An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, usually in the fallopian tubes. Risk factors include previous ectopic pregnancy, infections, scarring of the fallopian tubes, and fertility treatments. Ectopic pregnancies can cause life-threatening bleeding if not treated properly. Diagnosis involves beta-hCG levels and ultrasound imaging. Treatment options include medication with methotrexate, expectant management with close monitoring, or surgery depending on the stability of the patient and characteristics of the ectopic pregnancy.
2. Ectopic Pregnancy
Definition: It is defined as an implantation of a
conceptus outside the normal uterine cavity
Or
In theory, any mechanical or functional factors that
prevent or interfere with the passage of the fertilized
egg to the uterine cavity may be aetiological
factors for an ectopic pregnancy.
If not diagnosed on time, it may be life
threatening!!
Incidence (11.1/1000 pregnancies)
5. ETIOLOGY ,INCIDENCE
Mostly unknown
Premature implantation (infection –damage to tubes-
delay of passage of fertilized ovum along tubes)
One in 90 pregnancies is ectopic .
A combined intra uterine and extra uterine pregnancy
is very rare and occurs in 1;40000 spontaneous
pregnancies and 1;1000 IVF pregnancies.
“ Heterotopic pregnancy ”
6.
7. RISK FACTORS
Congenital anomalies of the fallopian tubes
Scarring due to a ruptured appendix
Previous ectopic pregnancy
Infections of the female genital organs
History of PID
Maternal age more than 35 yrs
IUCD
IVF- fertility treatment
Tubal ligation/ reversal of tubal ligation
Smoking
Progesterone only contraceptive pills
8. OUTCOME
Ectopic gestation mostly terminates between 6-10 weeks:
1) TUBAL ABORTION- 65 % of cases, usually in the fimbrial and
ampullary implantations. Repeated small hemorrhages from
the invaded area of the tubal wall detach the ovum, which dies
and :
1. Is absorbed completely
2. Is aborted completely through the tubal ostium into the
peritoneal cavity
3. Is absorbed incompletely with the result that the clot covered
conceptus distends the ostium
4. Forms a tubal blood mole
9.
10. Outcome
2) TUBAL RUPTURE- 35 % of the cases more
common when the implantation is in the
isthmus. This may occur earlier then the 6th
week.
The trophoblast burrows deeply and erodes
the serosal coat of the tube, causing it to break
and rupture.
If this is seen on the mesenteric side of the
tube a broad ligament hematoma will form
11.
12. Outcome
3) SECONDARY ABDOMINAL PREGNANCY
– very rarely the extruded ovum continues to
grow and attaches to the abdominal organs. A
few advance to term, the fetus dies and is
converted to a lithopaedion
14. CLINICAL PATTERNS:
1) Subacute presentation
Mild lower abdominal pain
Occasionally sharp pain and faintness
Slight vaginal bleeding
On examination lower abdominal tenderness, vaginal
examination may show a tender fornix or vague
mass.
Acute collapse ( incase of ruptured or incomplete
tubal abortion)
Cessation of symptoms (incase of complete abortion
with or without a pelvic hematocoele)
15. 2) Acute presentation
Sudden collapse (especially in isthmal tubal
pregnancy)
Acute lower abdominal pain
Fainting
Signs of Internal haemorrhage (leading to pallor,
collapse, falling blood pressure, rapid weak pulse )
Pain maybe either epigastric or shoulder tip pain
(referred)
Abdominal examination may reveal tenderness with
some fullness and muscle guarding.
Vaginal examination will reveal extreme cervical
tenderness.
16. Vitals:
BP, Pulse, Temperature, R/R
Laboratory Investigations:
CBC(complete blood count),
Blood Grouping and Cross Matching
Beta hCG ( Levels double every 48 hrs a rise <66%=EP )
Progesterone (Viable Preg: >79nmol/L, EP: <15.9 nmol/L)
Ultrasound
TVS (Transvaginal U/S Scan)
• Can detect 75-80% on initial scan and further 25% on follow
up.
• Transabdominal U/S has a limited role.
Laparoscopy
(Advantage: Diagnostic and Therapeutic)
17. Clinical suspicion of ectopic gestation
Measure B hCG
Negative
Ectopic
gestation
ruled out
Positive
Gestational
sac in uterus
Gestational
sac in tube
Doubtful
Laparotomy/
Laparoscopy/
Medical treatment
Laparoscopy
Laparoscopy/
Laparotomy
US not
available
Ultrasound
D
I
A
G
N
O
S
I
S
18.
19.
20. TREATMENT / ACTION TO BE TAKEN:
CHECK: Airway, Breathing, Circulation
In cases of shock maintain I/V line .
Morphine as a painkiller can be given.
