Ectopic Pregnancy

Dr. Jafrin Yasmin Choudhury

Assistant Professor
Department of Obstetric and Gynecology
An ectopic pregnancy is one in which the fertilized
ovum is implanted and develops outside the
normal endometrial cavity.
 Incidence
• The incidence is increasing dramatically in past few decades.
• 3-4% in all pregnancy.
• 1 in 300 to 1 in 150 deliveries
• There is 7-13 fold increase in subsequent pregnancy.
• Chance of intra uterine pregnancy is 50-80%
Types, according to implantation site:
 Risk Factors
• History of PID
• Contraception failure
• H/O tubal ligation
• Tubal reconstructive surgery
• Previous ectopic pregnancy
• H/O infertility
• ART
• IUD
• H/O endometriosis
 Fate of Ectopic pregnancy
• 1.Tubal mole
• 2.Tubal abortion
• 3.Tubal rupture
• 4.Tubal perforation
• Continuation of pregnancy
Clinical Features of Ectopic Pregnancy
• Acute(tubal rupture or abortion)
• Unruptured
• Sub acute(chronic or old)
 Clinical Presentation:
Acute Ectopic Pregnancy-
Symptoms—
• Abdominal pain 95%
• Amenorrhoea 80%
• Vaginal bleeding 70%
• Pregnancy symptoms 20%
• Syncope 50%
• Gastrointestinal symptoms 80%
 Classic triad of Symptoms
• Abdominal pain (100%)
• Amenorrhoea (75%)
• Vaginal bleeding (70%)
Clinical approach
• Acute ectopic pregnancy
• 30% are acute cases.
• Associated with tubal rupture, tubal abortion with massive intra
peritoneal hemorrhage.
• Profile:20-30 years
• Associated with risk factors
• Mode of onset is acute.
• symptoms
• Symptoms:
• Short period of amenorrhea 6-8 weeks
• Abdominal pain:
acute, agonizing or colicky
located in lower abdomen,
unilateral, bilateral or may be generalized.
• Shoulder tip pain 25%
• Vaginal bleeding
• Syncopal attack 10% (due to reflex vasomotor disturbances following
peritoneal irritation from haemoperitoneum)
 Signs/On examination
• Looks ill, quiet, conscious, blanched
• Pallor of varying degree.
• Features of shock
• Pulse- rapid, feeble, hypotension, extremities:cold, clammy.
• Abdomen-tens, tender, shifting dullness present.
• Cullens sign positive
• Bimanual examination: Vaginal mucosa pale
• Uterus normal size or bulky
• Extreme tenderness on cervical motion
• An ill defined, boggy and extremely tender mass felt through POD
 Chronic Ectopic Pregnancy
Symptoms:
• It can be diagnosed by high clinical suspicious
• Previous attack of acute pain from which she has recovered.
• She may have amenorrhea.
• Vaginal bleeding
• Dull pain in abdomen
• UB and Bowel complains like dysuria, frequency, or retention of urine.
• Rectal tenesmus.
O/E: Pt looks ill, varying degree of pallor.
• Slight increase of temperature.
• Features of shock are absent.

Per Abdominal Examination:

• Tenderness and muscle guard on the lower abdomen
• A mass may be felt, irregular and tender.
• PV examination: vaginal mucosa pale
• Uterus normal size
• Ill defined boggy tender mass felt through the post fornix.
 UnRuptured Ectopic Pregnancy
• Diagnosed in laparoscopy/laparotomy
• C/F: high degree of suspicion
• Delayed period
• Spotting with discomfort in lower abdomen
• P/V: uterus normal in size, firm
• Small tender mass felt in the fornix
• Investigation: TVS, Beta HCG, and Laparoscopy
 Chronic or Old Ectopic Pregnancy
• The onset is incidious. The pt had previous attacks of acute pain, from
which she had recovered or she had chronic features from the beginning.
• Short period of amenorrhoea.(6-8 weeks)
• Varying degree of lower abdominal pain.
• Vaginal bleeding: scanty,serosanguinus or dark colour.
• Sign:
• Patient looks ill.
• Pallor of variable degree.
• Pulse: persistant tachycardia even in rest.
• Features of shock absent.
• Temperature slightly raised.
• Abdominal examination: Tenderness, muscle guard
• A mass in the lower abdomen, (irregular and tender)
• Cullens sign positive(dark, bluish discoloration around umbilicus)
• P/V/E: vaginal mucosa pale,
• uterus normal/bulky,
• tenderness on cervical movement.
• an ill defined boggy and extremely tender mass, felt through the post-lat fornix
extending to POD
• P/R/E
• E/U/A
 D/D of Acute Ectopic Pregnancy
• Acute appendicitis
• Ruptured corpus luteum
• Twisted ovarian tumor
• Ruptured chocolate cyst
• Perforated peptic ulcer
 Investigations for Diagnosis
1.Blood examination:
ABO and RH typing
CBC and ESR
2.Culdocentesis: aspiration of non clotted blood, signifies ectopic pregnancy
3.B HCG: lower concentration, compared to intra uterine pregnancy
failed doubling time, in 2 days
4.Sonography:TVS,more informative
absence of IUP with positive pg test
endometrial cavity: trilaminar endometrial pattern(pseudo
gestational sac, decidual cyst)
fluid in POD
adnexal mass separated from ovary
4.Colour Doppler sonography: ring of fire pattern
increase uterine blood supply.
5.Serum progesterone:>25ng/ml—IUP
<15ng/ml—ectopic pg
<5ng/ml—ectopic/abnormal IUP non viable
6.Laparoscopy
7.laparotomy
 Management
Depends on individualization and clinical presentation
A) Acute Ectopic Pregnancy
Principle : Resucitation and laparotomy side by side.
Antishock treatment: wide bore IV line, crystalloid solution
draw 2 cc blood for blood grouping and typing
CBC
Colloid for volume replacement
Folly's catheterization
Indication of laparotomy:
hemodynamically unstable
laparoscopy contraindicated
evidence of rupture
Principle of laparotomy: quick in and quick out
Mx (cont.)

Principle of laparotomy: quick in and quick out

Rapid exploration of abdominal cavity

Salpingectomy is definitive surgery

Blood transfusion.

Ipsilateral ovary and its vascularity preserved.

Management of Unruptured Tubal Pregnancy
-Expectant
-Conservative
Medical
Surgical
-Ablative
 Medical Management
Prerequisite for medical Mx-
The patient must be
(i) Hemodynamically stable
(ii) Serum hCG level should be less than 3000 IU/L
(iii) Tubal diameter should be less than 4cm without any fetal
cardiac activity
(iv) There should be no intra abdominal hemorrhage.
Medical Mx (cont.)
The drugs commonly used are -
1.Methotraxate
2.Potassium chloride
3.PGF2a
4.Hyperosmolar glucose or actinomycin
For systemic therapy-
a single dose of methotrexate is given intra muscularly
Conservative surgery
Indication-
(a) Cases not fulfilling the criteria for medical therapy
(b) Cases where BhCG levels are not decreasing despite medical
therapy
(c) Persistent fetal cardiac activity
Conservative surgery (cont.)
Can be done laparoscopically or by micro-surgical laparotomy-
(1) Linear salpingotomy
(2) Segmental resection
(3) Fimbrial expression
(4) Salpingectomy