it tells about the ectopic pregnancy and the detail explanation of the tubal pregnancy

2. DEFINITION
 “ An ectopic pregnancy is one in which the fertilized
ovum is implanted and develops outside the normal
uterine cavity.”
 An ectopic pregnancy is one where implantation
occurs at site other than the uterine cavity.

3. IMPLANTATION SITES
 Extra uterine Uterine
Tubal Ovarian Abdominal Cervical Angular Cornual
Ampulla Isthmus Infundibulum Primary Secondary
(rare)
Interstitial
Intraperitoneal Extra-peritoneal
Broad ligament (rare)

5. RISK FACTORS OF ECTOPIC PREGNANCY
1. Alteration of normal function of uterine tube in
transporting the gametes contributes to the risk of
ectopic pregnancy
2. Previous ectopic pregnancy / induced abortion
3. Previous surgery on the uterine tube (Tubal Ligation)
4. History of PID
5. Contraception failure
6. Tubal reconstructive surgery
7. History of infertility
8. ART - if the tube are patent but damaged(assisted
reproductive technique)

6. ETIOLOGY
 A. Factors delaying and preventing migration of
fertilized ovum
Pelvic inflammatory disease (high risk of preg)
loss of cilia of lining at the epithelium
 Narrowing of the tubal lumen
 Formation of the pocket due to adhesions
 Peri- tubal adhesion results in kinking
B… `Iatrogenic
Contraceptive failure.
C. Tubal surgery
D Previous ectopic pregnancy

7. ETIOLOGY – continue---
E. Prior induces abortion
F. Developmental defect of the tube
 i.e. -Elongation
Diverticula,
G. Distortion of the tube (pull or twist, out of shape)
H. Tubal Spasm

8. ,

9. TUBAL PREGNANCY
Is a pregnancy that grows
in the fallopian tube, not
the uterus
If the pregnancy continues
and the tube ruptures,
there may be life-
threatening intraabdominal
bleeding
Even with the modern
practice of medicine, the
rupture of the tubal
ectopic pregnancy is still
one of the leading causes
of gynecological deaths

10. IN TUBAL PRGNANCY

11. TYPES
 Acute/ruptured (obst. emergency)
 Unruptured
 Chronic/subacute

12. CLINICAL PRESENTATION (ruptured)
 Amenorrhea-
of short period 6-8 weeks or a delayed period or slight spotting
 Abdominal pain
pain is colicky, in between colicky pain patient remains in agony
Causes of pain
Distention of tube by blood
Peritoneal irritation
Heamoperitoneum-shoulder pain/epigastric pain
 Vaginal bleeding- slight, dark coloured
 Nausea, vomiting, fainting attacks

13. ON EXAMINATION
 Tachycardia
 Hypotension
 Pallor
 P/A-tenderness
an irregular and tender mass in the lower abdomen
 Cullen's sign can indicate a ruptured ectopic pregnancy.
(Cullen's sign is blue-black bruising of the area around the
umbilicus. )

14. UNRUPTURED
CLINICAL SYMPTOMS
 Delayed period or spotting
 Uneasiness on one side of the flank, continuous
colicky in nature
SIGNS
 Uterus slightly smaller than the period of
amenorrhoea
 A small pulsatile, tender, well circumscribed mass felt
in one fornix separated from the uterus.

15. CHRONIC
CLINICAL SYMPTOMS
 Amenorrhea of 6-8 weeks
 Lower abdominal pain
 Vaginal bleeding
OTHER
 Bladder irritation, dysuria, frequency, retention of
urine
ON EXAMINATION
 Patient looks ill with varying degree of pallor not
proportionate to vaginal bleeding

16.  Persistent high pulse even at rest
 Features of shock are absent
 Temperature increase

17. DIAGNOSIS
 Blood examination
1. ABO and Rh grouping
2. Haemogram
 Examination of beta HCG
1. Lower concentration compared to normal intra-
uterine pregnancy
2. Doubling time in plasma fails to occur in 48 hrs
which usually double

18.  SONOGRAPHY-TVS/TAS
1.Absence of intrauterine pregnancy with positive
pregnancy test
2. Fluid in pouch of douglas
3. Adnexal mass separated from the ovary
4. G. sac/fetal pole/yolk sac/cardiac activity in the
adnexa surrounded by hyperechoic ring Bagel
sign/tubal ring sign

