ectopic pregnancy

2. ECTOPICECTOPIC
PREGNANCYPREGNANCY

3. IntroductionIntroduction
 An ectopic pregnancy is a complication of pregnancy
in which the embryo implants outside the
uterine cavity.
 With rare exceptions, ectopic pregnancies are not
viable. Furthermore, they are dangerous for the parent,
since internal haemorrhage is a life threatening
complication.
 Most ectopic pregnancies occur in the Fallopian tube
but implantation can also occur in the cervix, ovaries,
and abdomen.
 An ectopic pregnancy is a potential medical emergency,
and, if not treated properly, can lead to death.

4. Definition
 An Ectopic Pregnancy is one in which fertilized
ovum is implanted and develops outside the
normal uterine cavity.
 Any pregnancy where the fertilized ovum gets
implanted in a site other than in the normal
uterine cavity, is called ectopic pregnancy.

5. EtiologyEtiology
 Congenital causesCongenital causes
 tubal hypoplasia
 Congenital diverticuli
 Partial stenosis
 Cilial damageCilial damage
 Acquired factorsAcquired factors
a. inflammatory:a. inflammatory:
 Salpingitis
 PID
 Infection
 Inflammation of the tubal mucosa.

6. Cont.Cont.
b. Surgical:b. Surgical:
 Recanalization of the fallopian tubeRecanalization of the fallopian tube
 D & CD & C
 D & ED & E
 SalpingectomySalpingectomy
c. others:c. others:
 Use of IUDUse of IUD
 SmokingSmoking
 endometriosisendometriosis

7. Implantation sitesite
Intra uterineIntra uterine
extra uterineextra uterine
Tubal Ovarian Abdominal cervicalTubal Ovarian Abdominal cervical
angularangular cornual
Ampulla Extra PeritoneumExtra Peritoneum
Isthmus Intra PeritoneumIntra Peritoneum
Infundibulum

8. INCIDENCE
 Recent evidence indicates that the incidence ofRecent evidence indicates that the incidence of
ectopic pregnancy has been rising in manyectopic pregnancy has been rising in many
countries.countries.
 USA- 5 fold:USA- 5 fold: UK- 2 foldUK- 2 fold
 India -India - 1 in 100 deliveries1 in 100 deliveries
 Recurrence rateRecurrence rate
15% after 1 ectopic pregnancy15% after 1 ectopic pregnancy
25 % after 2 ectopic pregnancies25 % after 2 ectopic pregnancies

9. Risk FactorRisk Factor
 Tubal corrective surgery
 Tubal sterilization
 Previous ectopic pregnancy
 Intrauterine device
 Documented tubal pathology
 Moderate Risk Infertility
 Previous genital infection
 Slight Risk Previous pelvic or abdominal surgery
 Smoking

10. classificationclassification
 TubalTubal
 Non-tubalNon-tubal
 HeterotopicHeterotopic
 PersistentPersistent

11. Signs & symptomsSigns & symptoms
 on examination:on examination:
Patient lies quite, conscious & pallor
 Tachycardia
 Hypotension
Features of shock may be present
 Tenderness / Guarding / Rigidity
find on abdomen
 A mass felt in lower abdomen.

12. Cont.Cont.
 Per vaginal examination reveals:Per vaginal examination reveals:
 Cx Movement Tenderness
 Fornixial Tenderness
 abdominal pain acute or colicky.
Located in lower abdomen.
 Bleeding slight, dark& continues.
 nausea, vomiting, faintaining
 pain while urinating

13. Differential DiagnosisDifferential Diagnosis
 Acute PID
 Acute Appendicitis
 Rupture corpus luteal cyst
 Twisted ovarian tumour

14. DiagnosisDiagnosis
 Routine Blood Investigations
 Cullen's sign
 Culdocentesis
 Ultrasonography
 Laparoscopy
 Laprotomy

15. EARLY DIAGNOSISEARLY DIAGNOSIS
At 4-5 weeks:At 4-5 weeks:
 TVS can visualize a G-sacTVS can visualize a G-sac
 serum beta HCG levels are > 1600 mIU/mlserum beta HCG levels are > 1600 mIU/ml
 When Beta HCG levels are greater than aboveWhen Beta HCG levels are greater than above
levels and there is an empty uterine cavity onlevels and there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.TVS, ectopic pregnancy can be suspected.
 when the value of Beta HCG does not doublewhen the value of Beta HCG does not double
in 48 hrs, ectopic pregnancy is suggestivein 48 hrs, ectopic pregnancy is suggestive

16. EARLY DIAGNOSISEARLY DIAGNOSIS
After 5 weeksAfter 5 weeks
 tubal ring by 6 wks.tubal ring by 6 wks.
 After 5 mm D : as a complete sonoluscent sac with theAfter 5 mm D : as a complete sonoluscent sac with the
yolksac & embryonic pole with or without fetal heartyolksac & embryonic pole with or without fetal heart
activity.activity.
 Demonstration of the G sac with or without a liveDemonstration of the G sac with or without a live
embryo (Begel’s sign)-embryo (Begel’s sign)-
 Ruptured ectopic with fluid in POD and an emptyRuptured ectopic with fluid in POD and an empty
uterus.uterus.
color dopplercolor doppler,, the vascular colour in a characteristicthe vascular colour in a characteristic
placental shape fire pattern can be seen outside theplacental shape fire pattern can be seen outside the
uterine cavity while the uterine cavity is cold in respectuterine cavity while the uterine cavity is cold in respect
to blood flow.to blood flow.

17. An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age.

19. ManagementManagement
RUPTURED ECTOPIC
 Treatment of shock
 Laprotomy
UNRUPTURED ECTOPICUNRUPTURED ECTOPIC
 Conservative ManagementConservative Management
Medical
Surgery

20. Medical managementMedical management
 Methotrexate 1 mg/kg IM terminates the growth of the
developing embryo; this may cause an abortion, or the
tissue may then be either resorbed by the woman's body or
pass with a menstrual period.a menstrual period.
 Indication:
 GA less than 6 wks
 Tubal mass is less than 3.5cm diameter
 Fetus is dead
 Contraindications include liver, kidney, or blood disease, asContraindications include liver, kidney, or blood disease, as
well as an ectopic mass > 3.5 cm.well as an ectopic mass > 3.5 cm.
MonitorMonitor
 HMG, RFT & LFT

21.  Dose – Single dose - 50 mg / m2 IM.Dose – Single dose - 50 mg / m2 IM.
Measure beta HCG levels on days 4 & 7 .Measure beta HCG levels on days 4 & 7 .
If difference is > 15% : repeat weekly until undetectableIf difference is > 15% : repeat weekly until undetectable
If Difference is < 15% : repeat 2nd dose of methotrexateIf Difference is < 15% : repeat 2nd dose of methotrexate
& begin now day 1& begin now day 1
If fetal cardiac activity present on day 7, repeat dose &If fetal cardiac activity present on day 7, repeat dose &
begin day 1.begin day 1.
Surgical treatment if beta HCG levels not decreasing or fetalSurgical treatment if beta HCG levels not decreasing or fetal
cardiac activity present after 3 doses.cardiac activity present after 3 doses.

22. Surgical TreatmentSurgical Treatment
 Salpingostomy/ SalpingotomySalpingostomy/ Salpingotomy
 SalpingectomySalpingectomy
 Laprotomy in case of abdominal pregnancyLaprotomy in case of abdominal pregnancy
 LaparoscopyLaparoscopy
 Salpingo-oophrectomySalpingo-oophrectomy
 Colpotomy in case of pelvic abscess.Colpotomy in case of pelvic abscess.

23. Any questions