Ambulatory ultrasound for confirmation of diagnosis if
its an intrauterine or extra uterine pregnancy
Management may be:
A) Medical
B) Expectant
C) Surgical
21. Medical management
Methotrexate (Anticancer antifolate drug)
DOSE: Single intramuscular injection calculated from patients,
body surface area as 50mg/m2 or in 4 doses IM every
alternate day with 7.5mg cover of leucovorin on the other
alternative days
Investigation
Renal Function tests
Liver Function Tests
Complete blood count
Contraindication:
Chronic liver, renal and hematological disorder
Active infection
Immunodeficiency/ Breast feeding
22. Criteria:
Haemodynamically stable patient, no evidence of
haemoperitoneum on scan, mild or no pain
Serum βhCG <3000IU/L
No contraindication to the use of Methotrexate.
Adnexal mass, <4 cm size on ultrasound.
No fetal cardiac activity in the ectopic sac.
Patient compliance with follow up visits.
Monitoring
Check serum βhCG levels on days four and seven
A further dose, if βhCG levels have failed to fall by more
than 15% between day four and day seven.
Then check weekly till level falls to <5000IU/L
Active intervention is needed If patient become symptomatic
or Serum βhCG levels rises above (3000 IU/L) or plateau
23. Expectant management
Based on the assumption of spontaneous resolution of
pregnancy through regression i.e. without treatment:
CRITERIA:
Hemodynamically stable and asymptomatic
Serum βhCG at initial presentation <1000IU/L.
Adnexal mass <4cm on Transvaginal scan (TVS)
Less than 100 ml free fluid in pelvis
24. Women managed expectantly should be followed by:
Serial βhCG twice weekly measurements (ideally less than
50% of its initial level within seven days)
Weekly by transvaginal ultrasound (a reduction in the size of
adnexal mass by seven days)
Transvaginal ultrasound weekly βhCG, until levels are less
than 10IU/L.
Counsel about the importance of compliance with follow-up
and should be with in easy access to the hospital in question.
Active intervention is needed:
If patients become symptomatic
Serum βhCG rises or levels start to plateau.
25. Surgical management
If Serum βhCG is >3000IU/L
Patient is symptomatic(or hemodynamically unstable)
Salpingotomy: Removal of conceptus with conservation of
tubes
Done in women with diseased contralateral tube and fertility
desired
Salpingectomy: Removal of tube in the presence of healthy
contra lateral tube
Can be done by two methods;
Laparoscopy
Laparotomy
26. CRITERIA
Laparoscopy
Pt hemodynamically
stable
No previous surgeries
Unruptured ectopic
Adnexal mass<4cm
Laparotomy
Hemodynamically
unstable
Previous surgeries
Ruptured ectopic
Expertise for laparoscopy
is not available
27. Prognosis:
10-20 % are at risk of having a second
gestation with ectopic.
60 % will become pregnant again with a
normal intrauterine gestation.
Early careful monitoring is required in women
who become pregnant with previous history
of ectopic gestation. It is recommended to get
a TVS between 6-10 weeks .
Pelvic inflammatory disease (PID) is a bacterial infection of the female reproductive system. Most cases of PID are caused by an infection in the vagina or the neck of the womb (cervix) that has spread to the reproductive organs higher up.Many different types of bacteria can cause PID, but most cases are the result of a chlamydia infection, which is a type of sexually transmitted infection that can be spread during unprotected sex. Chlamydia often exhibits no noticeable symptoms, so women may be unaware they are infected. But the bacteria can cause inflammation of the fallopian tubes, which is known as salpingitis. Salpingitis leads to a four-fold increase in the risk of having an ectopic pregnancy.
2)Having a previous history of ectopic pregnancy means that you have an increased risk of having one in the future compared to other women.
Depending on the underlying factors, the risk of having another ectopic pregnancy is somewhere between 1 in 10 and 1 in 4.
3) If you have ever had surgery that involved your fallopian tubes, you have an increased risk of having an ectopic pregnancy. Types of surgery known to increase your risk include:
female sterilisation (specifically a type of surgery known as tubal ligation or ‘tying the tubes’) – in around 1 in 200 cases the surgery fails, the woman becomes pregnant and it can result in an ectopic pregnancy
earlier surgery to remove a previous ectopic pregnancy
4) Taking medication to stimulate ovulation (the release of an egg) can increase the risk of ectopic pregnancy by around four-fold.
In addition, the type of fertility treatment known as in-vitro fertilisation (IVF) is not always successful and can accidentally result in an ectopic pregnancy.
This occurs in around 1 in 22 cases of IVF.
5) The intrauterine device (IUD) and the intrauterine system (IUS) types of contraception are usually very effective in preventing pregnancy – estimated to be effective in around 99 out of 100 cases. But if a pregnancy does occur when using these types of contraception, it is more likely to be an ectopic pregnancy than a normal pregnancy.There is also a risk that if you take emergency contraception and it fails to work, any subsequent pregnancy could be an ectopic pregnancy.
An extrauterine gestational sac containing an embryo or yolk sac is also diagnostic and is seen in a significant percentage of ectopic pregnancies (Figure 13).8
Free fluid in the posterior pelvic cul-de-sac or in other intraperitoneal sites is highly suggestive of ectopic pregnancy (Figure 14).88