ectopic pregnancy3

8/17/2019 Ectopic Pregnancy3

1/80

Prof. M.C.BansalProf. M.C.Bansal

MBBS,MS,MICOG,FICOGMBBS,MS,MICOG,FICOG

Professor OBGYProfessor OBGYEx-Principal & ControllerEx-Principal & Controller

Jhalaar Me!ical Colle"e & #ospitalJhalaar Me!ical Colle"e & #ospital

Mahat$a Gan!hi Me!ical Colle"e, Jaip%r.Mahat$a Gan!hi Me!ical Colle"e, Jaip%r.


2/80

DEFINITIONDEFINITION

'n( pre"nanc( here the fertilise! o)%$'n( pre"nanc( here the fertilise! o)%$

"ets i$plante! & !e)elops in a site other"ets i$plante! & !e)elops in a site other

than nor$al %terine ca)it(*.than nor$al %terine ca)it(*.

It represents a serio%s ha+ar! to a o$ansIt represents a serio%s ha+ar! to a o$ans

health an! repro!%cti)e potential, re%irin"health an! repro!%cti)e potential, re%irin"pro$pt reco"nition an! earl( a""ressi)epro$pt reco"nition an! earl( a""ressi)e

inter)entioninter)ention..


3/80

Is one in which fertilized ovum is implanted &develops outside normal uterine cavity


4/80

IMPLANTATIONS SITSIMPLANTATIONS SITS

E/0'1/E0I2E 1/E0I2E

/1B'3 45-467

-'$p%lla 897-Isth$%s :;7

-Inf%n!i:?@9,999A

'BOMI2'3>:?:9,999A

-CE0=IC'3>:?:,999A-'2G13'0-CO021'3-C'ES'0E'2

SC'0 >D:A

P0IM'0Y SECO2'0Y

Intraperitoneal ExtraperitonealBroa! 3i"a$ent >rareA


5/80


6/80

IN!I"N!IN!I"N!

• Increase! !%e to PI, %se of I1C, /%'0/A.

• 0an"es fro$ :?;5 to :?;590an"es fro$ :?;5 to :?;59

• ')era"e ran"e is : in :99 nor$al')era"e ran"e is : in :99 nor$al

pre"nancies.pre"nancies.

• 3ate $arria"es an! late chil!


7/80

ETIOLOGYETIOLOGY::

'n( factor that ca%ses !ela(e! transport'n( factor that ca%ses !ela(e! transport

of the fertilise! o)%$ thro%"h the t%


8/80

ETIOLOGYETIOLOGY

CO2GE2I/'3CO2GE2I/'3

/%


9/80

'C1I0E'C1I0E --

Pelvic Inflammatory disease (6-10 times)Pelvic Inflammator y disease (6-10 times)

Chla$(!ia tracho$atis is $ost co$$onChla$(!ia tracho$atis is $ost co$$on

Contraceptive FaliureContrace ptive Faliure

C%/ - @7C%/ - @7 Pro"estasart -:87Pro"estasart -:87

Minipills -@-:97Minipills -@-:97

2orplant -H972orplant -H97


10/80

Tubal sterilization faliure -0!Tubal sterilization faliure -0! epen!s on sterili+ation techni%e an! a"e ofepen!s on sterili+ation techni%e an! a"e of

the patientthe patient

Bipolar Ca%terisation -657Bipolar Ca%terisation -657

1nipolar Ca%ter( -:871nipolar Ca%ter( -:87

Silicon r%


11/80

Tubal reconstructive sur#ery Tubal reconstructive sur #ery $%# times'$%# times'

$ssisted "eproductive tec%ni&ue $ssisted "eproductive tec%ni&ue

## O)%lation in!%ction, I=F-E/ an! GIF/ >@-87AO)%lation in!%ction, I=F-E/ an! GIF/ >@-87A

- 0is of heterotopic pre"nanc(>:7A- 0is of heterotopic pre"nanc(>:7A

Previous 'ctopic Pre#nancy Previous 'ct opic Pre#nancy

## 8-:57 chances of repeat ectopic pre"nanc(8-:57 chances of repeat ectopic pre"nanc(


12/80

t%er "is factorst%er "is factors

'"e H5-@5 (rs'"e H5-@5 (rs

Pre)io%s in!%ce! a


13/80

Iffy hypothesisIff y hypothesis

/heor( of refl%x* $enst%ral fl%i! thro the/heor( of refl%x* $enst%ral fl%i! thro thefertilise! o)%$ into the t%


