This document discusses ectopic pregnancy, including:
1) It provides a brief history and definitions, noting the first successful surgery was performed in 1883 and that implantation outside the uterus can be caused by factors interfering with normal fertilization and nidation.
2) It discusses the rising incidence of ectopic pregnancy, noting it was 1 in 300 pregnancies in 1970 but had risen to 1 in 70-200 by 1990 in the US.
3) It describes ectopic pregnancy as potentially lethal, noting it was the leading cause of maternal death in the US in 1988 and carries a 5 times higher risk of death for teenagers.
4) It then covers definitions, sites of occurrence, aetiological factors,
Ahmedabad Call Girls CG Road 🔝9907093804 Short 1500 💋 Night 6000
Ectopic pregnancy rs
1. ECTOPIC PREGNANCY
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
2. INTRODUCTION
• CASE DESCRIBED IN EGYPTIAN HEIRLOGRAPHICS
• DEFINITIVE SURGERY FIRST SUCCESSFULLY DONE
BY LAWSON TAIT IN 1883 AD - SALPINGECTOMY
• ANY FACTOR INTERFERING WITH NORMAL
FERTILISATION & NIDATION CAN CAUSE ECTOPIC
• INCIDENCE 1: 150-300 PREGNANCIES
• HIGHEST INCIDENCE REPORTED 1:28 WEST INDIES
(STD)
• ICMR 1990 INCIDENCE 3.2per1000 PREGNANCIES
3. Ectopic Pregnancy
The Rising Incidence
1per300 PREG-1970
1per70/200 PREG-1990
Trend of Ectopic Pregnancy Incidence in
the US
100 slide
80
Ectopics
60
40
20
0
1970 1975 1980 1985 1990
4. Ectopic Pregnancy
Potentially Lethal
• Leading cause of maternal death
• Accounted for 15% of all maternal deaths in the US in
1988 (1)
• Risk of deaths five times higher in teenagers (2)
(1) National Centre for Health Statistics. 1990; 38(13): 23
(2) Goldner T E et al. MMWR Morb Mortal. 1993; 42(SS-6): 73
5. DEFINITION
• Ectopic pregnancy is defined as implantation and
development of zygote at a site other than normal
implantation site
6. Then
what is the normal implantation site?
• Uterine cavity but does not include the angles of the
cavity and cervical canal.
14. PATHOLOGY
• INVASIVENESS OF TROPHOBLAST INTO THIN ANATOMICAL
STRUCTURE (MUSCULAR LAYER) LACK OF RESISTANCE LEADS TO
RUPTURE & HAEMORRHAGE
RECURRENT BLEEDING LAMINATIONS TUBAL MOLE
TUBAL ABORTION PELVIC HAEMATOCELE,EXPULSION
OF RPOC
ABSORPTION
TUBAL EROSION/PENETRATION/ PERFORATION
PERITUBAL HAEMATOMA
BROAD LIGAMENT/SECONDARY ABDOMINAL
PREGNANCY
TUBAL RUPTURE
BROAD LIGAMENT HAEMATOMA/PELVIC HAEMATOCELE
CONTINUATION OF PREGNANCY
15.
16.
17.
18.
19.
20. OVARIAN PREGNANCY
• EXTRAOVULAR / INTRAOVULAR
• SPEIGELBERG’S CRITERIA
TUBES SHOULD BE INTACT ABSOLUTELY.
SAC MUST BE CONNECTED BY OVARIAN
& MESO-OVARIAN LIGAMENT.
OVARIAN TISSUE MUST BE COVER SAC.
SAC MUST BE IN POSITION OCCUPIED BY
OVARY.
21.
22. CERVICAL PREGNANCY
• MORE COMMON AFTER MTP
• PROFUSE BLEEDING MAY OCCUR IN ASSOCIATION
WITH PAINLESS ABORTION
• D.D. CA CX / ENDOCervical CA /DEGENERATING
FIBROID POLYP / INCOMPLETE ABORTION
• RX. D&C WITH LIGATION DESCENDING CERVICAL
ARTERY OR SHIRODKAR’S CERVICAL SUTURE ;
TAMPONADE USING FOLEY’S CATHETER OR
SENGSTAKEN BLACKMORE TUBE ; HYSTERECTOMY .