19.  Combination of beta HCG values and TVS
 Laproscopy
 Dilatation and currettage- absent ch villi
 Serum progesterone-less than 5 ng
 Culdocentesis-aspiration of non clotting blood
signifies intraperitoneal bleeding

20. MANAGEMENT OF ACUTE EP
 RESUSCITATION LAPROTOMY
1. Anti shock treatment
2. Arrangement of blood transfusion
 LAPROTOMY-quick in and quick out
1. Haemodynamically unstable pt.
Laproscopy contraindicated
2. Evidence of rupture
 SALPINGECTOMY-definitive treatment
 OOPHERECTOMY only if ovary is damaged beyond
salvage
 SUBTOTAL HYSTERECTOMY-Ruptured interstitial
pregnancy

21. CHRONIC
 Laparotomy
 A pelvic haematocele found, blood clots removed, and
salpingectomy done.

22. MANAGEMENT IN UNRUPTURED TUBAL PREGNANCY
Expectant management
Indications- decreased hCG titter
Ectopic mass < 4cm
No evidence of bleeding, rupture
Surgical----- Salpingectomy
Medical-- Chemotherapeutic agents-systemic, local
Drugs- for Salpingocentesis- Methotrexate IM., KCL
hyper osmolar glucose,
actinomycin

23. CT-- MANAGEMENT
 Conservative Surgery
 Done by–
 Laparoscopically
Microsurgical laprotomy
1. Linear Salpingostomy
2. Linear Salpingotomy
3. Segmental resection
4. Plucking out from distal tube
Salpingectomy is done when whole tube is damaged.

24. ABDOMINAL PREGNANCY
Primary–
 Implantation of the ovum on the peritoneum is rare
Secondary—
 Abdominal pregnancy is almost always secondary
the primary site- tube, ovary, uterus.
Symptoms-
pain in lower abdomen, vaginal bleeding, nausea and
vomiting, constipation, increased fetal movement
Sign:- braxton –Hicks contraction is absent.

25. Abdominal pregnancy—
signs in advanced pregnancy
 Braxton-hicks contraction is absent in abdominal
pregnancy
 Fetal parts are felt easily
 Abdominal high position of fetus found in intraperitoneal
pregnancy
 Diagnosis
 Sonography
 X-ray examination shows—
 Abdominal higher of fetus
 Absence of uterine shadow
 Gas shadow
 Lateral x-ray –fetal skeleton shadow with maternal spine
shadow

26. Management– abdominal pregnancy
 Risks of continuation of abdominal pregnancy are.
 Catastrophic Hemorrhage
 Fetal death
 Increased Fetal malformation
 Increased 50 % neonatal loss
 Patient should be in the hospital under observation
 Laprotomy
 Removal of entire sac, fetus, placenta
 Placental activity to be monitored BhCG and
ultrasound

27. CONCLUSION
 Patient with ectopic pregnancy required prompt
medical services ,
 Early diagnosis and treatment is prime importance
 And must be treated as early as possible.

28. Methotrexate Treatment
 Anti-metabolite drug
 Inexpensive, easy to obtain, well tolerated
 Mixture containing at least 85% of folic acid antagonist "4-amino-
10-methylfolic acid„ and 25% of Leucovorum calcium (folic acid
agonist)
 The initial dose regimen
MTX (1 mg/kg IM ) or single IM dose of 50 mg/square
meter
Leukovorum (0.1 mg/kg IM )
 Don´t exceed 4 doses
 70-95% efficiency of cases treated
 Methotrexate management takes 4-6 weeks for complete
resolution of the ectopic pregnancy

29. Complications of Methotrexate
 Bone marrow suppression
 Acute and chronic hepatotoxicity transient elevations
in serum liver transaminases
 Progressive pulmonary toxicity (pneumonitis and
pulmonary fibrosis)
 Dermatologic effects (rashes, itch, folliculitis,
photosensitivity, pigment changes, rarely alopecia)
 Renal impairment
 GI side effects (stomatitis, gastritis, diarrhoea)

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