14/80

volutionvolution

/%


15/80

/he pre"nanc( is %na


16/80

In rare instances, a t%parietal peritone%$A, an! "i)es rise to aparietal peritone%$A, an! "i)es rise to a

)ia


17/80


18/80

Pictures showing TUBAL

ABORTION


19/80

!LINI!AL APP+OA!,!LINI!AL APP+OA!,

i"nosis can


20/80

A!-T !TOPI! P+.NAN!/A!-T !TOPI! P+.NAN!/

Classical tria!Classical tria! is present in 597 of pt ithis present in 597 of pt ithr%pt%re ectopic.r%pt%re ectopic.

-- P'I2?-P'I2?- $ost constant feat%re in 457 pt$ost constant feat%re in 457 pt

- )aria


21/80

O0O01#1# patient is restless in a"on(, loos


22/80

!,+ONI! !TOPI! P+.NAN!/!,+ONI! !TOPI! P+.NAN!/

It can


23/80

O01#O01# patient loo ill, )ar(in" !e"ree of pallor,patient loo ill, )ar(in" !e"ree of pallor,

sli"htl( raise! te$perat%re. Feat%res of shocsli"htl( raise! te$perat%re. Feat%res of shoc

are a


24/80

-N+-PT-+" !TOPI!-N+-PT-+" !TOPI!

#i"h !e"ree of s%spicion & ectopic conscio%s#i"h !e"ree of s%spicion & ectopic conscio%s

clinician can !ia"nose.clinician can !ia"nose.

ia"nose! acci!entall( in 3aparoscop( oria"nose! acci!entall( in 3aparoscop( or3aparoto$(3aparoto$(

!0(!0( !ela(e! perio!, spottin" ith !isco$fort in !ela(e! perio!, spottin" ith !isco$fort in

loer a

P0AP0A ten!erness in loer a

P02P02 sho%l!


25/80


26/80


27/80

DIAGNOSISDIAGNOSIS

**Pre#nancy in t%e fallopian tube is a blacPre#nancy in t%e fallopian tube is a blac

cat on a dar ni#%t+ It may mae itscat on a dar ni#%t+ It may mae its

presence felt in subtle ,ays and leap at you presence felt in subtle ,ays and leap at you

or it may slip past unobserved+ $lt%ou#% it isor it may slip past unobserved+ $lt%ou#% it isdifficult to distin#uis% from cats of ot%erdifficult to distin#uis% from cats of ot%er

colours in darness illumination clearlycolours in darness illumination clearly

identifies it+.identifies it+.

--/c+ Fadyen - 11--/c+ Fadyen - 11


28/80

DIAGNOSISDIAGNOSIS

In recent (ears, inspite of an increase in theIn recent (ears, inspite of an increase in the

inci!ence of ectopic pre"nanc( there has


29/80

I'G2OSISI'G2OSIS

Patient ith ac%te ectopic can


30/80

;.;. C%l!ocentesisC%l!ocentesis?- >89-497A?- >89-497A

- Can


31/80

'ndometrial cavity'ndometrial cavi ty

-$ trilaminar endometial pattern seen-$ trilaminar endometial pattern seen

-pseudo#estational sac-pseudo#estational sac

-decidual cyst may be seen-decidual cyst may be seen P2'342$C 5P2'342$C 5 'll pre"nancies in!%ce an en!o$etrial'll pre"nancies in!%ce an en!o$etrial

!eci!%al reaction, an! slo%"hin" of the !eci!%a can!eci!%al reaction, an! slo%"hin" of the !eci!%a can

create an intraca)itar( fl%i! collection calle! acreate an intraca)itar( fl%i! collection calle! a pseudosac pseudosac

