ECTOPIC PREGNANCY

Content
 Definition
 Types/sites
 Causes
 Signs and symptoms
 Differential diagnosis for ruptured ectopic
pregnancy
 Investigations
 Management
 Complications
Definition
 An ectopic pregnancy refers to
implantation of a zygote outside the
uterine cavity.
 Itoccurs when the conceptus implants
either outside the uterus or in an abnormal
position within the uterus
Types (sites)
I. Tubal pregnancy- 90%
 Ampulla- most common site (55%)
 Fimbria- uncommon site (12%)
 Isthmus-most dangerous, tubal rupture at about 4-5
weeks (25%)
 The interstitial part of the tube (2%)
II. Non-tubal (other sites)
 Abdominal- on the large intestine, in pouch of Douglas
 Ovary (0.5%)
 Cervical canal
Causes
 Previous inflammatory process in the tube
(salpingitis) or acute PID
 Peritoneal adhesions secondary to previous
surgery, pelvic infection
 Endometriosis
 Congenital anatomical irregularity- diverticula of
the uterine tube
 Previous tubal surgery
 IUCD use
 Previous ectopic pregnancy
Pathophysiology
 Classically,the pregnancy is initially
indistinguishable from an intrauterine
pregnancy. The patient may be
amenorrheic, may feel pregnant & the
pregnancy test will be positive. But
eventually the pregnancy will begin to fail
through over distention of the tube &
erosion into blood vessels.
Cont’d
 Atthis point the placenta & corpus luteum
begin to fail, hormone levels begin to drop.
The endometrium of the pregnancy begins
to slough & bleeding occurs.
 Occasionallythe decidua sloughs in one
large piece known as a decidua cast.
 HCG will plateau or decline.
Signs and symptoms

Before rupture:
 Amenorrhea for 2-3 months
 Vague lower abdominal pain
A slightly enlarged uterus or a mass on one
side of the uterus
Cont’d
After acute type of rupture:
 Sudden onset of lower abdominal pain
 Vomiting and fainting/dizziness
 Vaginal bleeding
 Pain at tip of the shoulder indicative of
free blood in the abdominal cavity causing
irritation of diaphragm
Cont’d
After chronic leaking rupture:
 Abdominal uneasiness
 Pain
 Occasional fainting
 Slight bleeding
Differential diagnoses for ruptured
ectopic pregnancy
 Acute PID
 Perforated peptic ulcer
 Fulminating appendicitis
 Torsion of the pedicle of an ovarian cyst
 Acute pyelonephritis
 Rupture of a corpus luteum with
intraperitoneal hemorrhage
General exam
 Includes
a record of pulse rate & blood
pressure.
 Speculum or bimanual exam must be
performed in an environment where
facilities for resuscitation are available as
this examination may provoke the rupture
of the tube.
Investigations
 Laparoscopy & uterine curettage; absence/
presence of placental villi in the curettage.
 Culdocentesis-To exclude hemoperitoneum; not
useful in detecting an early ectopic pregnancy.
 Transvaginal U/S; presence/ absence of an
intrauterine gestational sac
 Visualizationof a gestational sac & an embryo
with a detectable heart beat outside the uterus is
proof of ectopic pregnancy.
Outcomes
 Tubalabortion-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 clots around the
conceptus enclose it. Products are retained
in the tube & may need to be removed.
Cont’d
 Tubalrupture-Wall is distended by
pregnancy and penetrated by the
trophoblast to such an extent that it
ruptures. This can be gradual or occur as an
acute episode.
 Abdominal pregnancy- Ectopic gestation in
which the fertilized ovum embeds in the
abdominal cavity.
 Maternal death
Management
 Depends on clinical presentation and
patient choice
 Admitall cases of suspected ectopic
pregnancies
 StartIV fluids with saline and plasma
expander after obtaining specimen for GXM
to treat shock.
Cont’d
 Administer analgesics like morphine 10mg
or pethidine 100mg stat for the pain
 Ifin health center refer to a hospital after
resuscitation with IV fluids & where
possible with potential blood donors to
accompany the patient
 Transfuse if necessary
Cont’d
A patient with fresh rupture can be done
auto transfusion.
 Auto transfusion involves scooping blood from
the opened abdomen with a small gallipot
and pouring it through a filter made of three
or four layers of gauze into a sterile bowel or
jug containing sodium acid citrate solution
(anticoagulant) & set up on a drip.
Cont’d
 Systemic methotrexate- indicated for:
 Cornual pregnancy
 Persistent trophoblastic disease e.g.,
hydatid mole; choriocarcinoma
 Patient with one fallopian tube and
fertility desired
 Refused surgery or surgery is too risky
 Ectopic pregnancy where trophoblast is
adherent to bowel or blood vessel
Cont’d
 Surgery:
Laparoscopy is mainstay
Laparotomy- for severely compromised
patients or due to lack of endoscopic
facilities
Salpingotomy or salpingectomy
Complications
 Future tubal pregnancy in 10% of the cases
 Secondary infertility in approximately 0.5
of the patients.
 Hemorrhagic shock
 Anemia
 Pelvic adhesions and chronic pelvic pain
THE END

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