ECTOPIC PREGNANCY

Definition

Implantation of a conceptus out side the normal uterine cavity

• Incidence – 1%• Possible sites

– Fallopian tubes – 95 %– Ovaries– Peritoneal cavity– cervix

In fallopian tubes- Ampulla – 74%

Major cause for Maternal deaths

Risk factors

• Tubal disease due to PID• Previous ectopic pregnancy• Previous tubal surgery• Use of assisted reproductive techniques• History of subfertility• Endometriosis• IUCD in situ

Any female in reproductive age group presenting with abdominal pain and bleeding per vagina with a POA

Always exclude an ectopic pregnancy

Symptoms

• Pain – lower abdominal , classically unilateral

• Vaginal bleeding – small amount

• Shoulder tip pain – in ruptured ectopic due to diaphragmatic irritation from

blood

• Collapse – in ruptured

• Can be asymptomatic

Signs

• Uterus normal or < POA• PV – cervical excitation

- Adnexeal mass/Tender adnexae

• Peritonism – in ruptured ectopic due to intra abdominal blood

Diagnosis - Investigations

• Urine β hCG /Serum β hCG• Ultra sound scan to locate pregnancy

TVS/Abdominal

(Presence of a gestational sac with or with out yolk sac & fetal pole excludes an ectopic )

• USS features of ectopicPresence of extra uterine sac with a fetusPresence of an adnexeal masspresence of free fluid in pelvis with no IUPempty uterine sac with serum β hCG > 1500iu

• If serum β hCG is < 1500iu IUP may not be seen by USS

• Repeat serum β hCG in 48 hours– If a viable IUP is present this would doubles(>66%)– If not always suspect an ectopic pregnancy

• Laparoscopy – gold standard but used only when diagnosis cannot be made clinically and other investigations

Management

• Expectant • Medical • Surgical

Expectant

• Only for patients who are haemodynamically stable and asymptomatic

• Follow up with serum β hCG levels ,repeating every 48 hours until it becomes <5 iu

Medical

• Methotrexate Folic acid antagonist,inhibit DNA synthesis in

trophoblastic cells

• Only for patients with– Minimal symtoms– No evidence of rupture– Haemodynamically stable– Good compliance

• Follow up with serial β hCG levels

Surgical • Laparoscopy In unruptured or ruptured but Haemodynamically stable

Advantages –• Minimally invasive• Quick recovery• Less adhesions• Less blood loss

Disadvantages –• Costly

Surgical

• Laparotomyif haemodynamically unstable or no facilities for laparoscopy

surgically either salpingectomy or salpingostomy

Patient preperation

• 2 large bore IV cannulae – 14G/16G• IV fluids • Cross match blood – 5 units• Keep fasting• Inform seniors/theater/anaesthetist

Pregnancy of unknown location(PUL)

• When no sign of an intrauterine pregnancy , ectopic pregnancy or retained products of conception in the presence of positive pregnancy test

• Possibilities– Early intrauterine pregnancy– Ectopic pregnancy– Complete miscarriage

Management

• Severe abdominal pain,tenderness,haemoperitonium• Laparoscopy / laparotomy to exclude ectopic

• If patient is well & stable• Observe with serial serum β hCG measurements