroid & Adenomyosis of tube

32. CLINICAL APPROACH
•Diagnosis 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
patient to others with acute abdomen and in shock.

33. ACUTE ECTOPIC PREGNANCY
 Classical triad is present in 50% of pt with
rupture ectopic.
- PAIN:- most constant feature in 95% patient
- variable in severity and nature
- AMENORRHOEA:- 60-80% of patient
- 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.

34. O/E:- patient is restless in agony, looks blanched,
pale, sweating with cold clammy skin.
Features of shock, tachycardia, hypotension.
P/A:- abdomen tense, tender mostly in lower
abdomen , shifting dullness and rigidity may be
present.
P/S:- minimal bleeding may be present
P/V:- uterus may be bulky, deviated to opposite
side, fornix is tender, excitation pain on
movement of cervix.
POD may be full, uterus may floats as if in water.

35. 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 (short weeks < 8 weeks),
followed by vaginal bleeding with dull pain in
abdomen, and with bladder and bowel complaints like
dysuria ,frequency or retention of urine, rectal
tenesmus.

36. • O/E:- patient look ill, may be varying degree of pallor,
slightly raised temperature. Features of shock
are absent.
• P/A:- Tenderness and muscle guarding on the lower
abdomen.
A mass may be felt, irregular and tender.
• P/V:- Vaginal mucosa may be pale, uterus may be normal
in size or bulky, ill defined boggy tender
mass may be felt in one of the fornix.

37. UNRUPTURED ECTOPIC
• High degree of suspicion & ectopic conscious clinician can
diagnose.
• Diagnosed accidentally in USG , Laparoscopy or Laparotomy
C/F – delayed period, spotting with discomfort in
lower abdomen.
P/A – tenderness in lower abdomen
P/V – should be done gently
uterus is normal size, firm
small tender mass may be felt in the fornix

39. DIAGNOSIS
““Pregnancy in the fallopian tube is a black catPregnancy in the fallopian tube is a black cat
on a dark night. It may make its presence felton a dark night. It may make its presence felt
in subtle ways and leap at you or it may slipin subtle ways and leap at you or it may slip
past unobserved. Although it is difficult topast unobserved. Although it is difficult to
distinguish from cats of other colours indistinguish from cats of other colours in
darkness, illumination clearly identifies it.”darkness, illumination clearly identifies it.”
--Mc. Fadyen - 1981--Mc. Fadyen - 1981

40. DIAGNOSIS
In recent years, in spite of an increase in theIn recent years, in spite of an increase in the
incidence of ectopic pregnancy there has been a fall inincidence of ectopic pregnancy there has been a fall in
the case fatality rate.the case fatality rate.
This is due to the widespread introduction ofThis is due to the widespread introduction of
diagnostic tests and an increased awareness of thediagnostic tests and an increased awareness of the
serious nature of this disease.serious nature of this disease.
This has resulted in early diagnosis and effectiveThis has resulted in early diagnosis and effective
treatment.treatment.
Now the rate of tubal rupture is as low as 20%.Now the rate of tubal rupture is as low as 20%.

41. DIAGNOSIS
Patient with acute ectopic can be diagnosed clinically.
Blood should be drawn for Hb gm%, blood grouping and
cross matching, DC and TLC , BT, CT, platelets, PT:INR
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.

42. Other Investigations:-
1. Ultra Sonography-
a) Transvaginal Sonography (TVS):
- Is more sensitive
- It detect intrauterine gestational sac at
4-5 weeks and at S-β hCG level as low as 1500
IU/L .

43. USG PICTURE
1.‘Bagel’ sign – Hyperechoic ring around
gestational sac in adnexal region
2. ‘Blob’ sign – Seen as small inconglomerate
mass next to ovary with no evidence of sac
or embryo.
3. Adnexal sac with fetal pole and cardiac
activity is most specific.

44. Hyperechoic ring aroundHyperechoic ring around
gestational sac in adnexal regiongestational sac in adnexal region

45. Ring sign — a hyperechoic ringRing sign — a hyperechoic ring around an
extrauterine gestational sac.

46. 2. β-HCG Assay-
a) Single β-HCG: little value
b) Serial β-HCG: is required when result of
initial USG is confusing.
- When β-HCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.
-Rise of β-HCG <66% in 48 hours indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .

47. 3. Serum Progesterone –
- level >25 ngm/ml is suggestive of normal
intrauterine pregnancy.
- level <15 ngm/ml is suggestive of ectopic
pregnancy.
4. Diagnostic Laparoscopy (Gold standard)–
- Can be done only when patient is hemodynamically
stable.
-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.

48. SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive
Transvaginal USG
IU sac No IU sac
Quantitative S-hCG
+ S progesterone
< 66% rise in 48 hr or
S progesterone < 5-10 ng/ml
D & C
Villi present Villi absent
Incomplete
abortion
Laparoscopy
>66% rise in 48 hr or
S progesterone > 5-10 ng/ml
Repeat S-hCG in 48 hrs
till USG discrimination zone
No sac IU sac
Continue to monitor

49. 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
- Foley'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

51. MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
• EXPECTANT MANAGEMENT
• MEDICAL TREATMENT
• SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT
• SURGICAL MANAGEMENT

52. EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA (Ylostalo et al , 1993)- :
1. Tubal ectopic pregnancies only
2. Haemodynamically stable
3. Haemoperitoneum < 50ml
4. Adnexal mass of < 3.5 cm without heart beat.
5. Initial β HCG <1000 IU/L and falling in titre
SUCCESS RATE - Upto 60%
PROTOCOL:
- Hospitalization with strict monitoring of clinical symptom
- Daily Hb estimation
- Serum β HCG monitoring 3-4 days until it is <10 IU/L
- TVS to be done twice a week.

