Ectopicpregnancy final

2. Presented By
Soumya Ranjan Parida
Basic B.Sc. Nursing 4th year
Sum Nursing Collge
.

3. INTRODUCTION

4. DEFINITION
An Ectopic pregnancy is one in which the
fertilized ovum is implanted and develops
outside the normal uterine cavity.

5. IMPLANTATIONS SITES
EXTRAUTERINE UTERINE
TUBAL
95-96%
OVARIAN
(0.5%)
ABDOMINAL
1%
-CERVICAL
-ANGULAR
-CORNUAL
-CAESAREAN
PRIMARY SECONDARY SCAR (<1)
INTRAPERITO
NEAL
EXTRAPERITO
NEAL
AMPULLA
ISTHMUS
INFUNDIBULUM
INTERSTITIAL

7. INCIDENCE
I. Increased due to PID, use of IUCD, Tubal
surgeries, and ART.
II.Ranges from 1:25 to 1:250
III. Average range is 1 in 100 normal
pregnancies.

8. TUBAL PREGNANCY
• The incidence rate varies from 1 in 300 to 1
in 150 deliveries.

9. RISK FACTORS
i. History of PID
ii. History of tubal ligation
iii.Contraception failure
iv.Previous ectopic pregnancy
v. Tubal reconstructive surgery
vi.History of infertility
vii.ART particularly tubes are patent
and damaged
viii.IUD used
ix.Previous induced abortion

10. ETIOLOGY
FACTORS
RESPONSIBLE
Factors preventing or delaying
the migration of fertilized ovum
to the uterine tube
Factors facilitating nidation of
the fertilization ovum in the
tubal mucosa

11. FACTORS DELAYING OR PREVENTING MIGRATION
SALPINGITIS IATROGENIC
& PID
CONTRACEPTION
FAILURE.
CONTRACEPTION
FAILURE.
TUBAL SURGERY
INTRAPELVIC
ADHESION
AARRTT
OOTTHHEERRSS

12. FACTORS FACILITATING NIDATION IN THE
TUBE
Increased decidual reaction.
Tubal endometriosis.

15. Pictures showing TUBAL
ABORTION

16. CLINICAL FEATURES
•IN ACUTE ECTOPIC
1.Less common, about 30%
2.Patient profile
3.Mode of onset
4.Symptoms
• Short period of
amenorrhea
• Abdominal pain
• Vaginal bleeding
• Feeling of nausea,
vomiting, fainting attack

17. 6. On examination:
•Patient is conscious, perspires and looking
blanched.
•Pallor
•Features of shock
•Abdomen is tense, tumid and tender
•Bimanual examination-
 Blanched white vaginal
mucosa
 Normal size uterus
 Uterus floats
 Extreme tenderness in
fornix palpation

18. • IN UNRUPTURED CASES-Symptoms-
• presence of delayed period and spotting.
• Colicky pain or uneasiness to the one side of the flank.
Sign-
• Bimanual examination-uterus
is normal size, A pulsatile, firm
small tender mass may be felt in
the fornix.

19. CHRONIC OR OLD
ECTOPIC
• Onset is insidious
• Symptoms-
 Amenorrhoea
 Lower abdominal topic
 Vaginal bleeding
 Other symptoms.
• On examination.
• Per vaginal
• Per abdominal

20. On examination
patient look ill, varying degree of pallor,
slightly raised temperature. Features of shock
Per abdominal
Tenderness and muscle guard on
the lower abdomen.
A mass may be felt, irregular and tender.
Per vaginal
Vaginal mucosa pale,
Uterus may be normal in size or bulky,

21. DIAGNOSIS
““Pregnancy iinn tthhee ffaallllooppiiaann ttuubbee iiss aa
bbllaacckk ccaatt oonn aa ddaarrkk nniigghhtt.. IItt mmaayy mmaakkee
iittss pprreesseennccee ffeelltt iinn ssuubbttllee wwaayyss aanndd
lleeaapp aatt yyoouu oorr iitt mmaayy sslliipp ppaasstt
uunnoobbsseerrvveedd.. AAlltthhoouugghh iitt iiss ddiiffffiiccuulltt ttoo
ddiissttiinngguuiisshh ffrroomm ccaattss ooff ootthheerr ccoolloouurrss
iinn ddaarrkknneessss,, iilllluummiinnaattiioonn cclleeaarrllyy
iiddeennttiiffiieess iitt..””
----MMcc.. FFaaddyyeenn -- 11998811

22. DIAGNOSIS
• Patient with acute ectopic can be diagnosed clinically.
• Blood should be drawn for Hb gm%, blood grouping and
cross matching, DC and WBC, BT, CT.
• Should be catheterized to know urine output.
The investigations are
Urine pregnancy test:-
positive in 95% cases.

