Ectopic Pregnancy

By: Dr. Kalai Chandhini G

Definition
An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity Ectopic means out of place 95% egg settles at fallopion tube. Also known as tubal pregnancy

Anatomy

Site of implantation

Extra-uterine

uterine Cervical

Tubal (97%)
Ampula (55%)

ovarian
Interstitial (2%)

abdominal
Primary (rare) Secondary Intraperitoneal (common) extraperitoneal broad ligament (rare)

(<1%)

Isthmus (25%)

Infundubulum (18%)

Angular
Cornual

Caesarean scar(<1%)

Etiology
The cause is not always clear but it result from tubal abnormality that obstructs the zygote passage as in PID / Salpingitis Previous tubal surgery Contraception failure ( IUCD ) Congenital abnormality of the tube Migration of the ovum across the pelvic cavity to the opposite side

Presentation
Triad ( Pain , amenorrhea , vaginal bleeding) but only 50%. Vomiting, fainting attacks Constipation, pain abdomen, increased fetal movement, cramps With rupture, the patient may experience transient relief of pain since stretching of the serosa ceases back pain hemoperitoneal irritation of the diaphragm; may indicate intraabdominal hemorrhage

Vital signs
With rupture and intraabdominal hemorrhage, the patient develops tachycardia followed by hypotension

Abdominal and pelvic findings

Abdomen may be nontender or tender, with or without rebound Uterus may be enlarged, with findings similar to a normal pregnancy Cervical motion tenderness may or may not be present Bulging of the posterior cul-de-sac Adnexal mass palpable in up to 50% of cases

 intact ectopic: Mass: soft, tender, elastic ,pulsating .Nixon sign [unilateral. Pulsation ] , Dodds sign [unlateral. Tenderness] If slowly disturb ectopic: Pelvic haematocele,Para tubal haematocele,Peri tubal hematocele, Pelvic hematoma

Sign
Sudden Disturbed : Internal Hemorrhage advance abdominal : Painful quickening Tenderness + rigidity Easy palp.fetal movements + FHM No Braxton hicks sign Uterus may be felt separately Abn. Position + presentation

Laboratory findings
Hematology hCG assays Serum progesterone levels

Ultrasound imaging
Abdominal sonography Vaginal sonography

Surgical diagnosis
Laparoscopy Offers a reliable diagnosis in most cases of suspected EP and a ready transition to definitive operative therapy Laparotomy Open abdominal surgery is preferred when the woman is hemodynamically unstable or when laparoscopy is not feasible

Management
Acute Anti shock treatment Laparatomy Chronic (also treat as emergency) Laparatomy Resumption of ovulation and contraception

Interstitial pregnancy
Rarest of tubal Associated with massive intraperitoneal haemorrhage Rare occasion abortion through uterine cavity Hysterectomy

Unruptured tubal pregnancy

Expectant management Conservative management Medical management Monitoring Conservative surgery Salphingectomy Persistent ectopic pregnancy Future advice

Abdominal pregnancy
Primaryrare existence is questionable Secondary primary site being tubal ovary or even uterus then conceptus escapes out through the rent in uterine scar Signs in advanced uterine contour not well defined Braxton hicks is absent Fetal part easily felt

 Imaging studies Sonography X-ray MRI Diagnosis: Repeated failure of IOL Uterine contraction via oxytoxin could not be excited Surest evidence is by laparatomy

 Management:laparatomy Prognosis: maternal mortality <5%,morbidity >> Perinatal mortality >90% fetal malformation > 50%

Ovarian pregnancy
Tube on infected side is intact Gestatation sac in ovary Connected to uterus by ovarian ligament Ovarian tissue must be found on its wall on histological findings Salphino-oophorectomy

Cornual pregnancy
Pregnancy in rudimentary horn of bicornuate uterus Commonly diagnosed as fibroid or ovarian tumor with pregnancy Surgery-removal of rudimentary horn/ hysterectomy if pedicle is short and attachment is wide

Cervical pregnancy
Rubin diagnostic a)Soft enlarged cervix equal to or larger than the fundus b)Uterine bleeding following ammenorhea without cramping pain c)Poc entirely confined within endocervic d) A closed internal os and a partially opened external os