Content

on
Ectopic Pregnancy

Submitted to
Madam M. Roy ,
Senior Lecturer
Govt College of Nursing ,Burdwan

Submitted by
Anupama Jash ,
M.Sc Nursing student , 2nd Year,
Govt College of Nursing ,Burdwan

INTRODUCTION:
 st
Maternal mortality rate is the indicator of health status of a country. The leading cause of 1 trimester
maternal death and Second leading cause of all maternal deaths is ectopic pregnancy. Ectopic pregnancy
is an emergency condition which gives very little time to take decision. Prompt and quick diagnosis can
save life of the mother.

ANNOUNCEMENT OF THE TOPIC: ‘ ECTOPIC PREGNANCY’

DEFINITION: An ectopic pregnancy is one in which the fertilized ovum is implanted and develops
outside the normal endometrial cavity. Derived from ektopos- out of place

CLASSIFICATION ACCORDING TO SITE OF IMPLANTATION:

Site of implantation

Extra Uterine Uterine

Tubal Ovarian Abdominal Cervical Angular Cornual Caesarean scar

Ampulla Isthmus Infundibulam Interstitial

Primary Secondary

Intraperitoneal Extra peritoneal (Broad ligament)

RISK FACTOR FOR ECTOPIC PREGNANCY:

Any of the following alteration of the normal function of the uterine tube in transporting the
gamates contributes to the risk of ectopic pregnancy.

 Previous ectopic pregnancy

 Previous surgery on the uterine tube
 Exposure to diethylstilbosterol in utero
 Congenital abnormalities of the tube
 Previous infection including Chlamydia, gonorrhea and pelvic inflammatory disease
 Use of intrauterine contraceptive device
 Assisted reproductive technique

TUBAL PREGNANCY:

INCIDENCE: Varies from 1 in 300 to 1 in 150 deliveries

st
 Leading cause of 1 trimester maternal death,Second leading cause of all maternal deaths

ETIOLOGY:

 Salpingitis and Pelvic inflammatory Disease

 Iatrogenic:
 I) Contraceptive failure – a)IUD

b) Sterilization operation

c) Use of progestin only pill

II) Tubal Surgery

III) Intra pelvic adhesions following pelvic surgery:

IV) ART

V) Others: a) Previous ectopic pregnancy

b) Prior induced abortion

c) Developmental defect of the tube-elongation, diverticulum, accessory ostia

PATHOPHYSIOLOGY OF TUBAL PREGNANCY

 In uterine pregnancy the blastocyst embeds in the decidua and the trophoblast erodes the maternal
tissue anchoring the developing embryo.
 In tubal cyesis, the blastocyst rapidly erodes the epithelium and become attached to the muscle
layer. It grows and expand within the wall, distending the tube.
 Maternal vessels are exposed and the pressure caused by the resultant blood flow can destroy the
embryo.
 The uterus increases in size and changes associated with early pregnancy occur in the body
Degrees of change take place within the endometrium, under influence of hormones.

CLINICAL FEATURE:

Clinically three distinct type are described:

 Acute
 Unruptured
 Subacute

Acute Ectopic: Less common(30%) and associated with tubal rupture or tubal abortion with massive intra
peritoneal haemorrhage.

Patient profile:
  Maximum incidence between age 20 to 30 yrs
 Nulliparity and long period of infertility

Mode of onset: The onset is acute

Symptoms: Triad of symptom

Abdominal pain

Typical sign…………………………

Amenorrhea Vaginal bleeding

Amenorrhea: Short period of 6-8 weeks – delayed period or history of vaginal spotting

Abdominal pain:

 Acute , agonizing, colicky

 Pain is located at peritoneum-unilateral, bilateral or may be generalized
 Referred pain at shoulder due to diaphragmatic irritation from haemoperitoneum

Vaginal Bleeding: May be slight and continuous

Vomiting , Fainting attack: Syncopal attack( 10%) is due to reflex vasomotor disturbance

Signs:

 General look: conscious, perspires and blanched

 Pallor: Severe and proportionate to the amount of internal haemorrhage
 Features of shock: pulse rapid and feeble, hypotension, cold clammy extremities

Abdominal examination: tensed, tumid, tender. No mass is usually felt, shifting dullness present, bowels
may be distended. Muscle guard usually absent.

