ECTOPIC PREGNANCY

Definition
Implantation of a conceptus
out side the normal uterine
cavity

 Incidence 1%
Possible sites

Fallopian tubes 95 %
Ovaries
Peritoneal cavity
cervix

In fallopian tubes
- Ampulla 74%

Major cause for Maternal deaths

Risk factors

Tubal disease due to PID

Previous ectopic pregnancy
Previous tubal surgery
Use of assisted reproductive
techniques
History of subfertility
Endometriosis
IUCD in situ

Any female in reproductive age

group presenting with abdominal
pain and bleeding per vagina with a
POA

Always exclude an ectopic

pregnancy

Symptoms
Pain lower abdominal , classically unilateral
Vaginal bleeding small amount
Shoulder tip pain in ruptured ectopic due
to
blood

diaphragmatic irritation from

Collapse in ruptured
Can be asymptomatic

Signs
Uterus normal or < POA
PV cervical excitation
- Adnexeal mass/Tender adnexae

Peritonism
abdominal blood

in ruptured ectopic due to intra

Diagnosis - Investigations
Urine hCG /Serum hCG
Ultra sound scan to locate pregnancy
TVS/Abdominal

(Presence of

a gestational sac with or with out yolk sac & fetal

pole excludes an ectopic )

USS features of ectopic

Presence of extra uterine sac with a fetus
Presence of an adnexeal mass
presence of free fluid in pelvis with no IUP
empty uterine sac with serum hCG > 1500iu

 If serum hCG is < 1500iu IUP may

not be seen by USS
Repeat serum hCG in 48 hours
If a viable IUP is present this would
doubles(>66%)
If not always suspect an ectopic
pregnancy

Laparoscopy

gold standard but used only

when diagnosis cannot be made clinically and
other investigations

Management
Expectant
Medical
Surgical

Expectant
Only for patients who are
haemodynamically stable and
asymptomatic
Follow up with serum hCG levels
,repeating every 48 hours until it
becomes <5 iu

Medical
Methotrexate
Folic acid antagonist,inhibit DNA synthesis in
trophoblastic cells

Only for patients with

Minimal symtoms
No evidence of rupture
Haemodynamically stable
Good compliance

Follow up with serial hCG levels

Surgical
Laparoscopy
In unruptured or ruptured but Haemodynamically stable
Advantages
Minimally invasive
Quick recovery
Less adhesions
Less blood loss
Disadvantages
Costly

Surgical
Laparotomy
if haemodynamically unstable or no facilities for
laparoscopy

surgically either salpingectomy or

salpingostomy

Patient preperation

2 large bore IV cannulae 14G/16G

IV fluids
Cross match blood 5 units
Keep fasting
Inform seniors/theater/anaesthetist

Pregnancy of unknown location(PUL)

When no sign of an intrauterine
pregnancy , ectopic pregnancy or
retained products of conception in the
presence of positive pregnancy test
Possibilities
Early intrauterine pregnancy
Ectopic pregnancy
Complete miscarriage

Management
Severe abdominal
pain,tenderness,haemoperitonium
Laparoscopy / laparotomy to exclude ectopic

If patient is well & stable

Observe with serial serum hCG
measurements