ECTOPICECTOPICPREGNANCPREGNANC

YYTayebeh gharibiTayebeh gharibi

Ectopic PregnancyEctopic Pregnancy

Occurs when the conceptus Occurs when the conceptus

implants either outside the uterus implants either outside the uterus

(Fallopian tube, ovary or abdominal (Fallopian tube, ovary or abdominal

cavity) or in an abnormal position cavity) or in an abnormal position

within the uterus (cornua cervix).within the uterus (cornua cervix).

Epidemiology & Risk Epidemiology & Risk Factors:Factors:

• Between Between 95%95% and and 98%98% occur in the occur in the

fallopian tubefallopian tube..• More than More than 50% 50% of tubal pregnancies are of tubal pregnancies are

situated in the situated in the ampullaampulla . .• Approximately Approximately 20% 20% occur in the occur in the isthmusisthmus..• Around Around 12% 12% are fimbrial.are fimbrial.• Approximately Approximately 10%10% are interstitial. are interstitial.

Understanding Understanding The The

PathophysiologPathophysiologyy

• In theory, any mechanical or In theory, any mechanical or functional factors that prevent or functional factors that prevent or interfere with the passage of the interfere with the passage of the fertilized egg to the uterine cavity fertilized egg to the uterine cavity may be aetiological factors for an may be aetiological factors for an ectopic pregnancy.ectopic pregnancy.

• 50% 50% operated for ectopic operated for ectopic pregnancy have evidence of pregnancy have evidence of chronic chronic pelvic inflammatory diseasepelvic inflammatory disease..

mechnicalmechnical

• AnatosalpingitisyAnatosalpingitisy• Pelvic surgeryPelvic surgery• IudIud• TumorTumor• Preferal adheisionPreferal adheision• endosendos

functionalfunctional

• Hormonal(minipill,iud,ocp)Hormonal(minipill,iud,ocp)• SmokingSmoking• endometriosisendometriosis

ClinicalClinicalFeaturesFeatures

Vaginal bleedingVaginal bleeding

- (usually old blood in small - (usually old blood in small amounts) and chronic pelvic pain amounts) and chronic pelvic pain (iliac fossa, sometimes bilateral) are (iliac fossa, sometimes bilateral) are the most commonly reported the most commonly reported symptoms.symptoms.

General ExaminationGeneral Examination

• Shoulder pain which may occur Shoulder pain which may occur secondary to blood irritating the secondary to blood irritating the diaphragm and vascular instability diaphragm and vascular instability characterized by low blood pressure, characterized by low blood pressure, fainting, dizziness and rapid heart fainting, dizziness and rapid heart rate may be noted. rate may be noted.

• Symptoms are present in about Symptoms are present in about 59%59% of patients and most typical patients of patients and most typical patients whose ectopic pregnancy has whose ectopic pregnancy has ruptured (intra-abdominal bleeding).ruptured (intra-abdominal bleeding).

Gynaecological ExaminationGynaecological Examination

• Speculum or bimanual examination Speculum or bimanual examination must be performed in an must be performed in an environment where facilities for environment where facilities for resuscitation are available, as this resuscitation are available, as this examination may provoke the examination may provoke the rupture of the tube.rupture of the tube.

Laparoscopy & Uterine Laparoscopy & Uterine CurettageCurettage

• The mere absence of placental villi The mere absence of placental villi in the curretage does not in the curretage does not completely exclude a diagnosis of completely exclude a diagnosis of ectopic pregnancy because an ectopic pregnancy because an ectopic pregnancy in a tube, cornu ectopic pregnancy in a tube, cornu or the cervix may partially abort.or the cervix may partially abort.

Human chorionic Human chorionic gonadotrophin and gonadotrophin and transvaginal ultrasoundtransvaginal ultrasound

• One of the most important parameters One of the most important parameters is the discriminatory hCG level above is the discriminatory hCG level above which the gestational sac of an which the gestational sac of an intrauterine pregnancy should be intrauterine pregnancy should be detectable by ultrasonography (usually detectable by ultrasonography (usually 1000iu/L).1000iu/L).

• An empty ectopic sac or a hetero An empty ectopic sac or a hetero genous adnexal mass is a more genous adnexal mass is a more common ultrasound feature.common ultrasound feature.

• The presence of fluid in the pouch of The presence of fluid in the pouch of Douglas is a non-specific sign of ectopic Douglas is a non-specific sign of ectopic pregnancy.pregnancy.

• 10-20%10-20% ectopic pregnancies, a ectopic pregnancies, a pseudogestational sac is seen as a small, pseudogestational sac is seen as a small, centrally located endometrial fluid centrally located endometrial fluid collection surrounded by a single collection surrounded by a single echogenic rim.echogenic rim.

• Laparoscopy should be considered in Laparoscopy should be considered in women with hCG above the discriminatory women with hCG above the discriminatory level and absence of an intrauterine level and absence of an intrauterine gestational sac on ultrasound.gestational sac on ultrasound.

ManagementManagement

• Treating ectopic pregnancy has Treating ectopic pregnancy has always been always been surgicalsurgical (salpingectomy (salpingectomy or salpingotomy)or salpingotomy), either by , either by laparotomy or laparoscopy.laparotomy or laparoscopy.

• Non-surgicalNon-surgical (medical) (medical) therapeutic therapeutic approaches have been introduced, approaches have been introduced, such as puncture and aspiration of such as puncture and aspiration of the ectopic sac, local injections of the ectopic sac, local injections of prostaglandins, potassium chloride, prostaglandins, potassium chloride, hyperosmolar glucose or hyperosmolar glucose or methotrexate.methotrexate.