'arly #estational sac 'arl y #estational sac Pseudosac Pseudosac locationlocation belo, t%e midline ec%o alon# t%ebelo, t%e midline ec%o alon# t%e

burried into endometium cavity line b, burried into endometium cavity line b,

endometrial layersendometrial layers

s%apes%ape usually round may c%an#eoviod usually round may c%an#eoviod

bordersborders double rin# sin#le layer double rin# sin#le layer

color flo,color flo, %i#% avascular %i#% avascular

pattern pattern perip%eral flo, perip%eral flo,

4'CI43$7 C82T4'CI43$7 C82T


32/80

4'CI43$7 C82T 4'CI43$7 C82T

It is i!entifie! as an anechoic area l(in" ith in theIt is i!entifie! as an anechoic area l(in" ith in theen!o$etri%$


33/80


34/80

-S. PI!T-+-S. PI!T-+

:.Ba"el si"n #(perechoic rin" aro%n! "estational:.Ba"el si"n #(perechoic rin" aro%n! "estational

sac in a!nexal re"ionsac in a!nexal re"ion

;. Blo


35/80

#(perechoic rin" aro%n!#(perechoic rin" aro%n!"estational sac in a!nexal re"ion"estational sac in a!nexal re"ion


36/80

Ring sign — a hyperechoic ringRing sign — a hyperechoic ring around an

extrauterine gestational sac.


37/80

5454 66#,!. Assay##,!. Assay#

aA Sin"leaA Sin"le NN-#CG? little )al%e-#CG? little )al%e


38/80

7474 Serum Pro)esteroneSerum Pro)esterone 88

- le)el ;5 n"$L$l is s%""esti)e of nor$al- le)el ;5 n"$L$l is s%""esti)e of nor$al

intra%terine pre"nanc(.intra%terine pre"nanc(.

- le)el D:5 n"$L$l is s%""esti)e of ectopic- le)el D:5 n"$L$l is s%""esti)e of ectopic

pre"nanc(.pre"nanc(.

- le)el D5 n"$L$l in!icates non)ia


39/80

4 "ilatation & !uretta)e 84 "ilatation & !uretta)e 8

- Is reco$$en!e! in s%specte! case of- Is reco$$en!e! in s%specte! case of

inco$plete aPP:@A !ecrease in EP

- P'PP' >Pre"nanc( 'ssociate! Plas$a Protein 'A,- P'PP' >Pre"nanc( 'ssociate! Plas$a Protein 'A,

P'PPC >schan"erchaft protein :A has lo )al%eP'PPC >schan"erchaft protein :A has lo )al%ein EPin EP

- C'-:;5, Maternal ser%$ creatine inase,- C'-:;5, Maternal ser%$ creatine inase,Maternal ser%$ 'FP ele)ate! in ectopicMaternal ser%$ 'FP ele)ate! in ectopic

pre"nanc(.pre"nanc(.


40/80

S-SP!T" !TOPI! P+.NAN!/S-SP!T" !TOPI! P+.NAN!/

1rine Pre"nanc( test positi)e1rine Pre"nanc( test positi)e

/rans)a"inal 1SG

I1 sac 2o I1 sac%antitati)e S-hCG

S pro"esterone

D 667 rise in @ hr orS pro"esterone D 5-:9 n"L$l

& C

=illi present =illi a


41/80

"I((+NTIAL "IA.NOSIS"I((+NTIAL "IA.NOSIS

"0" of Acute ctopic"0" of Acute ctopic

:. 0%pt%re corp%s l%te%$ of pre"nanc(:. 0%pt%re corp%s l%te%$ of pre"nanc(

;. 0%pt%re of chocolate c(st;. 0%pt%re of chocolate c(st

H. /iste! o)arian c(stH. /iste! o)arian c(st

@. /orsion L !e"eneration of pe!%nc%late! fi


42/80

"0" O( !,+ONI! $S-: A!-T' !TOPI!"0" O( !,+ONI! $S-: A!-T' !TOPI!

