Ectopic pregnancy- Define, Type, Etiology, Sign and Symptoms, Treatment, Surgery made By sonal patel

1. ECTOPIC
PREGNANCY

2. ECTOPIC PREGNANCY
Definition
An Ectopic Pregnancy is one in which
fertilized ovum is implanted and develops
outside the normal uterine cavity.
Type
• Acute Ectopic
• Chronic Ectopic

3. Extra Uterine
Tubal
Ampulla
Isthmus
Infundibulum
Interstitial
Ovarian
Abdominal
Primary
Secondary
Extra Peritonium
Intra Peritonium

4. Uterine
Cervical pregnancy
Angular pregnancy
Cornual pregnancy

5. INCIDENCE
• Recent evidence indicates that the incidence of
ectopic pregnancy has been rising in many
countries.
• USA- 5 fold: UK- 2 fold
• India - 1 in 100 deliveries
• Recurrence rate
15% after 1 ectopic pregnancy
25 % after 2 ectopic pregnancies

6. AETIOLOGY
Factors Preventing OR delaying migration
of fertilized ovum.
CHRONIC PID
DEFECT OF TUBE
IATROGENIC
TRANS PERITONIAL MIGRATION
TUBAL SPASM

7. Chronic PTD
• Loss of Cilia
• Narrowing of tubal lumen
• Adhesions between mucosal Folds
• Kinking Peritubal adhesions
Defects of tube
• Elongation
• Diverticula's
• Accessory Ostia

8. Iatrogenic
Surgery
• Tubal ligation
• Microsurgery of tube
• IUCD

9. Factors facilitating nidation in tube
Premature degeneration of zona pellucida
Increased decidual reaction
Tubal endometriosis

10. Tubal Mole
• Complete absorption
• Abortion
Tubal Abortion
• Complete
• Incomplete

11. Tubal Rupture
• Floor
• Roof
Tubal Perforation
• Secondary abdominal Pregnancy
• Secondary intra ligamentary Pregnancy

12. Acute Ectopic : Clinical Presentation
• Reproductive age
• Stable to shock
• Amenorrhoea
• Abdominal pain
• Fainting attack
• Vaginal bleeding

13. Signs
• Pallor
• Tachycardia
• Hypotension
• Tenderness / Guarding / Rigidity
• Cx Movement Tenderness
• Fornixial Tenderness

14. Differential Diagnosis
• Acute PID
• Acute Appendicitis
• Rupture corpus luteal cyst
• Twisted ovarian tumour

15. Diagnosis
• Routine Blood Investigations
• UPT
• Culdocentesis
• Ultrasonography
• Laproscopy

16. EARLY DIAGNOSIS
At 4-5 weeks:
• TVS can visualize a G-sac
• serum beta HCG levels are > 1600 mIU/ml
• When Beta HCG levels are greater than above
levels and there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.
• when the value of Beta HCG does not double
in 48 hrs, ectopic pregnancy is suggestive

17. EARLY DIAGNOSIS
After 5 weeks
• tubal ring by 6 wks.
• After 5 mm D : as a complete sonoluscent sac with the
yolksac & embryonic pole with or without fetal heart
activity.
• Demonstration of the G sac with or without a live
embryo (Begel’s sign)-
• Ruptured ectopic with fluid in POD and an empty
uterus.
color doppler, the vascular colour in a characteristic
placental shape fire pattern can be seen outside the
uterine cavity while the uterine cavity is cold in respect
to blood flow.

18. Management
RUPTURED ECTOPIC
• Treatment of shock
• Laprotomy
UNRUPTURED ECTOPIC
• Conservative Management
Medical
Surgery

19. Medical
• Methotrexate, folinic acid
• GA less than 6 wks
• Tubal mass is less than 3.5cm diameter
• Fetus is dead
• Intramuscular Methotrexate 1.0mg /kg
• Alternating folinic acid 0.1mg/kg
• Monitoring of B-HCG levels daily / Alternate day
Monitor
• HMG
• RFT
• LFT

20. • Methotrexate OR Potassium Chloride into
amniotic sac through laparoscopy OR
Sonography guidance
Surgical Conservative Management
Laparoscopic
• Linear Salpingectomy
• Salpingectomy
• Segmental resection Anastomosis
• Fimbrial Evacuation – Milking

21. Surgical Treatment
• Salpingostomy/ Salpingotomy indicated when
• Pt Desire to conserve her fertility
• Patient is haemodinamically stable
• Tubal preg is accessible
• Unruptured & < 5 cm Size
• Contralateral tube absent or damaged.
• Chapron et al (1993) have described a scoring system to
decide which surgical treatment to be taken up based on
patients previous gynae history & appearance of pelvic
organs-

22. FERTILITY REDUCING FACTOR SCORE
• Antecedent one ectopic 2
• Antecedent each further ectopic 1
• Antecedent Adhesiolysis 1
• Antecedent Tubal microsugery 2
• Antecedent salpingitis 1
• Solitary tube 2
• Homolateral Adhesions 1
• Contralateral Adhesions 1
• Conservative surgery is indicated with a score of 1-4 only, while
radical treatment to be performed if score is 5 or more.
• Rationale behind the scoring system is to decide the risk of
recurrent ectopic preg.

23. • Medical Treatment by Methotrexate
• The Antineoplastic drug which acts as a folic acid antagonist and
is highly effective against rapidly proliferating trophoblast.
• Used when 1. Ectopic mass size < 3.5 cm
2. Preg < 6 wks.
3. beta HCG levels < 15,000 MIU/ ml.
• Dose – Single dose - 50 mg / m2 IM.
Measure beta HCG levels on days 4 & 7 .
If difference is > 15% : repeat weekly until undetectable
If Difference is < 15% : repeat 2nd dose of methotrexate
& begin now day 1
If fetal cardiac activity present on day 7, repeat dose &
begin day 1.
Surgical treatment if beta HCG levels not decreasing or fetal
cardiac activity present after 3 doses.

24. PERSISTENT ECTOPIC PREGNANCY (PEP)
• This is a complication of salpingotomy/
salpingostomy
• When residual trophoplast continues to survive
because of incomplete evacuation of ectopic preg.
• Diagnosis made because of raised postoperative beta
HCG.
• Treatment reoperation & Salpingectomy
Administration of IM/ oral
Methotrexate in a single dose of
50 mg/m2

25. CHRONIC ECTOPIC PREGNANCY
• INVESTIGATIONS :
1. Laboratory/ Chemical Test-
• Serial quantitative beta HCG level by RIA
• Serum progesterone level ( < 5 ng / ml in ectopic )
• Low levels of tropholastic proteins such as SPI & PAPP –
Placental protein 14 & 12.
2. USG – usually haematocele is found.
3. Laparoscopy
• TREATMENT : Mainly Surgical
• Salpingectomy of the offending tube
• If pelvic haematocele is infected, posterior colpotomy is to
be done to drain the pelvic abscess.
• Salpingoopherectomy

26. Surgical
Laparotomy Laparoscopy
• Hospital Cost More? Less?
• Post op Adhesions More Less
• Recurrence Same Same
• Future fertility Same Same
• Experience Surgeon Trained Special