An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus.

ic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. The most common location for an ectopic pregnancy is within a fallopian tube, which is why it is often referred to as a tubal pregnancy. However, ectopic pregnancies can also occur in other locations such as the ovary, abdominal cavity, or the cervix.

Causes
Several factors can increase the risk of an ectopic pregnancy, including:

Previous ectopic pregnancy
Inflammation or infection (e.g., pelvic inflammatory disease)
Fertility treatments or surgeries
Structural abnormalities in the fallopian tubes
Smoking
Symptoms
Ectopic pregnancy can present with the following symptoms:

Sharp or stabbing pain in the abdomen, pelvis, shoulder, or neck
Vaginal bleeding that is heavier or lighter than usual
Gastrointestinal symptoms
Weakness, dizziness, or fainting

1. ECTOPIC PREGNANCY

2. Ectopic Pregnancy Definition An ectopic pregnancy is the one in which the fertilised ovum is implanted & develops outside the normal endometrial cavity.

3. Incidence Accounts for 1 in 300 to 1 in 150 deliveries Rising due to PID, use of IUCD, tubal surgeries, ART & STIs Recurrence rate – 15% after 1 st , 25% after 2 ectopics

4. Increased t he incidence of STI and salphingitis Increased incidence of pregnancy following ART procedures Increased tubal surgery Early detection of cases otherwise may undergo spontaneous absorption Reasons for rising incidence of ectopic pregnancy Reasons for rising incidence of ectopic pregnancy Rreasons for rising the incidence

5. TYPES IMPLANTATION SITES EXTRAUTERINE UTERINE TUBAL (97%) Ampulla (55) Isthmus (25) Infundibulum (18) Interstitial (2) OVARIAN (0.5%) ABDOMINAL (1%) Cervical (1%) Angular Cornual CS Scar (<1) PRIMARY SECONDARY Intraperitoneal Extraperitoneal Broad Ligament (rare )

6. ETIOLOGY Factors preventing or delaying the migration of the fertilized ovum to the uterine cavity. Factors facilitating nidation of the fertilized ovum in the tubal mucosa.

7. Factors preventing or delaying the migration of the fertilized ovum Pelvic inflammatory disease Chlamydia trachomatis infection Endosalpingitis Loss of cilia of lining epithelium and impairment of muscular peristalsis Narrowing of lumen Peritubal adhesion resulting kinking and angulation of the tube Salphingitis isthmica nodosa

8. 2. IATROGENIC A. Contraceptive failure IUD-7 times more Sterilization operation -15-50% chance Use of progestin pills by impaired tubal motility B. Tubal reconstructive surgery C. Intra pelvic adhesions following pelvic surgery D. ART-Tubal pregnancy is increased following ovulation induction , IVF, GIFT 12/13/2018

9. OTHERS Previous ectopic pregnancy Prior induced abortion Congenital factors like tubal tortuosity, accessory ostia , diverticula, and partial stenosis. Developmental defects of the tube include elongation, diverticulam , accessory lobe Endometriosis Smoking(research study chow et.al 88,89,93)

10. Factors facilitating nidation of the fertilized ovum Early resumption of trphoblastic activity Increased decidual reaction Tubal endometriosis

11. Risk factors Advanced maternal age Previous ectopic pregnancy Previous pelvic or abdominal surgery Have pelvic inflammatory disease Had several induced abortion Pregnancy after taking contraceptive pills Smoking,Tubal reconstructive surgery History ofinfertility Fertility treatments and medications IUD devices,Tubal endometriosis

12. MODE OF TERMINATION Tubal pregnancies rapidly invade the mucosa, feeding from the tubal vessels, which become enlarged and engorged. The segment of the affected tube is distended as the pregnancy grows. The tubal pregnancy does not usually proceed beyond 8-10 weeks due to : Lack of decidual reaction in the tube, the thin wall of the tube , the inadequacy of tubal lumen, bleeding in the site of implantation as trophoblast invades

13. Possible outcomes of such abnormal gestations are as follows:

14. Outcomes Tubal mole Repeated small haemorrhages occur in the chorio -capsular space separating villi from their attachments. Complete absorption Pelvic hematocele (collection of encysted blood in POD)

15. 2.Tubal abortion

16. Common mode of termination if ovum had been implanted in the ampullary portion of the tube Gestational sac is separated and expelled into the peritoneal cavity through the tubal ostium If explulsion was complete forming pelvic haematocele Incomplete separation - diffuse intraperitoneal haemorrhage

17. 3.Ruptured ectopic pregnancy

18. WWW.SMSO.NET 19 Extraperitoneal rupture (rupture through f loor of the tube) may lead to intraligamentary hematoma with death of the ovum.