Pelvic Examination: i) Vaginal mucosa- blanched white

ii) Uterus seems normal in size or slightly bulky

iii) Extreme tenderness on fornix palpation or on movement of cervix

 iv)No mass felt through the fornix

v) The uterus float as if in water.

Unruptured tubal pregnancy:

Symptom:

 Presence of delayed period or spotting with features suggestive of pregnancy

 Uneasiness on one side of the flank which is continuous or at times colicky in nature.

Signs: Bimanual examination :i) Uterus is soft showing evidence of early pregnancy

ii) A pulsatile tender mass may be felt

Investigations:

 TVS
 Radioaminoassay of β hCG
 Laparoscopy

CHRONIC OR OLD ECTOPIC:

Onset is insidious. Patient had previous attack of acute pain from which she had recovered or she had
chronic features from the beginning

Symptoms:

 Amenorrhea: Short period of 6-8 weeks – delayed period or history of vaginal spotting
 Lower abdominal pain : Start as acute and gradually becomes dull or colicky in nature.
 Vaginal bleeding: Scanty, sanguinous or dark coloured and continuous in nature
 Other symptom: Dysuria, frequency of micturation, retention of urine,rise of temperature due to
infection

Maternal death Outcome of tubal pregnancy:

 Tubal abortion: The developing conceptus separates and is expelled through the fimbriated end of
the uterine tube.
 Tubal mole: Bleeding around the embryo results in its death. The blood clots around the conceptus
enclosing it.Products are retained in the tube and may need to be removed.
 Tubal rupture: The wall is distended by pregnancy and penetrated by the trophoblast to such an
extent that it rupture.This can be gradual or occur as an acute episode
 Abdomonal pregnancy

DIAGNOSIS OF ECTOPIC PREGNANCY

Acute ectopic:
  Classical history of acute abdominal pain with fainting attack and collapse associated with feature
of intra abdominal haemorrhage in a women of child bearing age
 Estimation of Haemoglobin and blood grouping.

Sub acute ectopic:

 History of vaginal bleeding followed by pain

 Bilateral mass on internal examination.
 Blood examination-Blood grouping and typing, TC,DC,ESR( increased)
 Culdocentesis- Through a 18bguaze lumber puncture needle fitted with a syringe the posterior
fornix is punctured to gain access to the pouch of doglus-aspiration of nonclotting blood with
haematocrit > 15% signifies ruptured ectopic pregnancy.
 Estimation of β hCG
 Sonography: Tranvaginal sonography is more informative- Absence of intrauterine pregnancy
with positive pregnancy test,fluid in pouch of doglus, cardiac motion, color Doppler sonography
identify placental shape and enhanced blood flow pattern outside the uterine cavity.
 Combination of β hCG and sonography
 Laparoscopy
 Laparotomy
 Dilatation and curettage
 Serum Progesterone- > 25ng/ml is suggestive of viable intrauterine pregnancy, < 5ng/ml suggest
ectopic pregnancy

DIFFERENTIAL DIAGNOSIS:

 Incomplete abortion
 Salpingitis
 Appendicitis
 Twisted ovarian tumour
 Ruptured chocolate cyst of the ovary
 Ruptured corpus luteum

MANAGEMENT OF ECTOPIC PREGNANCY

ACUTE:

Principle: The principle in the management of of acute ectopic is resuscitation and laparotomy.

Anti- shock treatment:

 Ringer’s solution( crystalloid) is started

 Sample for grouping and cross matching
 Blood transfusion and volume replacement with colloid
 Laparotomy – indications are patient is haemodynamically unstable, evidence of rupture
CHRONIC ECTOPIC:

 Emergency admission
 Investigation and laparotomy.

MANAGEMENT OF UNRUPTURED TUBAL PREGNANCY

Expectant management: indications are- i) initial serum

Conservative management

Medical management- Methotrexate (50mg/M2), potassium chloride, prostaglandin(PGF2α), Hyperosmolar

glucose or actinomycin . The patient must be hemodynamically stable ii) Serum hCG level should be <
3000IU/L iii) tubal diameter should be less than 4 cm without any fetal cardiac activity.