:. Pel)ic a


43/80

MANA.MNTMANA.MNT

Expectant$ana"e$ent Me!ical$ana"e$ent S%r"ical$ana"e$ent

3ocal S(ste$ic>1SG or 3aparoscopicA

salpin"ocentesis

- Methotrexate- Potassi%$ chlori!e- Prosta"la!in>PGF;QA

- #(pers$olar "l%cose- 'ctino$(cin - Mifepristone

Methotrexate

0a!ical

Salpin"ecto$(

Conser)ati)e

-Salpin"osto$(

-Salpin"oto$(

- Se"$entalresection

-Milin" or fi$


44/80

MANAGEMENT OF RUPTURED ECTOPICMANAGEMENT OF RUPTURED ECTOPIC

P0I2CIP3E?P0I2CIP3E? +esuscitation and Laparotomy+esuscitation and Laparotomy

ANTI S,O!; T+ATMNT1ANTI S,O!; T+ATMNT1

- I= line $a!e patent, cr(stalloi! is starte!- I= line $a!e patent, cr(stalloi! is starte!

- Bloo! sa$ple for #sent for #P st%!(A- Salpin"ecto$( is the !efiniti)e s%r"er( >sent for #P st%!(A

- Bloo! transf%sion to


45/80


46/80

MANAGEMENT OF UNRUPTUREDMANAGEMENT OF UNRUPTURED

ECTOPIC PREGNANCYECTOPIC PREGNANCY

OP/IO2S? -OP/IO2S? -

S10GIC'3-S10GIC'3-

S10GIC'33Y 'MI2IS/E0ES10GIC'33Y 'MI2IS/E0E

MEIC'3 >S'MA /0E'/ME2/MEIC'3 >S'MA /0E'/ME2/

MEIC'3 /0E'/ME2/MEIC'3 /0E'/ME2/

EPEC/'2/ M'2'GEME2/EPEC/'2/ M'2'GEME2/


47/80

7'#$/lostalo et al = 3>>7'# 11

:. /%


48/80

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

Spontaneo%s resol%tion occ%rs in 8;7,hile ;7 illSpontaneo%s resol%tion occ%rs in 8;7,hile ;7 illnee! laparoscopic salpin"osto$(nee! laparoscopic salpin"osto$(

In spontaneo%s resol%tion, it $a( tae @-68 !a(sIn spontaneo%s resol%tion, it $a( tae @-68 !a(s

>$ean ;9 !a(sA for the ser%$ #CG to ret%rn to non>$ean ;9 !a(sA for the ser%$ #CG to ret%rn to nonpre"nant le)el.pre"nant le)el.

/he percenta"e fall in ser%$ #CG


49/80

M"I!AL MANA.MNTM"I!AL MANA.MNT

S%r"er( is the $ainsta( of /Lt orl!i!eS%r"er( is the $ainsta( of /Lt orl!i!e

Me!ical ML$ $a( M/A 1nr%pt%re! sac D H.5c$ itho%t car!iac acti)it(1nr%pt%re! sac D H.5c$ itho%t car!iac acti)it(

S-hCG D :9,999 I1L3S-hCG D :9,999 I1L3 Persistant Ectopic after conser)ati)e s%r"er(Persistant Ectopic after conser)ati)e s%r"er(

P#YSICI'2 C#ECR 3IS/P#YSICI'2 C#ECR 3IS/ CBC, 3F/, 0F/, S-hCGCBC, 3F/, 0F/, S-hCG /rans)a"inal 1SG ithin @ hrs/rans)a"inal 1SG ithin @ hrs O


50/80

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

ME/#O/0E'/E?ME/#O/0E'/E? It can


51/80


52/80

!ontd??!ontd??

'!)anta"es '!)anta"es

Mini$al #ospitalisation.1s%all( o%t!oorMini$al #ospitalisation.1s%all( o%t!oor

treat$enttreat$ent

%ic reco)er(%ic reco)er(

497 s%ccess if cases are properl( selecte!497 s%ccess if cases are properl( selecte!

isa!)anta"es-isa!)anta"es-

Si!e effects lie GI & SinSi!e effects lie GI & Sin

Monitorin" is essential- /otal


53/80

SURGICALLY ADMINISTERED MEDICAL TtSURGICALLY ADMINISTERED MEDICAL Tt

(SAM)(SAM)

Aim Aim- trophoRiss, :44HA


54/80

Trophotoxic substances used-Methtrexate >Pans(, :44A

Potassi%$ Chlori!e >0o01 @6APGF;α >3i$


55/80

INST+-!TION TO T, PATINTSINST+-!TION TO T, PATINTS

If /Lt on o%tpatient

Chance of t%


56/80

S-+.I!AL MANA.MNT O( !TOPI!S-+.I!AL MANA.MNT O( !TOPI!

