Ectopic pregnancy
• Ectopic pregnancy is an implantation of fertilized ovum at the site other then uterine cavity.
• It can be outside the uterus or in abnormal position within the uterus (cornua, cervix)
Sites:
• Fallopian tube (commonest, 95%)
• Ovaries
• Abdominal cavity
• Cervix
• Vagina
• Broad ligament
• Rudimentary horn of uterus
Incidence:
• 1 in 200-300 pregnancies or 22 per 1000 live births
• More prevalent among black races
Tubal ectopic pregnancy
Aeitiology:1. Pelvic inflammatory disease2. Tubal surgery3. Tubal disease4. IUCDs5. Diethylstilboestrol exposure6. Termination of pregnancy7. Assisted reproduction techniques8. Ovum transmigration
Presentation:
1. Acute presentation
2. Subacute/chronic presentation
Acute presentation:
Ruptured tubal pregnancy associated with
intraperitoneal hemorrhage leading to acute
abdomen & often presents with hypovolemic
shock.
Symptoms:
Characteristic symptoms:• Amenorrhea• Abdominal pain• Vaginal bleedingOther symptoms:• Shock• Subjective• Syncope• Shoulder pain
• On GPE, patient is sweating, skin is pale, cold, clammy with low blood pressure and weak pulse.
• On abdominal examination there is occasional distension, rigidity, rebound tenderness and diminished or absent bowel sounds.
• On speculum examination small amount of dark blood may be seen in vagina while on bimanual exam. Patient complains of severe pain on moving the cervix or uterus (chandelier sign)
Subacute/chronic presentation:
• Seen when intraperitoneal bleeding from the
tube is recurrent & small in amount.
• Symptoms are vague & so diagnosis can easily be missed if patient is not evaluated thoroughly.
• On examination pulse and BP are normal, abdomen is soft, tender & rigidity restricted to iliac fossa.
• On bimanual examination of pelvis, patient complains of pain, uterus is of normal size or may be enlarged & affected adnexa is tender.
Differential diagnosis:
• Spontaneous abortion• Ovarian pathology• Corpus luteum haemorrhage• Acute pelvic inflammatory disease• Appendicitis• Subserous fibroid• Retroverted gravid uterus• Perforated pelvic ulcer• UTI• Ureteric colic
Outcome of tubal pregnancy:
• Rupture
• Tubal abortion
• Tubal mole
• Abdominal pregnancy
• Spontaneous regression
Investigations:
• Ultrasound
• Serum hcg
• Ultrasound & hcg
• Laparoscopy
• Colpocentesis
• Serum progesterone
Treatment:
• Surgical
• Medical
• Conservative
Surgical treatment:
• Laparotomy
• Laparoscopy
Laparotomy:
Indications for laparotomy:
• Ruptured tubal pregnancy
• Patient is haemodynamically unstable
• Laparoscopy is contra-indicated
• When ectopic pregnancy is in cornua or rudimentary horn of uterus.
At laparotomy ectopic pregnancy is treated with:
• Salpingectomy
• Tubal repair
Laparoscopic surgery:
Pre-requisites are:
• Ectopic pregnancy of <6 cm diameter
• B-hcg <600 iu/l
• Adequate surgical skills
• Proper equipment
• Minimal adhesions in abdomen
• No massive haemperitoneum
Medical treatment:
• Methotrexate (50mg with 2ml aqueous sol)
• Actinomycin-D
• Prostaglandin
• Mifepristone
• Hyperosmolar glucose
• 20% potassium chloride
Ovarian pregnancy:
• Symptomatology, clinical findings & investigations are same as for tubal ectopic pregnancy.
• Treated with oophorectomy or salpingo-oophorectomy.
Abdominal pregnancy:
• Can be primary or secondary to tubal abortion or tubal rupture
• Patient gave history of bleeding or pain in early part of pregnancy
• On clinical examination, uterus is palpable separate from baby
• Laparotomy is the treatment
Cervical pregnancy:
• Extremely rare
• Patients with high parity & history of surgical manipulations of uterus are at an increased risk
• Vaginal bleeding is prominent symptom
• Hysterectomy is the treatment of choice.