 Patient is monitored by measuring serum of β hCG . if it is< 10mIU /ml. A second dose of MTX
50 mg/M2 is given on day 7. A variable dose of Methotrexate- 1mg/kg IM on D 1,3,5,7 and
Leukovorin 0.1mg/kg IM on D2,4,6,8. Serum β hCG is monitored weekly until < 5.0 mIU/ml

Conservative surgery:

 Linear salpingostomy

 Linear salpinostomy
 Segmental resection
 Fimbrial expression

SCHEME OF MANAGEMENT OF TUBAL ECTOPIC PREGNANCY

o Detailed history, evaluation of high risk factor and examination

 o Urine- β hCG /Serum β hCG
o Ultra sound scan( transvaginal)

Some clinical feature Some clinical feature Some clinical feature

β hCG- Negative β hCG- positive β hCG- positive

Patient in shock/unstable haemodynamically

Repeat β hCG in 1 week Ultra sonography Resuscitation and laparotomy

Negative

Pregnancy excluded Ruptured tubal ectopic pregnancy

Intra uterine sac Empty uterine cavity

With adrenal mass

Determine viability Laparoscopy

 β hCG increase>68% in 48 hrs

 Sr.progesterone> 25ng/ml Unruptured tubal pregnancy
 Rpt USG

Expectant Medical Surgery

Direct local Systemic

USG guided laparoscopy MTX ,Actinomycin

Conservative Extirpative

ABDOMINAL PREGNANCY:
It is rare , fetal development may take place in the abdominal cavity and follows early rupture or abortion
of tubal pregnancy. The placenta remain attached to the uterine tube. Fetus develop within the peritoneal
cavity.

Symptoms:

 pain lower abdomen

 exaggerated minor ailments

Sign:

 Absent Braxton hicks contraction

 Easily felt fetal parts
 Abnormal high position of the fetus

Management: Laparotomy irrespective of period of pregnancy

OVARIAN PREGNANCY: Salpingo oophorectomy is the definite surgery

CORNUAL PREGNANCY: Pregnancy occurring in rudimentary horn of a bicornuate uterus

CERVICAL PREGNANCY: Implantation occur in the cervical canal at or below the internal os.

PROGNOSIS OF ECTOPIC PREGNANCY

Early diagnosis, adequate blood replacement and surgery even in desparately ill patient can reduce
maternal mortality 0.05%

Chance of recurrent ectopic- 1 in 10

One-third of women who have had one ectopic pregnancy are later able to have a baby. A repeated
ectopic pregnancy may occur in one-third of women. Some women do not become pregnant again.

The likelihood of a successful pregnancy after an ectopic pregnancy depends on:

 The woman's age

 Whether she has already had children
 Why the first ectopic pregnancy occurred

how long to wait after an ectopic pregnancy before trying to conceive again? Some doctors suggest
waiting 3 to 6 months.

CONCLUSION:Most women who have an ectopic pregnancy have normal pregnancies and births in
the future, even if a fallopian tube was removed. If the ectopic pregnancy was caused by a treatable
illness, such as a sexually transmitted disease, getting treated for it can improve the chances of a
successful pregnancy. Counseling or pregnancy loss support groups can help the woman and her partner
cope. Ask your doctor about
REFERENCES:

1. Dutta D. C(2011),Text book of Obstetrics including Perinatology,7 th edition, New central

book agency(p) Ltd, 148-149.

2. Cooper M.A and Fraser D.M , Myles Text book forMidwives ,14 th edition,Elsevier,

3. Dawn CS , Text book of Gynaecology 14 th edition, Dawn book stall ,Kolkata

4. www.authorstream.com/.../ravimohanv-779718-management-of-tubal-ec...
Share Jan 16, 2011 - Management of Tubal Ectopic Pregnan

5. www.mef.unizg.hr/meddb/slike/pisac79/file3214p79

6. www.slideshare.net/drmcbansal/ectopic-pregnancy