!onservative Sur)ery!onservative Sur)ery

Can


57/80

2A+IO-S !ONS+2ATI2 S-+.+IS2A+IO-S !ONS+2ATI2 S-+.+IS

34Linear Salpin)ostomy34Linear Salpin)ostomy??

- In!icate! in %nr%pt%re! ectopic D;c$ in a$p%llar( re"ion.- In!icate! in %nr%pt%re! ectopic D;c$ in a$p%llar( re"ion.

- 3inear incision "i)en on anti$esentric


58/80

%4 Milin) or fim*rial Bpression1%4 Milin) or fim*rial Bpression1

-- /his is i!eal in !istal a$p%llar( or inf%n!i


59/80

":ATA:L ISS-S":ATA:L ISS-S

CC Salpin"ecto$( =s Salpin"osto$(Salpin"ecto$( =s Salpin"osto$(

CC 3aparoto$( =s 3aparoscop(3aparoto$( =s 3aparoscop(

CC 0epro!%cti)e o%tco$e 0epro!%cti)e o%tco$e

CC 0is of 0ec%rrent Ectopic 0is of 0ec%rrent Ectopic

SALPIN.!TOM/SALPIN.!TOM/


60/80

2S2S

SALPIN.OSTOM/ 0 SALPIN.OTOM/SALPIN.OSTOM/ 0 SALPIN.OTOM/

'll t%


61/80

CONTD……CONTD……

/he choice of s%r"ical treat$ent !oes not infl%ence the/he choice of s%r"ical treat$ent !oes not infl%ence the

post treat$ent fertilit(, :44HA ha)e

!escri


62/80

(ertility reducin) factor(ertility reducin) factor ScoreScore 'ntece!ent one Ectopic pre"nanc('ntece!ent one Ectopic pre"nanc( ; ; 'ntece!ent each f%rther'ntece!ent each f%rther

Ectopic pre"nanc(Ectopic pre"nanc( : : 'ntece!ent '!hesiol(sis'ntece!ent '!hesiol(sis : : 'ntece!ent /%


63/80

Laparotomy 2s LaparoscopyLaparotomy 2s Laparoscopy

- 3aparoscop( is reser)e! for pt ho are- 3aparoscop( is reser)e! for pt ho are

he$o!(na$icall( sta


64/80

LAPAROSCOPIC SALPINGECTOMYLAPAROSCOPIC SALPINGECTOMY It is carrie! o%t Recstein et al :44;A'r"on laser >Recstein et al :44;A– 3aparoscopic scissors an! a


65/80

P+SISTNT !TOPI! P+.NANA!/P+SISTNT !TOPI! P+.NANA!/ /his is a co$plication of salpin"oto$( L salpin"osto$(/his is a co$plication of salpin"oto$( L salpin"osto$(

hen resi!%al trophoD 6 s a$enorrhoeaA

;. S$aller si+e D ; c$ >Inco$plete re$o)alA;. S$aller si+e D ; c$ >Inco$plete re$o)alA

H. Preoperati)e hi"h ser%$H. Preoperati)e hi"h ser%$ NN #CG > H,999 I1L3A an!#CG > H,999 I1L3A an!

postoperati)e a(: titre is D 597 of preoperati)e le)el, ispostoperati)e a(: titre is D 597 of preoperati)e le)el, is

pre!ictor of persistent EP.pre!ictor of persistent EP.

@. I$plantation $e!ial to the salpin"osto$( site.@. I$plantation $e!ial to the salpin"osto$( site.

TreatmentTreatment

s%r"er(

/otal or partial

salpin"ecto$(

Me!ical>selecte! 's($pto$atic ptA

M/ 3e%o)orin

O2A+IAN !TOPI! P+.NAN!/O2A+IAN !TOPI! P+.NAN!/


66/80

Incidence1Incidence1 :?@9,999:?@9,999

+is factor1 #+is factor1 # I1CI1C

- En!o$etriosis on s%rface of o)ar(- En!o$etriosis on s%rface of o)ar(

!ourse1!ourse1

CLF are sa$e as t%


67/80

A:"OMINAL P+.NAN!/A:"OMINAL P+.NAN!/Incidence1Incidence1 0arest0arest

MM+ 1MM+ 1 8- ti$es t%O0 1O0 1 - '


68/80

"ia)nosis1"ia)nosis1 Confir$e!