24. SECONDARY ABDOMINAL
PREGNANCY
• History suggestive of Threatened Abortion/Ectopic
pain , bleeding , fainting .
• Minor ailments of pregnancy severely exaggerated .
• Fetus felt very easily , also fetal movements .
• Abnormal position in abdomen .
• No Braxton Hick’s contractions .
• Uterus separate from fetus .
• X-ray abdomen AP & Lateral :
Gas shadows & intestinal shadows overlie fetus
shadows
Fetal skeleton overlies maternal spine
25. SECONDARY ABDOMINAL
PREGNANCY
• INV : sounding uterus, HSG , USG , Doppler , Placentography
• Terminate pregnancy when diagnosis confirmed, as it is
associated with 50%foetal malformation rate.
• Keep 4-5 Units blood available at laparotomy.
• Wait only if issueless , elderly primigravida , BOH , POG =32
weeks . NO CONGENITAL ANAMOLIES DETECTED .
• Placenta should not be removed from adherent invaded
tissues . Only separated parts of placenta or part attached to
omentum, may be removed along with omentum , leave drain
, give METHOTREXATE .
• Patients usually have failure to lactate due to placental
hormones
26.
27.
28.
29. CLINICAL SYMPTOMATOLOGY &
SIGNS
• ABDOMINAL PAIN ILIAC FOSSAE 95% CASES
(Precedes Bleeding PV)
ill fitting pain/lancinating/pulsatile/colicky/ tenesmus
suprapubic–epigastric /shoulder tip
• AMENORRHOEA followed by BLEEDING PV 75% CASES
(Irregular around menses in 4-5%) Blood
Brownish-Violet with disintegrated granular endometrial tissue
• PREGNANCY SYMPTOMS i.e. NAUSEA/EMESIS
• PYREXIA MILD < 100.4*F
• 5 P’s :
PALLOR,PAIN,PROSTRATION,PULSE(TACHYCARDIA), PRE
SSURE(HYPOTENSION)
• LETHARGY / LISTLESS
30. Ectopic Pregnancy
The Masquerader & The Chameleon
• Varied presentations
• Features may change character even in the same
patient over time
• The ‘classic’ triad of pain, amenorrhea and
vaginal bleeding seen in less than half
• In a classic history, only 14% had ectopic
pregnancy
(1) Schwartz et al. Obstet Gynecol. 1980;56:197
31. CLINICAL SYMPTOMATOLOGY &
SIGNS
• ACUTE PRESENTATION (1%)
PAIN ABDOMEN
AMENORRHOEA followed by BLEEDING PV
SHOCK FEATURES
• CHRONIC PRESENTATION
AMENORRHOEA
BLEEDING PV
PAIN ABDOMEN
DYSURIA / TENESMUS / DIARRHOEA (increase frequency
of motion)
PALLOR
ICTERUS
ABDOMINAL TENDERNESS REBOUND/FIXED POINT
PV : ADNEXAL MASS
32. CLINICAL SYMPTOMATOLOGY &
SIGNS
• Abdomen :
Inspection – Reduced movements,
Peri umbilical discolouration (Cullen’s Sign)
Palpation – Guarding, tenderness, Rebound
tenderness, Fixed point tenderness(Adler’s Sign)
• Per Vaginal :
Cervical Rocking test + 20% Cases ? fallacious tenderness
Pulsatile Fornix , Boginess in fornix
Uterus enlargement < 6 weeks
TENDER ADNEXAL MASS
33.
34. CLINICAL SYMPTOMATOLOGY &
SIGNS
SYMPTOM ACUTE CHRONIC
Pain Abdomen +++ Silent / Less severe
Bleeding PV +++ +
Syncope ++ -/+
Shoulder tip Pain ++ -
SIGNS
CVS Collapse +++ -
Abd Tender ++ -/+
PV Tender + +
Fornix Mass -/+ ++
35. Ectopic Pregnancy
A Diagnostic Dilemma
Net result of these vagaries of presentation of ectopic
pregnancy is that accuracy of the initial clinical evaluation
is less than 50%
Tuomivaara L et al. Arch Gynecol. 1986; 237: 135
36. Ectopic Pregnancy
How is the woman deceived?
