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What is Ectopic Pregnancy Pregnancy
1. Inside uterus – NORMAL Pregnancy Location
2. Outside Uterus – ECTOPIC PREGNANCY
Incidence – approx. 2%
Commonest Site – Fallopian tube
Other sites – Ovary , Cervix , Abdomen
Why Worry About Ectopic Pregnancy
DANGEROUS
Intra-abdominal Haemorrhage & Death
Loss of TUBE - Fertility Compromised
Risk Factors / Etiology ETIOLOGY of Ectopic Pregnancies is unknown
RISK FACTORS 1. Current or previous Pelvic Inflammatory Disease 2. Previous Ectopic pregnancy 3. Previous Tubal surgery (including reversal of tubal sterilisation
operation) 4. Pregnancy with Intra Uterine Contraceptive Device still in place 5. Pregnancies resulting from Fertility Treatments (including IVF) 6. Failed Emergency Contraceptive Pill (progestin only) 7. Prior Abdominal Surgeries ( esp. Ruptured appendix) 8. Congenital Uterine Malformations
SYMPTOMS Women with Ectopic Pregnancy may present in
many different ways and a high index of clinical suspicion is needed to diagnose this condition.
Missed Period
Abdominal Pain
Vaginal Bleeding
Dizziness/ Fainting/Shoulder tip pain
ASYMPTOMATIC
SIGNS Tachycardia
Hypotension
Pallor
Distended Abdomen / free fluid / tenderness
Vaginal Assessment – Tender Pelvis
Differential Diagnosis Abortion (Intrauterine Pregnancy)
Ovarian Cyst – Torsion / Haemorrhage
Corpus Luteal Haematoma
Acute Appendicitis
UTI
Ureteric Colic
Acute Abdomen
FINAL VERDICT WHO IS AT RISK - ALL PREGNANT WOMEN
HIGH INDEX OF SUSPICION
All women of the childbearing age presenting with acute abdomen or cramping and abnormal vaginal bleeding should have a pregnancy test performed to confirm or exclude the possibility of pregnancy (Intrauterine or Ectopic).
HOW TO DIAGNOSE ECTOPIC PREGNANCY EARLY? STEP 1 Correct Diagnosis of Pregnancy
History of Missed Period – UNRELIABLE
Urine Pregnancy Test – Usually Positive
Beta hCG ( Blood Pregnancy Test) – positive in all pregnant women. Level less than 5 rules out pregnancy
Ultrasound
1. TRANSABDOMINAL - Unreliable
2. TRANSVAGINAL –very early pregnancy not diagnosed
DIAGNOSIS OF ECTOPIC PREGNANCY Clinical Scenario 1 – Woman presents to Emergency
with acute abdomen & is in Haemorrhagic Shock & pregnancy test is positive
Clinical Scenario 2 – Asymptomatic patient with +ve pregnancy test +/- risk factors for ectopic pregnancy
Clinical Scenario 3 – Patient with pain abdomen and/or bleeding per vaginum in early pregnancy
DIAGNOSIS IN STABLE PATIENT Perform Trans Vaginal Sonography(TVS)
1. Intrauterine pregnancy confirmed ( I.U. Gestational Sac with yolk sac +/- embryo)
2. Ectopic Pregnancy confirmed ( Empty Uterus , Adnexal Mass with Gestational Sac , Free fluid in pelvis/ abdomen)
3. Empty uterus , no adnexal mass (NO EVIDENCE of PREGNANCY)
DIAGNOSTIC DILEMMNA – POSITIVE PREGNANCY TEST ,EMPTY UTERUS ON TVS
Beta hCG test should be performed
Beta hCG < 1500 . The test should be repeated at 48 hours and if doubling of the previous titre is seen then it is likely to be intrauterine pregnancy. Transvaginal Ultrasound should then be repeated by an experienced sonographer when the level is >1500 and intrauterine pregnancy should be identified
.
Beta hCG > 1500-2000 with an empty uterus on Transvaginal sonography by an experienced sonographer generally implies an ectopic pregnancy (exception being a multiple gestation) and the woman should be counselled accordingly.
Let’s Remember Diagnose pregnancy by pregnancy test (urine or
beta hCG)
Perform pregnancy test in all cases of acute abdomen in women of childbearing age
Trans Vaginal Sonography should detect pregnancy in all cases when beta hCG > 1500. Failure to detect ( empty Uterus)implies possible Ectopic Pregnancy
Management of Ectopic Pregnancy Case 1 – Patient presents with Haemorrhagic
Shock
IMMEDIATE RESUSCITATION WITH LAPAROTOMY
Case 2 – Stable Patient with Ectopic Pregnancy
1. Laparoscopy & Surgical Management
2. Medical Management with Methotrexate
ROLE of LAPAROSCOPY
Tubal Ectopic pregnancies are readily diagnosed and treated by laparoscopic approach.
Surgical procedures that are performed are
1. removal of the involved tube (Salpingectomy)
2. removal of the pregnancy tissue with conservation of tube (salpingostomy).
What is Medical Management of Ectopic Pregnancy? Methotrexate (folate antagonist) has good activity against pregnancy tissue
(trophoblastic tissue) and has been used to destroy the ectopic gestation in carefully selected women.
The prerequisites for methotrexate administration are
1. Haemodynamically stable patient with no intraabdominal bleed. 2. Beta hCG </=3000 3. No cardiac activity demonstrated in the fetus on Ultrasound(TVS) 4. Ectopic size<3.5 cm 5. No Medical problems in the women (exclude anaemia, kidney or liver or
haematological disorders) 6. Good patient compliance with follow up visits as tubal ruptures have been
known to occur in some women in the resolution phase of the disease.
Post Ectopic pregnancy -Some Counselling Points Risk of Ectopic Pregnancy in next pregnancy is
around 7-10% and hence she must report early in next pregnancy.
Contraception – Barrier methods or OC Pills are advocated. Should avoid Intra Uterine Contraceptive Device and progestin only emergency pills
Anti D should be administered to Rhesus negative non sensitised women.
SUMMARY To summarise , early diagnosis of Ectopic pregnancies
requires constant vigilance on the part of the clinician and we have been greatly helped in this endeavour by the modern improved pregnancy diagnosis(serum Beta hCG)methods and Transvaginal Scanning.This ,along with operative laparoscopic techniques , has improved the outcomes for great majority of women with Ectopic Pregnancies.