Ectopic Pregnancy – At A Glance


It is the implantation of a fertilized ovum in a site other than normal site of implantation


Normal site of implantation : Posterior wall of body of uterus near the fundus


Sites Of Ectopic Pregnancy

  1. Fallopian tubes (95–98%)
    • Ampulla : 55%
    • Isthmus : 25%
    • Fimbria : 17%
    • Intrauterine : 3%
  2. Uterine cornu (2–2.5%)
  3. Ovary
  4. Cervix
  5. Abdominal cavity (Less than 1%)   Such as Pouch of douglas



Risk Factors / Aetiological Factors Of Ectopic Pregnancy

  1. Pelvic inflammatory diseases
  2. Use of intrauterine contraceptive devices (IUCDs)
  3. Ovulation inducing pregnancy
  4. Assisted reproductive technology (ART) pregnancies
  5. Tubal damage
  6. Tubal surgery
  7. Prior ectopic pregnancy
  8. Age risk of ectopic is 3-fold greater in women of 35–44 years as compared to 18–24 years
  9. Smoking
  10. Endometriosis
  11. Developmental errors



Outcome Of Ectopic Pregnancy



Management Of Ectopic Pregnancy

Clinical features

  1. Short period of amenorrhoea (About 6 – 8 weeks)
  2. Lower abdominal pain, which is colicky in nature
  3. Slight dark per-vaginal bleeding

Examinations

  • On general examination
    1. Anaemia (Depends on the blood loss)
    2. In case of ruptured ectopic pregnancy
      • Severe anaemia
      • Signs of shock
      • Patient maybe restless and confused
  • On per-abdominal examination
    1. Tense and tender abdomen 
    2. Shifting dullness may be present
    3. Height of the uterus : Reduced
  • On per-vaginal examination
    • Usually not done due to the fear of precipitating more bleeding and extreme tenderness
    1. Cervical excitation test positive
    2. Adnexal mass present
    3. Extreme tenderness of the fornix

Investigations

  1. USG
    • Empty uterine cavity
    • Pseudodecidual signs
    • Ectopic sac and embryo
    • Fluid filled enlarged fallopian tube
    • Pooled blood in POD
    • Adnexal mass may be present
  2. β – HCG : Elevated
  3. Pregnancy test : Positive in 50% of cases
  4. Serum progesterone
    • More than 5 ng/ml is suggestive of ectopic pregnancy
  5. Diagnostic uterine curettage
    • Presence of decidual tissue with no chorionic villi
  6. Laparoscopy
    • When there is a confusion with pelvic lesion
  7. Complete blood count
  8. ABO blood grouping and Rh typing

D. Treatment

  • General management
    1. Immediate hospitalization
    2. Haemodynamic stabilization (If necessary)
    3. IV fluids
    4. Blood transfusion
    5. Catheterization of the patient
    6. Prophylactic antibiotics should be given
    7. Analgesics to reduce pain
  • Expectant treatment (Wait and watch)
    • Pre-requisites include….
      1.  Asymptomatic
      2. Good compliance
      3. β – HCG : Less than 1000mIU/mL
      4.  Haemodynamically stable
  • Medical treatment
    • Pre-requisites include….
      1. Haemodynamically stable
      2. Good compliance
      3. β – HCG : Less than 2000mIU/mL
      4. Adnexal mass should be less than 4 cm
      5. No fetal cardiac activity
      6. No fluid in the pouch of Douglas
    • Inj. Methotraxate 50gm/m2 OR 1gm/kg of body weight, given IV
    • Drug response is observed by Measuring β – HCG after 72hrs of methotraxate administration
    • More than 50% reduction in the level β – HCG, indicates that the drug is responding
    • If no response occurs, another dose of Methotrexate can be given OR surgical treatment is done
  • Surgical treatment
    • Done by laparoscopy or laparatomy
    1. If family complete : Salphingectomy with opposite tube ligature
    2. If family incomplete and opposite tube health : Salphingectomy
    3. If family incomplete and opposite tube unhealthy : Salphingostomy



Salphingostomy
Linear incision is given on the fallopian tube & remove the product of conception and allow to heal by primary healing without any suturing

Salphingotomy
Linear incision is given on the fallopian tube & remove the product of conception and suturing is done

Salphingectomy
Removal of the portion of the tube where the ectopic pregnancy occurs


Management Of Ruptured Ectopic Pregnancy

It is a gynaecological emergency

  1. Call for help
  2. Resuscitation of the patient and preparation of the patient for immediate laparotomy should be done simultaneously
  3. Open two wide bore IV channels & fluid is given
  4. Inj. Haartman solution
  5. Inj. Colloid solution
  6. Blood is sent for blood grouping, Rh typing & cross matching & ready at least two units of blood
  7. Catheterization of the patient
  8. Prophylactic antibiotics are given
  9. Counseling of the patient for laparotomy
    • In a haemodynamically unstable person laparascopy cannot be done, so laparatomy is done under general anaesthesia
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