Dr Manavita Mahajan

MD (PGI Chandigarh) , FRCOG (London)

Sr Consultant Obstetrician & Gynecologist

What is Ectopic Pregnancy Pregnancy

1. Inside uterus – NORMAL Pregnancy Location

2. Outside Uterus – ECTOPIC PREGNANCY

Incidence – approx. 2%

Commonest Site – Fallopian tube

Other sites – Ovary , Cervix , Abdomen

Why Worry About Ectopic Pregnancy

DANGEROUS

Intra-abdominal Haemorrhage & Death

Loss of TUBE - Fertility Compromised

Risk Factors / Etiology ETIOLOGY of Ectopic Pregnancies is unknown

RISK FACTORS 1. Current or previous Pelvic Inflammatory Disease 2. Previous Ectopic pregnancy 3. Previous Tubal surgery (including reversal of tubal sterilisation

operation) 4. Pregnancy with Intra Uterine Contraceptive Device still in place 5. Pregnancies resulting from Fertility Treatments (including IVF) 6. Failed Emergency Contraceptive Pill (progestin only) 7. Prior Abdominal Surgeries ( esp. Ruptured appendix) 8. Congenital Uterine Malformations

SYMPTOMS Women with Ectopic Pregnancy may present in

many different ways and a high index of clinical suspicion is needed to diagnose this condition.

Missed Period

Abdominal Pain

Vaginal Bleeding

Dizziness/ Fainting/Shoulder tip pain

ASYMPTOMATIC

SIGNS Tachycardia

Hypotension

Pallor

Distended Abdomen / free fluid / tenderness

Vaginal Assessment – Tender Pelvis

Differential Diagnosis Abortion (Intrauterine Pregnancy)

Ovarian Cyst – Torsion / Haemorrhage

Corpus Luteal Haematoma

Acute Appendicitis

UTI

Ureteric Colic

Acute Abdomen

FINAL VERDICT WHO IS AT RISK - ALL PREGNANT WOMEN

HIGH INDEX OF SUSPICION

All women of the childbearing age presenting with acute abdomen or cramping and abnormal vaginal bleeding should have a pregnancy test performed to confirm or exclude the possibility of pregnancy (Intrauterine or Ectopic).

HOW TO DIAGNOSE ECTOPIC PREGNANCY EARLY? STEP 1 Correct Diagnosis of Pregnancy

History of Missed Period – UNRELIABLE

Urine Pregnancy Test – Usually Positive

Beta hCG ( Blood Pregnancy Test) – positive in all pregnant women. Level less than 5 rules out pregnancy

Ultrasound

1. TRANSABDOMINAL - Unreliable

2. TRANSVAGINAL –very early pregnancy not diagnosed

DIAGNOSIS OF PREGNANCY

Urine Pregnancy Test

Blood Pregnancy Test

DIAGNOSIS OF ECTOPIC PREGNANCY Clinical Scenario 1 – Woman presents to Emergency

with acute abdomen & is in Haemorrhagic Shock & pregnancy test is positive

Clinical Scenario 2 – Asymptomatic patient with +ve pregnancy test +/- risk factors for ectopic pregnancy

Clinical Scenario 3 – Patient with pain abdomen and/or bleeding per vaginum in early pregnancy

DIAGNOSIS IN STABLE PATIENT Perform Trans Vaginal Sonography(TVS)

1. Intrauterine pregnancy confirmed ( I.U. Gestational Sac with yolk sac +/- embryo)

2. Ectopic Pregnancy confirmed ( Empty Uterus , Adnexal Mass with Gestational Sac , Free fluid in pelvis/ abdomen)

3. Empty uterus , no adnexal mass (NO EVIDENCE of PREGNANCY)

DIAGNOSTIC DILEMMNA – POSITIVE PREGNANCY TEST ,EMPTY UTERUS ON TVS

Beta hCG test should be performed

Beta hCG < 1500 . The test should be repeated at 48 hours and if doubling of the previous titre is seen then it is likely to be intrauterine pregnancy. Transvaginal Ultrasound should then be repeated by an experienced sonographer when the level is >1500 and intrauterine pregnancy should be identified

.

Beta hCG > 1500-2000 with an empty uterus on Transvaginal sonography by an experienced sonographer generally implies an ectopic pregnancy (exception being a multiple gestation) and the woman should be counselled accordingly.

Let’s Remember Diagnose pregnancy by pregnancy test (urine or

beta hCG)

Perform pregnancy test in all cases of acute abdomen in women of childbearing age

Trans Vaginal Sonography should detect pregnancy in all cases when beta hCG > 1500. Failure to detect ( empty Uterus)implies possible Ectopic Pregnancy

Management of Ectopic Pregnancy Case 1 – Patient presents with Haemorrhagic

Shock

IMMEDIATE RESUSCITATION WITH LAPAROTOMY

Case 2 – Stable Patient with Ectopic Pregnancy

1. Laparoscopy & Surgical Management

2. Medical Management with Methotrexate

ROLE of LAPAROSCOPY

Tubal Ectopic pregnancies are readily diagnosed and treated by laparoscopic approach.

Surgical procedures that are performed are

1. removal of the involved tube (Salpingectomy)

2. removal of the pregnancy tissue with conservation of tube (salpingostomy).

Salpingectomy video

What is Medical Management of Ectopic Pregnancy? Methotrexate (folate antagonist) has good activity against pregnancy tissue

(trophoblastic tissue) and has been used to destroy the ectopic gestation in carefully selected women.

The prerequisites for methotrexate administration are

1. Haemodynamically stable patient with no intraabdominal bleed. 2. Beta hCG </=3000 3. No cardiac activity demonstrated in the fetus on Ultrasound(TVS) 4. Ectopic size<3.5 cm 5. No Medical problems in the women (exclude anaemia, kidney or liver or

haematological disorders) 6. Good patient compliance with follow up visits as tubal ruptures have been

known to occur in some women in the resolution phase of the disease.

Post Ectopic pregnancy -Some Counselling Points Risk of Ectopic Pregnancy in next pregnancy is

around 7-10% and hence she must report early in next pregnancy.

Contraception – Barrier methods or OC Pills are advocated. Should avoid Intra Uterine Contraceptive Device and progestin only emergency pills

Anti D should be administered to Rhesus negative non sensitised women.

SUMMARY To summarise , early diagnosis of Ectopic pregnancies

requires constant vigilance on the part of the clinician and we have been greatly helped in this endeavour by the modern improved pregnancy diagnosis(serum Beta hCG)methods and Transvaginal Scanning.This ,along with operative laparoscopic techniques , has improved the outcomes for great majority of women with Ectopic Pregnancies.

Thank you