Ectopic Pregnancy

Definition

Implantation of the fertilised ovum on a tissue other than the normal endometrial lining of the uterus.

Classification

Risk factors

Previous ectopic pregnancy (? 10 – fold↑)

•PID, salpingitis (Chlamydia and Neisseria gonococcus)

•Previous tubal surgery.

•Age(women 35 -44 years 3x more than women 15 -24 years).

•Assisted reproductive technology like IVF and GIFT when multiple embryos or gametes are implanted into the uterus or the fallopian tubes.

•Heterotopic pregnancy.

Progesterone – only IUCDs: decrease the motility of the fallopian tube

•Previous hx of uterine synechiae

•Salpingites isthmica nodosa

Ovulation induction or ovarian stimulation.

• Recurrent appendicitis

• Cigarette smoking

• in utero exposure to Diethyl stilbesterol

Symptoms

•Pain(abdominal/pelvic, generalized or localized, unilateral or bilateral, radiating to shoulder epigastrium or back)

•Amenorrhoea

•Syncope

•Dizziness

•Pregnancy symptoms 10 – 20 •Nausea 15

•Urge to defecate(blood collection in POD presses against rectum)

• bleeding per vaginum as spotting for up to 10days

•decidua cast shedding

•diarrhea

•jaundice

Triad of symptoms

1. Abdominal pain

2. Amenorrhea

3. Abnormal vaginal bleeding

Signs

varies from asymptomatic

to severe pallor and shock(cold clammy extremities, weak rapid pulse, decreased bp)

Diffuse or localized abdominal mass,supra pubic tenderness,

CET,

adnexal mass

Uterine softening and slight increase in size

Investigations

EUCr: to check baseline kidney function in case surgery is needed

Blood group and xM: in case transfusion is necessary

time of rupture

Isthmic: 6-8wks

Ampullary: 8-12wks

Interstitial/cornual:12-16wks

DISCRIMINATORY LEVEL

OF BHCG

Significance of above

What is it called?

>6,500 miu/ml –gestational sac should be seen for transabdominal scan.

•> 2,500 miu/ml for trans vaginal scan.

Bhcg levels above discriminatory zone with empty uterus suggests ectopic pregnancy.

Kadar diagnostic criteria

U/S findings for ectopic pregnancy

Unilateral mass

•Fluid in the pouch of Douglas

•Absence of a well-defined gestation sac/fetus in the uterus.

•Presence of fetal cardiac

U/S findings for ectopic pregnancy

Unilateral mass

Extrauterine gestational sac with/ wO live embryo(bagel’s sign)

•Fluid in the pouch of Douglas

•Absence of a well-defined gestation sac/fetus in the uterus.

•Presence of fetal cardiac

Treatment modalities for unruptured

Treatment for Ruptured

1. Expectant mgt

2. Surgical mgt

3. Surgically administered medical mgt

4. Medical mgt

1. Resuscitation

2. Definitive treatment(laparotomy and salpingectomy)

Indications for expectant mgt

•no sign of intra uterine Pregnancy

•Falling BHCG levels at 2-day intervals

•<4cm diameter of ectopic preg

•No sign of rupture or active bleeding.

• hemodynamically stable

•

Substances used for SAM

Drugs used for medical mgt

1. Systemic methotrexate 1mg/kg body wt IM

2. Actinomycin D

3. Mifepristone

Contra Indications for medical treatment

Haemodynamic instability

•Free fluid in POD or pelvic pain

•Known sensitivity to methotrexate

•Non – compliant patient

•˃3.5cm diameter with positive fetal heart motion.

•Liver, pulmonary and renal diseases, peptic ulcer patients

•Immunodeficiency

Indications

1. Clinically stable

2. Ectopic mass <3.5cm without cardiac activity

3. HCG is positive after salpingotomy(persistent ectopic pregnancy)

4. Absence of contraIs

Surgical treatment and surgical procedures

1. Laparotomy or laparoscopy

1. Linear salpingotomy: the procedure where the pregnancy is removed from the tube through an incision on the antimesenteric border

Prevention

•Comprehensive education: •Effects of sexually transmitted diseases, smoking, drug use and douching, unsafe sex

•During preconception counseling, the woman can be screened for predisposing factors to ectopic pregnancy

•reminded again of the signs and symptoms of ectopic pregnancy.

••Before any reproductive procedure, such as tubal ligation, the woman should be informed of the increased risk of ectopic pregnancy.

Spiegelberg’s criteria for ovarian pregnancy

Treatment?

1. Fallopian tube on the affected side is intact

2. The gestational sac must occupy ovarian position

3. The sac must be connected to the uterus by the utero ovarian ligament

4. Ovarian tissue must be identified histologically in the wall of the gestational sac

Oophorectomy with/ without ipsilateral salpingectomy

Studdiford criteria

Rubin’s criteria