69/80

(AT O( S!ON"A+/ A:"OMINAL P+.NAN!/ 1(AT O( S!ON"A+/ A:"OMINAL P+.NAN!/ 1

:.:. eath of o)%$ co$plete a$alfor$ationA

M0M1M0M1

## 1r"ent 3aparato$( irrespecti)e of perio! of "estation1r"ent 3aparato$( irrespecti)e of perio! of "estation

- I!eal to re$o)e entire sac fet%s, placenta, $e$


70/80

!+2I!AL P+.NAN!/!+2I!AL P+.NAN!/

I$plantation occ%rs in cer)ical canal at or


71/80

"ia)nosis1"ia)nosis1

C3I2IC'3 C0I/E0I'C3I2IC'3 C0I/E0I'?? Paulman @ /c'llinPaulman @ /c'llin

:. 1terine


72/80

,ISTOPAT,OLO.I! !+IT+IA1 "ubin s

:. Cer)ical "lan!s present opposite to placenta:. Cer)ical "lan!s present opposite to placenta

;. Placental attach$ent to the cer)ix $%st


73/80

MANA.MNTMANA.MNT

S%r"icalMainsta( therap( in past

0a!icals%r"er(

#(sterecto$(

Conser)ati)e

& C>ris of torrential


74/80

SIT1SIT1 I$plantation occ%rs in r%!i$entar( horn of Bicorn%ateI$plantation occ%rs in r%!i$entar( horn of Bicorn%ate

%ter%s%ter%s

!O-+S 1!O-+S 10%pt%re of horn occ%rs


75/80

,T+OT/PI! P+.NAN!/

Co-existin" intra%terine an! extra %terine pre"nanciesCo-existin" intra%terine an! extra %terine pre"nancies

Incidence1Incidence1 : ? H9,999: ? H9,999 ith '0/ :?8999ith '0/ :?8999

ith o)%lation in!%ction :?499ith o)%lation in!%ction :?499

More liely1More liely1

aA 'ss. repro!%cti)e techni%eaA 'ss. repro!%cti)e techni%e


76/80

INT+STITAL P+.NAN!/ $5F'INT+STITAL P+.NAN!/ $5F'

It r%pt%res late at H-@ $onths "estation.It r%pt%res late at H-@ $onths "estation.

(atal rupture(atal rupture se)ere


77/80

!ASA+AN S!A+ !TOPI! P+.NAN!/!ASA+AN S!A+ !TOPI! P+.NAN!/

0ecentl( reporte!0ecentl( reporte! 1SG slos on e$pt( %terine ca)it( an! "estational1SG slos on e$pt( %terine ca)it( an! "estational

sac attache! lo to the loer se"$ent caesareansac attache! lo to the loer se"$ent caesareanscar.scar.

!0(!0( 11 si$ilar to threatene! or ine)ita


78/80

O S

:. M%ltiple Ectopic pre"nanc(:. M%ltiple Ectopic pre"nanc(

;. Pre"nanc( after h(sterecto$(;. Pre"nanc( after h(sterecto$(

H. Pri$ar( splenic pre"nanc(H. Pri$ar( splenic pre"nanc(

@. Pri$ar( hepatic pre"nanc(@. Pri$ar( hepatic pre"nanc(

5. 0ectroperitoneal pre"nanc(5. 0ectroperitoneal pre"nanc( 6. iaphra"$atic pre"nanc(6. iaphra"$atic pre"nanc(

MO0/'3I/Y ? In "eneral pop%lation is :9-:57 $ainl(MO0/'3I/Y ? In "eneral pop%lation is :9-:57 $ainl(

!%e to hae$orrha"e.!%e to hae$orrha"e.

SUMMARY - KEY POITS SUMMARY - KEY POITS


79/80

Inci!ence of ectopic pre"nanc( is risin" hile $aternalInci!ence of ectopic pre"nanc( is risin" hile $aternal$ortalit( fro$ it is fallin".$ortalit( fro$ it is fallin".

Ectopic pre"nanc( can


80/80

ectopic pregnancy3

Documents