• Does not suspect pregnancy at all
• She thinks she is normally pregnant
• She thinks she is aborting a uterine pregnancy
37. Ectopic Pregnancy
Nothing Characteristic About It
• Pain extremely variable in intensity, location and character
• Amenorrhea may be absent in a fourth of women
• Adnexal mass in only upto 50% women
• Cervical motion tenderness may not be present
39. DIFFERENTIAL DIAGNOSIS
• DYSMENORRHOEA WITH IRREGULAR PERIODS
• RETROVERTED GRAVID UTERUS
• ABORTION WITH SALPINGITIS
• THREATENED ABORTION
• RUPTURED / BLEEDING CORPUS LUTEUM CYST
• TORSION OF OVARIAN CYST / ADNEXAL MASS
• BLEEDING INTO ENDOMETRIOTIC CYST
• PREGNANCY WITH OVARIAN CYST / PEDUNCULATED
FIBROID
• RED DEGENERATION OF FIBROID
40. Ectopic Pregnancy
How to Diagnose It Then?
‘Be Ectopic Minded’
‘Keep a high index of suspicion’
‘Be paranoid about ectopic’ – after all, paranoia is but
a heightened sense of awareness!
Have no regrets that it wasn’t ectopic – even if you find that
after a laparoscopy or laparotomy!
41. INVESTIGATIONS
• BASIC 1. Hb, TLC, DLC, BT, CT, PCV
2. Blood Group ABO/Rh
3. Urine RE/ME
4. LFT
• DISEASE 1. Urine Pregnancy Test
2. Beta hCG Assay
3. Ultrasonography Abdominal / TVS
Plain 53% 70%
Doppler 73% 93%
Gestational Sac absent in uterus
Thickened Endometrium
Adnexal Mass
POD Collection
Ring of Fire
4. Diagnostic Laproscopy
5. Culdocentesis / Paracentesis
6. D & C
963AD ALBUCASIS described Abdominal Pregnancy. 1693AD BUSIERE found tubal ectopic in prisoner executed Paris.1731AD GIFFORD complete description of fertilised ovum implanted outside uterine cavity. 1900AD OTT started Culdoscopy Petrograd. 1901AD FELLING described Celoscopy. 1910AD JACOBAEUS started Laproscopy Diagnostic was then used. 1968AD LATHROP & BOWLES described Non-surgical management using Methotrexate. 1973AD SHAPRIO started Laproscopic Surgical management.
Right side > Left side 60 : 40 some even 70 : 30 .Post-tubectomy 15-16% Pregnancies are Ectopic.
Diagnose case before rupture. Ectopic minded for women in reproductive phase. History of KOCH’S . History Primary/Secondary Infertility, PID or STD , Sinusitis. Family History KARTAGENER’s Syndrome. Recurrance 1 : 30.
Syncope due to chemical peritonitis(even small amount of blood) .
Problem when patient with irregular periods & dysmenorrhoea comes with pain and bleeding at 40 days. Tachycardia, febrile low grade, symptoms/signs of pregnancy point towards ECTOPIC.
To Differentiate from Salpingitis . Patient pale,listless > toxic. Pulse and temp do not correlate. Unilateral tenderness and bogginess.Criticism of tenderness present in menses (congestion), Dysmenorrhoea , PID , Endometriosis .
Serum Beta hCG absolute value >1000 IU/ml should visualise Gestational sac & Fetal pole. 6500 IU/ml Kadar Fetal Heart motion viable pregnancy. Levels low see trend, should double in 3 days. USG 2% decidual cast. Diag. Laproscopy may miss diagnosis in early Ectopics with no tubal change.
Injection PGF2 alpha into Gestation Sac OR Injection Hypertonic glucose/saline/urea. Oral Mifepristone 2OOmg.
Laprotomy Procedures Milking of tubes / Linear Salpingotomy or Salpingostomy / Resection Anastomosis