ECTOPIC PREGNANCY

BY N.M.S
DEFINITIONS
• A PREGNANCY THAT OCCURS OUTSIDE THE UTERINE
CAVITY.
• IMPLANTATION OF A CONCEPTUS OUTSIDE THE UTERUS
• IMPLANTATION AND DEVELOPMENT OF AN EMBRYO
OUTSIDE THE UTERINE CAVITY
• IMPLANTATION OF PRODUCTS OF CONCEPTION AT A SITE
OTHER THAN THE ENDOMETRIAL CAVITY.
TYPES: IS BASED ON SITE OF IMPLANTATION
NOTE:
• The common site of ectopic pregnancy is the
fallopian tube(tubal ectopic) and occurs mostly in
the ampulla region as the most common region.
• The most non tubal site of ectopic pregnancy is the
ovary
• The most least site of ectopic pregnancy is a
ceasarean scar/ cervical
RISK FACTORS
• Previous ectopic pregnancy
• Smoking
• Contraceptives(progesterone only pils,iucd,postcoital estrogen
preparartions)
• History of infertility
• Endometriosis
• Pelvic infections(pid,nonspecific salpingitis)
• Genital TB
• Multiple sexual partners
• Low socioeconomic status
• Tubal surgery
• Inutero exposure to DES
CLINICAL FEATURES
• Are of three distinct types namely:
• ACUTE(RUPTURED)
• UNRUPTURED
• SUBACUTE(CHRONIC OR OLD)
HISTORY AND EXAMINATION
• HISTORY/SYMPTOMS
• A.) ACUTE(RUPTURED):
• Acute in onset
• mostly limited to nulliparity or following long period of infertility
• presents with a classical triad of:
• ABDOMINAL PAIN-located at lower abdomen, may be
unilateral/bilateral/generalized, is acute, colicky and agonizing.
• AMENORRHEA-with short period of 6-8weeks, there may be
period or history of vaginal spotting. may even be absent.
• VAGINAL BLEEDING- maybe slight and continous, expulsion of
decidual cast maybe there.
• other symptoms: vomiting, fainting attck.
• Examination/signs of ACUTE(RUPTURED):
• Danforth sign-pain referred to the shoulder during inspiration due to hemoperitoneum
and diaphragmatic irritation giving a shoulder tip pain.
• Cullen sign- hemorrhagic discoloration of the umbilical area due to intraperitoneal
hemorrhage.
• General exam- patient is conscious, perspires and looks blanched, pallor is also
present
• Abdominal exam- tense, timid and tender lower abdomen, shifting dullness is
present, distended bowels, absence of masseses as well as absence of guarding.
• Pelvic exam- blanched vaginal mucosa,normal or slightly bulky uterus size, extreme
tenderness on fornix palpation or on movement of cervix, no mass is felt through the
fornix and uterus float as if on water.
• Features of shock- feeble and rapid pulse, hypotension and cold extremities.
• B.) UNRUPTURED:
• Symptoms - Presence of delayed period or
spotting with features suggestive of pregnancy,
uneasiness on one side of the flank, maybe
continous or colicky at times.
• Examination/signs:
• Bimanual exam- small pulsatile and well
circumscribed tender mass maybe felt through one
fornix separated from the uterus.
C.)SUBACUTE(CHRONIC OR OLD)
SUMMARY
INVESTIGTIONS
• NOTE:HIGH INDEX OF SUSPICION IS PARAMOUNT.
• Urine pregnancy test
• Estimation of serum BETA HCG: doubles every 48 hrs in a normally sited
pregnancy. failure to double is suggestive, this follows the discriminatory zone( serum
concentration on which gestational sac can be seen, 1500miul/ml on
transvaginal sonography(TVS) and 5000-6000miul/ml on transabdominal
sonography(TAS))
• Culdocentesis: to exclude hemoperitoneum in the admission room. positive in
ruptured ectopic and negative in unruptured ectopic.
• Sonography: TVS is more diagnostic. diagnostic features are, empty uterine cavity/
thickened endometrial cavity(sometimes), pseudosac formation, a complete
inhomogenous adnexal mass separate to the with an empty gestational sac(tubal
ring or beagle sign), ring of fire appearance on color doppler.
• Serum progesterone- levels >25ng/ml suggestive of intrauterine pregnancy, levels
<5ng/ml suggestive of ectopic or abnormal intrauterine pregncy.
• Laparoscopy: gold standard, can be diagnostic and curative in
unruptured ectopic.
• Laparotomy
• PSEUDOGESTATIONAL SAC
• RING OF FIRE • BEAGLE SIGN
CULDOCENTESIS
DIFFERENTIAL DIAGNOSIS
• SPONTANEOUS ABORTION
• RUPTURED CORPUS LEUTEUM CYST
• TUBO OVARIAN ABSCESS
• OVARIAN TORSION
• ACUTE APPENDICITIS
• PYELONEPHRITIS
• RENAL/ URETERIC CALCULI
• SALPINGITIS
MANAGEMENT
• Can be:
• EXPECTANT
• MEDICAL-
• This is employed for unruptured ectopic.
• local injections of prostaglandins, potassium chloride, methotraxate.
• systemic injections of methotraxate
• SURGICAL- LAPAROSCOPY OR LAPAROTOMY
• Salpingectomy-removal of uterine tube
• Salpingotomy-opening the tube, removing the pregnancy and closing
• Sapingostomy-leaving the tube open, after removing the
pregnancy.
• Operative laparoscopy for unruptured ampullary or infundibular
pregnancy > 3cm diameter with little or no bleeding.
MANAGEMENT OF ACUTE SITUATIONS
• Iv access and resuscitan with fluids
• Group and X-match
• full blood count
• if in shock, emergency laparotomy
• priorities to stop hemorrhage and prevent bleeding
• conservative surgery is less likely to be possible under
these circumstances.
REFERENCES
• ESSENTIALS OF OBSTETRICS (2ND EDITION) BY LAKSHMI
SESHADRI.2019.
• DC DUTTAS OBSTETRICS BY HILAR KONAR(7TH
EDITION).2013.
• LIVINGSTONE PROTOCOL AND MANAGEMENT(2019)
•
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