53. EXPECTANT MANAGEMENT
Spontaneous resolution occurs in 72%,while
28% will need laparoscopic salpingostomy
In spontaneous resolution, it may take 4-67
days (mean 20 days) for the serum HCG to
return to non pregnant level.
The percentage fall in serum HCG by day 7 is
a better indicator than the percentage fall by
day 2.

54. MEDICAL MANAGEMENT
Surgery is the mainstay of T/t worldwide
Medical management may be tried in selected cases
CANDIDATES FOR METHOTREXATE (MTX)
Unruptured sac < 3.5cm without cardiac activity
S-hCG < 10,000 IU/L
Persistant Ectopic after conservative surgery
PHYSICIAN CHECK LIST
CBC, LFT, RFT, S-hCG
Transvaginal USG within 48 hrs
Obtain informed consent
Anti-D Ig if patient is Rh negative
Follow up on day1, 4 and 7.

55. MEDICAL MANAGEMENT ( Cont .. )
METHOTREXATE:
It can be used as oral, intramuscular ,intravenous usually along with folinic
acid.
Resolution of tubal pregnancy by systemic administration of Methotrexate
was first described by Tanaka et al (1982)
Mostly used for early resolution of placental tissue in abdominal
pregnancy. Can also be used for tubal pregnancy.
Mechanism of action-Methotrexate is a folic acid antagonist that
inactivates the enzyme dihydrofolate reductase.Interferes with
the DNA synthesis by inhibiting the synthesis of pyrimidines
leading to trophoblastic cell death. Auto enzymes and maternal
tissues then absorb the trophoblast.

56. Dose :
•Administering a single 75mg IM injection of
methotrexate is a suitable treatment for ectopic
pregnancy in cases where beta hcg is<3000IU/ml.
• THE REGIMEN INVOLVES ADMINISTRATION OF
METHOTREXATE AS 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
•Serum βhCG should be assessed at day 0, 3, 5 and 7
until hCG declines by 15%
•After response is achieved, the patient is monitored
with weekly βhCG levels until these are
undetectable

57. Contd……
Advantages –
Minimal Hospitalisation. Usually outdoor
treatment
Quick recovery
 90% success if cases are properly selected
Disadvantages-
Side effects like GI upset & Skin lesion
Monitoring is essential- Total blood count, LFT
& serum HCG once weekly till it becomes
negative

58. SURGICALLY ADMINISTERED MEDICAL Tt
(SAM)
Aim- trophoblastic destruction without systemic side
effects
Technique- Injection of trophotoxic substance into the
ectopic pregnancy sac or into the affected tube by-
Laparoscopy or
Ultrasonographically guided
Transabdominal (Porreco, 1992)
Transvaginal (Feichtingar, 1987)
With Falloposcopic control (Kiss, 1993)

59. Trophotoxic substances used-
Methotrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2α (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
Advantage of local Methotrexate :
- Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up: - Serum β HCG twice weekly till < 10 IU/L
- TVS weekly for 4-6 weeks
- HCG after 6 months for tubal patency
SURGICALLY ADMINISTERED MEDICAL Tt (SAM) Cont …

60. INSTRUCTION TO THE PATIENTS
If treatment on outpatient basis rapid
transportation should be available
Refrain from alcohol, sunlight, multivitamins with
folic acid, and sexual intercourse until S-hCG is
negative.
Report immediately when vaginal bleeding,
abdominal pain, dizziness, syncope (mild pain is
common called separation pain or resolution
pain)
Failure of medical therapy require retreatment
Chance of tubal rupture in 5-10 % require
emergency Laparotomy.

61. SURGICAL MANAGEMENT OF ECTOPIC
Conservative Surgery
Can be done Laparoscopically or by microsurgical laparotomy
INDICATION:
- Patient desires future fertility
- Contralateral tube is damaged or surgically removed
previously
CHOICE OF TECHNIQUE: depends on
- Location and size of gestational sac
- Condition of tubes
- Accessibility

62. VARIOUS CONSERVATIVE SURGERIES
1.Linear Salpingostomy
Indicated in unruptured ectopic <2cm in
ampullary region.
opening the tube and removal of ectopic , tubal
incision left open
2. Linear Salpingotomy
opening, removal of ectopic, closure
3. Segmental Resection & Anastomosis

63. 4. Milking or fimbrial Expression:
- This is ideal in distal ampullary or infundibular pregnancy.
- It has got increased risk of persistent ectopic pregnancy.
ADVANTAGES OF LAPAROSCOPY
- It helps in diagnosis, evaluation, and treatment .
- Diagnose other causes of infertility.
- Decreased hospitalization, operative time, recovery period,
analgesic requirement.
Follow up after conservative surgery
- With weekly Serum β HCG titre till it is negative.
- If titre increases methotrexate can be given.

64. MANAGEMENT
Expectant
management
Medical
management
Surgical
management
Local Systemic
(USG or Laparoscopic)
salpingocentesis
- Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Actinomycin D
- Mifepristone
Methotrexate
Radical
Salpingectomy
Conservative
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbrial
expression

65. SUMMARY - KEY POINTS
Incidence of ectopic pregnancy is rising while maternal mortality
from it is falling.
Ectopic pregnancy can be diagnosed early (before it ruptures) with
recent advances in Immunoassay to detect S-hCG , high resolution
USG, and diagnostic Laparoscopy.
Laparotomy should be done when in doubt
The choice today is Laparoscopic treatment of unruptured ectopic
pregnancy.
Careful monitoring and proper counselling of patients is
mandatory.

66. THANK YOU