Ectopic pregnancy

• Ectopic pregnancy is an implantation of fertilized ovum at the site other then uterine cavity.

• It can be outside the uterus or in abnormal position within the uterus (cornua, cervix)

Sites:

• Fallopian tube (commonest, 95%)

• Ovaries

• Abdominal cavity

• Cervix

• Vagina

• Broad ligament

• Rudimentary horn of uterus

Incidence:

• 1 in 200-300 pregnancies or 22 per 1000 live births

• More prevalent among black races

Tubal ectopic pregnancy

Aeitiology:1. Pelvic inflammatory disease2. Tubal surgery3. Tubal disease4. IUCDs5. Diethylstilboestrol exposure6. Termination of pregnancy7. Assisted reproduction techniques8. Ovum transmigration

Presentation:

1. Acute presentation

2. Subacute/chronic presentation

Acute presentation:

Ruptured tubal pregnancy associated with

intraperitoneal hemorrhage leading to acute

abdomen & often presents with hypovolemic

shock.

Symptoms:

Characteristic symptoms:• Amenorrhea• Abdominal pain• Vaginal bleedingOther symptoms:• Shock• Subjective• Syncope• Shoulder pain

• On GPE, patient is sweating, skin is pale, cold, clammy with low blood pressure and weak pulse.

• On abdominal examination there is occasional distension, rigidity, rebound tenderness and diminished or absent bowel sounds.

• On speculum examination small amount of dark blood may be seen in vagina while on bimanual exam. Patient complains of severe pain on moving the cervix or uterus (chandelier sign)

Subacute/chronic presentation:

• Seen when intraperitoneal bleeding from the

tube is recurrent & small in amount.

• Symptoms are vague & so diagnosis can easily be missed if patient is not evaluated thoroughly.

• On examination pulse and BP are normal, abdomen is soft, tender & rigidity restricted to iliac fossa.

• On bimanual examination of pelvis, patient complains of pain, uterus is of normal size or may be enlarged & affected adnexa is tender.

Differential diagnosis:

• Spontaneous abortion• Ovarian pathology• Corpus luteum haemorrhage• Acute pelvic inflammatory disease• Appendicitis• Subserous fibroid• Retroverted gravid uterus• Perforated pelvic ulcer• UTI• Ureteric colic

Outcome of tubal pregnancy:

• Rupture

• Tubal abortion

• Tubal mole

• Abdominal pregnancy

• Spontaneous regression

Investigations:

• Ultrasound

• Serum hcg

• Ultrasound & hcg

• Laparoscopy

• Colpocentesis

• Serum progesterone

Treatment:

• Surgical

• Medical

• Conservative

Surgical treatment:

• Laparotomy

• Laparoscopy

Laparotomy:

Indications for laparotomy:

• Ruptured tubal pregnancy

• Patient is haemodynamically unstable

• Laparoscopy is contra-indicated

• When ectopic pregnancy is in cornua or rudimentary horn of uterus.

At laparotomy ectopic pregnancy is treated with:

• Salpingectomy

• Tubal repair

Laparoscopic surgery:

Pre-requisites are:

• Ectopic pregnancy of <6 cm diameter

• B-hcg <600 iu/l

• Adequate surgical skills

• Proper equipment

• Minimal adhesions in abdomen

• No massive haemperitoneum

Medical treatment:

• Methotrexate (50mg with 2ml aqueous sol)

• Actinomycin-D

• Prostaglandin

• Mifepristone

• Hyperosmolar glucose

• 20% potassium chloride

Ovarian pregnancy:

• Symptomatology, clinical findings & investigations are same as for tubal ectopic pregnancy.

• Treated with oophorectomy or salpingo-oophorectomy.

Abdominal pregnancy:

• Can be primary or secondary to tubal abortion or tubal rupture

• Patient gave history of bleeding or pain in early part of pregnancy

• On clinical examination, uterus is palpable separate from baby

• Laparotomy is the treatment

Cervical pregnancy:

• Extremely rare

• Patients with high parity & history of surgical manipulations of uterus are at an increased risk

• Vaginal bleeding is prominent symptom

• Hysterectomy is the treatment of choice.