23. 2. Culdocentesis:- (70-90%)
- Can be done with 16-18 G lumbar
puncture needle through posterior fornix
into POD.
- Positive tap is 0.5ml of non clotting blood.
3. Ultra Sonography-a)
Transvaginal Sonography (TVS):
- Is more sensitive
- It detect intrauterine gestational sac at
4-5wks.

24. b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
-Identify the placental
shape(ring-of-fire pattern) and
blood flow outside the uterine cavity.
c) Transabdominal Sonography:
- can identify gestational sac at 5-6 wks
- S-β hCG level at which intrauterine
gestational sac is seen by TAS is 1800

25. HHyyppeerreecchhooiicc rriinngg aarroouunndd
ggeessttaattiioonnaall ssaacc iinn aaddnneexxaall rreeggiioonn

26. Ring sign —— a hyperechoic ring around an
extrauterine gestational sac.

27. 4. β-HCG Assay-
When hCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.
-Rise of β-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .
Biochemical pregnancy is applied to those
women who have two β-HCG values >10 IU/L

28. 5. Serum Progesterone –
- level >25 ng/ml is suggestive of normal
intrauterine pregnancy.
- level <15 ng/ml is suggestive of ectopic
pregnancy.
- level <5 ng/ml indicates nonviable
pregnancy, irrespective of its location.
6. Laparoscopy (Gold standard)–
Can be done only when patient Is haemodynamically
stable.
It confirms the diagnosis and removal of ectopic mass
can be done at the same time.

29. DIFFERENTIAL DIAGNOSIS
1. Rupture corpus luteum of pregnancy
2. Twisted ovarian cyst
3. Incomplete abortion.
4. Acute Appendicitis.
5. Perforated peptic ulcer.
6. Renal colic.

30. MANAGEMENT

32. MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY

33. MANAGEMENT
Expectant
management
Medical
management
Surgical
management
Local Systemic
(USG or Laparoscopic)
salpingocentesis
Methotrexate
- Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Actinomycin D
- Mifepristone
Radical
Salpingectomy
Conservative
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbrial
expression

34. EXPECTANT MANAGEMENT
PROTOCOL:
- Hospitalization with strict monitoring of
clinical symptom
- Daily Hb estimation
- Serum β HCG monitoring 3-4 days until it
is <10 IU/L

35. MEDICAL MANAGEMENT
CANDIDATES FOR METHOTREXATE (MTX)
 Unruptured sac < 3.5cm without cardiac activity
 β -hCG < 10,000 IU/L
 Persistant Ectopic after conservative surgery
PHYSICIAN CHECK LIST
 CBC, LFT, RFT, β -hCG
 Transvaginal USG within 48 hrs
 Obtain informed consent
 Anti-D Ig if pt is Rh negative
 Follow up on day1, 4 and 7.

36. MEDICAL MANAGEMENT
METHOTREXATE:
• Mechanism of action-
 Methotrexate Interferes with the DNA synthesis by
inhibiting the synthesis of pyrimidines leading to
trophoblastic cell death.
 Auto enzymes and maternal tissues then absorb the
trophoblast.

37. Contd……
• Advantages –
• Minimal Hospitalisation.Usually outdoor
treatment
• Quick recovery
• 90% success if cases are properly
selected
• Disadvantages-
• Side effects like GI & Skin
• Monitoring is essential- Total blood
count, LFT & serum HCG once weekly
till it becomes negative

38. SURGICAL MANAGEMENT OF ECTOPIC
Conservative Surgery
Can be done Laparoscopically or by microsurgical
laparotomy
INDICATION:
- Patient desires future fertility
- Contralateral tube is damaged or surgically
removed previously
CHOICE OF TECHNIQUE: depends on
- Location and size of gestational sac
- Condition of tubes
- Accessibility

39. VARIOUS CONSERVATIVE SURGERIES
1.Linear Salpingostomy:
- Indicated in unruptured ectopic <2cm in ampullary region.
2. Linear Salpingotomy :
- Incision line is closed in two layers with 7-0 interrupted
vicryl sutures.
3. Segmental Resection & Anastomosis:
- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at later
date

40. ADVANTAGES OF LAPAROSCOPY
- It helps in diagnosis, evaluation, and treatment .
- Diagnose other causes of infertility.
- Decreased hospitalization, operative time, recovery period,
analgesic requirement.
Follow up after conservative surgery
- With weekly Serum β HCG titre till it is negative.
- If titre increases methotrexate can be given.

42. BIBLIOGRAPHY