Presented By

Soumya Ranjan Parida

Basic B.Sc. Nursing 4th year

Sum Nursing Collge.

INTRODUCTION

DEFINITION

An Ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal uterine cavity.

IMPLANTATIONS SITES

EXTRAUTERINE UTERINE

TUBAL 95-96%

OVARIAN(0.5%)

ABDOMINAL1%

-CERVICAL-ANGULAR-CORNUAL-CAESAREAN SCAR (<1)PRIMARY SECONDARY

INTRAPERITONEAL

EXTRAPERITONEAL

AMPULLA

ISTHMUS

INFUNDIBULUM

INTERSTITIAL

INCIDENCE

I. Increased due to PID, use of IUCD, Tubal surgeries, and ART.

II.Ranges from 1:25 to 1:250

III. Average range is 1 in 100 normal pregnancies.

TUBAL PREGNANCY

• The incidence rate varies from 1 in 300 to 1 in 150 deliveries.

RISK FACTORS

i. History of PIDii. History of tubal ligationiii.Contraception failureiv.Previous ectopic pregnancyv. Tubal reconstructive surgeryvi.History of infertilityvii.ART particularly tubes are patent

and damagedviii.IUD usedix.Previous induced abortion

ETIOLOGY

FACTORS RESPONSIBLE

Factors preventing or delaying the migration of fertilized ovum

to the uterine tube

Factors facilitating nidation of the fertilization ovum in the

tubal mucosa

FACTORS DELAYING OR PREVENTING MIGRATION

IATROGENICSALPINGITIS & PID

CONTRACEPTION FAILURE.

CONTRACEPTION FAILURE.

ARTART

OTHERSOTHERS

TUBAL SURGERY

INTRAPELVIC ADHESION

Increased decidual reaction.Tubal endometriosis.

FACTORS FACILITATING NIDATION IN THE TUBE

Pictures showing TUBAL ABORTION

CLINICAL FEATURES•IN ACUTE ECTOPIC1.Less common, about 30%2.Patient profile3.Mode of onset4.Symptoms

• Short period of amenorrhea

• Abdominal pain• Vaginal bleeding• Feeling of nausea,

vomiting, fainting attack

6. On examination: •Patient is conscious, perspires and looking blanched.

•Pallor

•Features of shock

•Abdomen is tense, tumid and tender

•Bimanual examination-

Blanched white vaginal mucosa

Normal size uterus Uterus floats Extreme tenderness in

fornix palpation

• IN UNRUPTURED CASES-Symptoms- • presence of delayed period and spotting.• Colicky pain or uneasiness to the one side of the flank.

Sign-• Bimanual examination- uterus is normal size, A pulsatile, firm small tender mass may be felt in the fornix.

CHRONIC OR OLDECTOPIC

• Onset is insidious

• Symptoms- Amenorrhoea Lower abdominal topic Vaginal bleeding Other symptoms.

• On examination.

• Per vaginal

• Per abdominal

On examination patient look ill, varying degree of pallor, slightly raised temperature. Features of shock

Per abdominal Tenderness and muscle guard on the lower abdomen. A mass may be felt, irregular and tender.

Per vaginal Vaginal mucosa pale, Uterus may be normal in size or bulky,

DIAGNOSIS

““Pregnancy in the fallopian tube is a Pregnancy in the fallopian tube is a black cat on a dark night. It may make black cat on a dark night. It may make

its presence felt in subtle ways and its presence felt in subtle ways and leap at you or it may slip past leap at you or it may slip past

unobserved. Although it is difficult to unobserved. Although it is difficult to distinguish from cats of other colours distinguish from cats of other colours

in darkness, illumination clearly in darkness, illumination clearly identifies it.” identifies it.”

--Mc. Fadyen - 1981--Mc. Fadyen - 1981

DIAGNOSIS

• Patient with acute ectopic can be diagnosed clinically.

• Blood should be drawn for Hb gm%, blood grouping and cross matching, DC and WBC, BT, CT.

• Should be catheterized to know urine output.

The investigations areUrine pregnancy test:- positive in 95% cases.

2. Culdocentesis:- (70-90%)

- Can be done with 16-18 G lumbar puncture needle through posterior fornix into POD. - Positive tap is 0.5ml of non clotting blood. 3. Ultra Sonography-

a) Transvaginal Sonography (TVS): - Is more sensitive - It detect intrauterine gestational sac at 4-5wks.

b) Color Doppler Sonography(TV-CDS):

- Improve the accuracy.

