Ectopic pregnancy

Ectopic (Extra-uterine) pregnancy definition

Is the implantation of the fertilized ovum outside the endometrial cavity.

The most common site for ectopic implantation

90% of the fertilized ovum occur in the fallopian tube.

Ectopic (Extra-uterine) pregnancy definition

Is the implantation of the fertilized ovum outside the endometrial cavity.

The most common site for ectopic implantation

90% of the fertilized ovum occur in the fallopian tube.

Other sites for ectopic implantation

Ovary

Cervix

Abdominal cavity

Causes and risk factors for Ectopic pregnancy

PID

Smoking

History of ectopic pregnancy

Infertility

Artificial reproductive therapy (ART)

IUCD

Previous pelvic surgery

Long tubes

Asherman syndrome

Clinical presntation for ecotpic pregnancy

complaining of abdominal pain and/ or abnormal vaginal bleeding with a positive pregnancy test, and with or without Amenorrhoea.

Usual time of presentation

6-8 weeks of pregnancy

Other symptoms of ectopic pregnancy

Syncope

Vomiting

Diarrhoea

Pain with defecation

Findings on abdominal examination

Pain and tenderness in the lower abdomen.

Findings on vaginal examination

The uterus may be bulky, with soft cervix.

A tender Adnexal mass may be palpated.

Cervical excitement test is positive.

Clincal presntation for ruptured ectopic pregnancy

Severe abdominal pain

Dizziness

Irritability

Signs of hypovolaemic shock

Findings on examination

the patient looks pale, in pain, restless and irritable.

The pulse is weak and rapid (tachycardia).

The BP is low (hypotension).

Findings on abdominal examination

Severe tenderness.

Rebound tenderness.

Rigidity (acute abdomen).

Investigations in Ectopic pregnancy

Trans-vagainal ultrasound

Urine pregnancy test or urine βhCG

Serum βhCG

Serum progestrone level

Laparoscopy

Laparotomy

Culdocentesis

U/S findings suggestive of ectopic pregnancy include

Adnexal mass

Minimal clear fluid in the culde-sac

The presence of a gestational sac inside the uterus

A pseudosac

Rupture of tubal pregnancy

Rupture of the tube usually occurs when the embryo reaches 8-10 weeks, when the tube can no longer be distended to accommodate the growing pregnancy.

Ruptured Ectopic Pregnancy

A medical emergency requiring immediate intervention due to intra-peritoneal hemorrhage, which can lead to hypovolemic shock and death.

Symptoms of Ruptured Ectopic Pregnancy

Severe lower abdominal pain, shoulder pain (due to diaphragm irritation by intraperitoneal blood clots), dizziness, restlessness, reduced level of consciousness, pallor, irritability, tachycardia, weak pulse, hypotension, severe abdominal tenderness, rebound tenderness, rigidity, muscle guarding, and ultrasound showing intraperitoneal free fluid.

Hypovolemic Shock

A condition of reduced blood volume leading to symptoms like dizziness, restlessness, pallor, tachycardia, weak pulse, and hypotension, often associated with severe blood loss.

Chronic Ectopic Pregnancy

An ectopic pregnancy that may be asymptomatic or cause mild abdominal pain and irregular bleeding, eventually stopping growth and possibly degenerating or disappearing spontaneously, though it can sometimes become infected and form a pelvic abscess.

Intra-peritoneal Hemorrhage

Bleeding within the peritoneal cavity, often a result of a ruptured ectopic pregnancy, leading to severe complications such as hypovolemic shock.

Ultrasound Findings in Ruptured Ectopic Pregnancy

Intraperitoneal free fluid, extending from the pelvis to the para-colic gutter and under the diaphragm, indicating internal bleeding.

Pelvic Abscess

A rare complication of chronic ectopic pregnancy where the pregnancy becomes infected, potentially leading to the formation of an abscess in the pelvic region.

Differential Diagnosis

Miscarriage

Acute PID

Ruptured or twisted ovarian cyst

Acute appendicities

Ureteric stone

Management of Ectopic Pregnancy

Depends on the presentation and general condition of the patient, with different approaches for haemodynamically unstable and stable patients.

Haemodynamically Unstable Patient

If the patient presents with a ruptured ectopic pregnancy and is haemodynamically unstable, immediate laparotomy and salpingectomy are performed after resuscitation and preparation of four to six units of blood.

Haemodynamically Stable Patient

If the patient is haemodynamically stable, there are two treatment options: surgical and medical.

Surgical Treatment

Preferred method is laparoscopic surgery (minimally invasive) over laparotomy (open surgery). Surgical options include salpingostomy or salpingectomy.

Medical Treatment Criteria

Can be considered if the ectopic pregnancy is unruptured, less than 3 cm in diameter, with no fetal heart activity, and serum βhCG level is less than 5000 mIU/ml.

Methotrexate Treatment

Administered at a dose of 50 mg/m² intramuscularly. Serum βhCG levels are monitored every 4-7 days; if levels do not decrease by 25%, another dose is given or surgery is performed.

Methotrexate Success Rate

Approximately 87%, but there is a risk of rupture of the ectopic pregnancy.

Salpingectomy

Surgical removal of the fallopian tube, often performed in cases of ruptured ectopic pregnancy.

Salpingostomy

Surgical procedure to make an incision in the fallopian tube to remove an ectopic pregnancy without removing the tube itself.

Prevention of ectopic pregnancy

Avoidance of multiple sex partners, as this is a risk factor for PID

Avoidance of and treatment of Sexually Transmitted Diseases (STDs).

Discourage smoking