Ectopic PregnancyZaryab Ghauri (Final Year MBBS Batch-E)

Definition

Ectopic Pregnancy is defined as implantation of a conceptus outside the normal uterine cavity.

What is Heterotrophic pregnancy?

Causes Of Ectopic Pregnancy

Tubal Disease; Pelvic Infection Previous Ectopic Pregnancy Previous Tubal Surgery Sub fertility Use Of Intrauterine Devices

Pathophysiology Of Ectopic Pregnancy In normal pregnancy the egg is fertilized in the

fallopian tube and the embryo is transported into the uterus.

Any abnormality in tubal morphology or function may lead to ectopic pregnancy1)Mucosal Damage2)Dysfunction Of Tubal Smooth Muscle

Common Sites Of Implantation

Fallopian Tubes 95% Ampulla 74% Isthmus 12% Fimbrial End Of The Tube 12% Interstitium 2%

Ovaries 3% Peritoneal Cavity 1%

Clinical Presentation

Sub acute Clinical Picture Abdominal/ Pelvic Pain (Localized to Illiac

Fossa)+ Vaginal Bleeding (Dark Red-Brown Indicative Of Old Blood)

Occasionally shoulder tip pain and dizziness. On Bimanual examination tenderness in the fornices and cervical excitation

Acute Clinical Picture Hypovolaemic shock and acute abdomen

Examination and Investigations

Vaginal examination in women with suspected ectopic pregnancy is of little value and it should not be routinely employed

BP, Pulse, Temperature Laboratory Investigations:

HaemoglobinGroup and Save(or cross match if patient is severely compromised)Beta HCG

Diagnosis

Ultrasound Transabdominal Transvaginal

Laparoscopy

Management

Expectant Medical Surgical

Depends on Clinical presentation and Patient’s Choice.

Expectant ManagementPatients who are haemodynamically stable and asymptomatic

Medical ManagementMethotrexate

Surgical ManagementLaparoscopy (Mainstay Of Management)Laparatomy

During surgery Salpingectomy or Salpingotomy is done.

Non-Tubal Ectopics

Interstitial EctopicThe implantation of the conceptus in the proximal portion of the fallopian tube, which is within the muscular wall of the uterus, is called an interstitial pregnancy.Management:Rupture Removing the pregnancy tissue and suturing the rupture site. If extreme bleeding a cornual resection or in rare cases a hysterectomy may be necessary to arrest the bleeding.Early Diagnosis Laparoscopic cornual resection, cornuostomy or SalpingotomyUn-ruptured and <12weeks Methotrexate

Pregnancies located below the internal os: (Cervical and Caesarean scar Ectopics)Cervical pregnancy is defined as the implantation of the conceptus within the cervix, below the level of the internal os.Cervical and Caesarean Ectopics progress to full term. In these cases women usually develop placenta praevia/accreta, which is often complicated by severe postpartum hemorrhage and peripartum hysterectomy. Various methods directed at reducing the bleeding from the implantation site have been used in conjunction with dilatation and curettage, including:

Insertion of a Foley catheter into the cervix, Intracervical vasopressin injection, Cervical Shirodkar cerclage, Transvaginal ligation of the cervical branches of uterine arteries angiographic uterine artery embolization. The use of any of these methods in conjunction with dilatation and curettage reduces the risk of hysterectomy to less than 5%

Ovarian Pregnancy:Ovarian pregnancy is defined as the implantation of the conceptus on the surface of the ovary or inside the ovary, away from the fallopian tubes.Laparoscopy Gold StandardInvolves ovarian resection or aspiration of the pregnancy combined with coagulation of the implantation site using a thermocoagulator. However, in cases with profuse intraoperative bleeding an oophorectomy or salpingo-oophorectomy may be necessary to achieve haemostasis.

Abdominal Pregnancy:Most abdominal pregnancies are the result of reimplantation of ruptured undiagnosed tubal ectopic pregnancies.

Clinical Features are like Tubal Pregnancies.Abdominal pregnancy should be suspected in women with persistent abdominal pain later in pregnancy and in those who complain of painful fetal movements.

In abdominal pregnancy it is often difficult to obtain clear images of the fetus due to overlying bowel loops, and there is often evidence of oligohydramnios and early intrauterine growth restriction.

Surgery

Thank You Reference: Gynaecology By Ten Teachers (19th Edition)

Dewhurst's Textbook of Obstetrics 'n' Gynaecology