Ectopic Pregnancy

DEFINITION
Customarily it is called extrauterine pregnancy.

It refers to the implantation of fertilized ovum on any tissue other than the mucous membrane lining the body of uterine cavity.

Classification
fallopian tube (1.ampulla 2. isthmus 3.infundibulum 4.interstitial)
termed as tubal pregnancy 95 percent of all ectopic pregnancy the ampulla is the commonest site the scale is 60%. cervix ovary abdominal cavity broad ligament

INCIDENCE
In China the incidence is about 1 case to
56~93 mature intrauterine pregnancy.

In Britain is 1 case to 150. In some countries where pelvic infection is

common, the incidence is much higher. It is 1 in 28.

ETIOLOGY
1.Chronic salpingitis 2.Developmental or functional abnormalities of the tube 3.Use of intrauterine contraceptive devices (IUD) 4.Previous operation on the tube 5.Pelvic endometriosis 6.Transmigration of ovum

PATHOLOGY
1.Termination of the tubal pregnancy 2.Uterus

Termination of the tubal pregnancy

the tube has no decidua and the muscular wall of the tube is thin, so the embryo is not suitable to be growing in tube. (three layer: serosa, muscle, and mucosa) A tubal pregnancy may terminate in follow ways: (1) Tubal abortion (2) Rupture of tubal pregnancy (3) Abdominal pregnancy isthums rupture occurs early at about 6 weeks ampulla rupture at 8~12 weeks interstitial rupture at 3~4 months

Uterus
It is slight enlargement and softening. Endometrium is altered to become a decidue. If embryo dies, endometrium may be passed
(or is shed in fragments), it is called decidual cast. The patients have some external bleeding.

CLINICAL FEATURE
Amenorrhea Abdominal pain Symptoms Vaginal bleeding Syncope Shock General condition Signs Abdominal examination Pelvic examination

Amenorrhea
Usually The A
patients have a menopause about 6~8 weeks except interstitial pregnancy. absence of missed menstrual period by no means rules out tubal pregnancy. history of amenorrhea is not obtained in 20 percent of cases.

Abdominal pain
Severe pain is due to sudden rupture of tube. In the presence of hemoperitoneum, pain from
diaphragmatic irritation may be experienced.

Appreciable blood in the peritoneal cavity may

lead to a degree of peritoneal irritation and varying degrees of discomfort.

Vaginal bleeding
Slight
dark brownish bleeding may be intermittent or continuous.

Decidual

cast may be expelled in some cases.

Syncope and shock

This
occurs due to abdominal pain and severe bleeding.

Profuse

intraperitoneal heamorrhage and severe pain will result in sudden shock and collapse of the woman.

General condition
Skin is pallor. Pulse is rapid. Blood pressure is low when shock occurs. The
temperature may be normal or even low after acutehemorrhage. When temperature up to 38, it perhaps related to hemoperitoneam. Higher temperature usually shows infection.

Abdominal examination
Signs of abdominal palpation: (when tubal rupture occurs)

shifting dullness is positive

extremely tender and distention pelvic mass (soft ,elastic, or firm )

Pelvic examination
---speculum & bimanual examination

Vagina: the posterior fornix bulge because of

blood in the cul-de-sac Cervix: marked pain on motion Uterus: slight enlargement and softening Adnexa: A tender, boggy mass may be felt on one side of the uterus In existence of interstitial pregnancy, the uterine size corresponds to the gestational age, but is asymmetrical. The feature of rupture looks like rupture of uterus.

DIAGNOSIS
It
based on history, symptoms, signs and supplementary examination.

The classic trail of amenorrhea, vaginal

bleeding and pain occurs in only 25% of cases.

DIAGNOSIS
There are five common supplementary examinations: Culdocentesis Pregnancy test Sonography Laparoscopy Endomentrial curettage

Culdocentesis
It is used to diagnose the presence of hemoperitoneum.
As the cervix is pulled toward the symphysis with a tenaculum, a long 18-gauge needle is inserted through the posterior vaginal fornix into the cul-de-sac. Fluid can be aspirated. If fluid is dark blood and contain small clots or blood is non-coagulable, the diagnosis may be confirmed.

Pregnancy test
Three methods for testing human chorionic gonadotropin ( hCG, secreting by the trophoblastic cells ) : agglutination inhibition assays (older method) enzyme-linked immunosorbent assay (ELISA) radioimmunoassay (RIA)

Pregnancy test
Pregnancy tests based on hCG are often misleading (false-positive and falsenegative) Specific radioimmunoassays for beta subunit of hCG (-hCG) will minimize the likelihood of false-negative tests.

Sonography
The effect of B-ultrasonic examination is
less than HCG determination in early diagnosis. But it is significant in making a diagnosis of interstitial diagnosis.

It is useful in distinguishing ectopic from

early intra-uterine pregnancy in which a gestational ring can be dectected .

Laparoscopy
It It It
is more time-consuming but more reliable. is very useful in the management of patients suspected to having an ectopic pregnancy. more recently has been used for operative management.

Endometrial curettage
Its only decidua without chrorionic villi.

DIFFERENTIAL DIAGNOSIS
Tubal pregnancy differentiates with:

abortion of intrauterine pregnancy acute appendicitis rupture of luteum or follicular cyst salpingitis

MANAGEMENT
Surgical treatment. Therapy
Chinese medicine. of combining traditional medicines and western

Surgical treatment
It is the major therapy of tubal pregnancy. Once diagnosis is made, immediate laparotomy is
required. Salpingectomy will permit. In interstitial ectopic pregnancy, either before or after rupture, operation is required. Conservative surgical treatment is done in young woman who wants to labor another baby. Take blood transfusion when patient is in shock.

Therapy of combining traditional Chinese medicines and western medicine Methotrexate is effective in the management of gestational trophoblastic disease and may have a place in the treatment of selected cases of ectopic pregnancy.