-Identify the placental

shape(ring-of-fire pattern) and

blood flow outside the uterine cavity.

c) Transabdominal Sonography:

- can identify gestational sac at 5-6 wks

- S-β hCG level at which intrauterine

gestational sac is seen by TAS is 1800

IU/L.

Hyperechoic ring around Hyperechoic ring around gestational sac in adnexal regiongestational sac in adnexal region

Ring sign — a hyperechoic ring Ring sign — a hyperechoic ring around an extrauterine gestational sac.

4. β-HCG Assay- When hCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy.

-Rise of β-HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy .

Biochemical pregnancy is applied to those women who have two β-HCG values >10 IU/L

5. Serum Progesterone – - level >25 ng/ml is suggestive of normal

intrauterine pregnancy.

- level <15 ng/ml is suggestive of ectopic

pregnancy.

- level <5 ng/ml indicates nonviable

pregnancy, irrespective of its location.

6. Laparoscopy (Gold standard)–

Can be done only when patient Is haemodynamically stable.

It confirms the diagnosis and removal of ectopic mass can be done at the same time.

DIFFERENTIAL DIAGNOSIS 1. Rupture corpus luteum of pregnancy 2. Twisted ovarian cyst 3. Incomplete abortion. 4. Acute Appendicitis. 5. Perforated peptic ulcer. 6. Renal colic.

MANAGEMENT

MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY

MANAGEMENT

Expectant management

Medicalmanagement

Surgicalmanagement

Local Systemic(USG or Laparoscopic)

salpingocentesis

- Methotrexate- Potassium chloride- Prostagladin(PGF2α)- Hypersmolar glucose- Actinomycin D- Mifepristone

Methotrexate

Radical

Salpingectomy

Conservative

-Salpingostomy

-Salpingotomy

- Segmental resection

-Milking or fimbrial expression

EXPECTANT MANAGEMENT

PROTOCOL:

- Hospitalization with strict monitoring of clinical symptom

- Daily Hb estimation

- Serum β HCG monitoring 3-4 days until it is <10 IU/L

MEDICAL MANAGEMENT

CANDIDATES FOR METHOTREXATE (MTX) Unruptured sac < 3.5cm without cardiac activity β -hCG < 10,000 IU/L Persistant Ectopic after conservative surgery

PHYSICIAN CHECK LIST CBC, LFT, RFT, β -hCG Transvaginal USG within 48 hrs Obtain informed consent Anti-D Ig if pt is Rh negative Follow up on day1, 4 and 7.

MEDICAL MANAGEMENT

METHOTREXATE:

• Mechanism of action- Methotrexate Interferes with the DNA synthesis by

inhibiting the synthesis of pyrimidines leading to trophoblastic cell death.

Auto enzymes and maternal tissues then absorb the trophoblast.

Contd……

• Advantages –

• Minimal Hospitalisation.Usually outdoor treatment

• Quick recovery• 90% success if cases are properly

selected• Disadvantages-

• Side effects like GI & Skin

• Monitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative

SURGICAL MANAGEMENT OF ECTOPIC Conservative Surgery

Can be done Laparoscopically or by microsurgical laparotomy

INDICATION: - Patient desires future fertility

- Contralateral tube is damaged or surgically removed previously

CHOICE OF TECHNIQUE: depends on

- Location and size of gestational sac

- Condition of tubes

- Accessibility

VARIOUS CONSERVATIVE SURGERIES

1.Linear Salpingostomy:

- Indicated in unruptured ectopic <2cm in ampullary region.

2. Linear Salpingotomy :

- Incision line is closed in two layers with 7-0 interrupted

vicryl sutures.

3. Segmental Resection & Anastomosis:

- Indicated in unruptured isthmic pregnancy

- End to end anastomosis is done immediately or at later

date

ADVANTAGES OF LAPAROSCOPY

- It helps in diagnosis, evaluation, and treatment . - Diagnose other causes of infertility. - Decreased hospitalization, operative time, recovery period, analgesic requirement.

Follow up after conservative surgery

- With weekly Serum β HCG titre till it is negative. - If titre increases methotrexate can be given.

BIBLIOGRAPHY