19. 2.Intraperitoneal rupture Common Rent is situated on the roof or sides of tube Bleeding is intraperitoneal

20. 4. Tubal perforation 1. Secondary abdominal pregnancy (rare) Slow process of perforation Amnion intact Chorion not injured Herniation of amniotic sac with ovum and placenta Placenta establish vascularity with neighbouring structure Formation of secondary amniotic sac with intestine, omentum adherent to it

21. 2.Secondary broad ligament pregnancy Rarely pregnancy continues in between two layers of the peritoneum WWW.SMSO.NET 22

22. Tubal pregnancy – effect on uterus Continuation of pregnancy- rare.

23. Triad symptoms

24. Clinical Features- acute ectopic - Pain May be unilateral / bilateral & may occur in upper or lower abdomen dull, sharp or crampy continuous or intermittent Shoulder tip pain - Bleeding slight and continuous expulsion of decidual cast

25. Other Clinical Features- acute ectopic Feeling of nausea Vomiting fainting attack syncope attack ( due to reflex vasomotor disturbance may be present)

26. Clinical Features Contd.. Physical examination Pallor –severe and out of proportion to visible bleeding. Evidence of shock -hypotension , rapid and feeble pulse and cold and clammy extremity . Abdominal examination- abdomen is tense, tumid and tender. Bimanual examination a ) vaginal mucosa – blanched white b) Uterus normal or slightly bulky in size c) extreme tenderness on fornix palpation or movement of cervix d) Mass may or may not be felt through fornix.

27. Cl SHO CHRONIC ECTOPIC amenorrhoea of 6- 8wks Lower abdominal pain starts as acute and gradually becomes dull and colicky Vaginal bleeding – scanty sanguinous or dark coloured Slight intermittent pyrexia

28. Clinical Features- Chronic ectopic Shoulder-tip pain -due to internal bleeding irritating the diaphragm when woman breathe in and out Bladder or bowel problems – dysuria, frequency or retention of urine . Rectal tenesmus may appear following infected hematocele . Pallor Features of shock are absent Persistent high pulse rate

29. Clinical Features- Chronic ectopic Abdominal examination a) tenderness and muscle guard on lower abdomen specially on affected site b) irregular and tender mass may be felt in lower abdomen c) Cullens sign- haemoperitoneum of 2 or 3 wks can cause bruising around umblicus . Bimanual examination an irregular , boggy and tender mass felt through posterolateral fornix

30. Investigation General investigation Hb , blood grouping & cross matching, TC, DC, BT, CT,ESR Urine pregnancy test : positive in 95% cases

31. Investigation contd. Culdocentesis : It can be done with 18-20G spinal needle through posterior fornix into POD. If non clotting blood is obtained, results are positive.If serous fluid is present,results are negative

32. Ultrasonography: Transvaginal USG is superior to transabdominal USG Evidence of an empty uterus, detection of adnexal masses , free peritoneal fluid & signs of ectopic pregnancy are more reliable Identification of double decidual sac sign is the best method to differentiate true sacs from pseudosacs Presence of free cul-de-sac fluid is frequently associated with ectopic pregnancy TVS can detect gestational sac at 4 weeks & by TAS at 6 wks

33. USG PICTURE Bagel sign – Hyperechoic ring around gestational sac in adnexal region Hyperechoic Hyperechoic ring around gestational gestational in adnexal region

34. Color Doppler Sonography : It improve the accuracy & identify the placental shape (ring of fire pattern) & blood flow outside the uterine cavity

35. Quantitative B- hCG : Diagnostic cornerstone for ectopic pregnancy The hCG enzyme immunoassay is positive in virtually all documented ectopic pregnancies Rise of B- hCG < 66% in 48 hrs indictate ectopics or nonviable intrauterine pregnancy If the s. β hcg value is >1500IU/L and intrauterine pregnancy is not visualized on TVS, it is likely to be an ectopic.

36. Dilatation & Curettage: It is performed when the pregnancy is confirmed to be nonviable & location of pregnancy cannot be confirmed by USG Identification of decidua without chorionic villi is suggestive of extra uterine pregnancy

37. Laparoscopy: Gold standard for the diagnosis of ectopic pregnancy Diagnosis & removal of ectopic mass can be done at the same time

38. a) Estradiol: Levels are significantly lower in ectopic pregnancies when compared with viable pregnancies b) Relaxin : is a protein hormone produced solely by corpus luteum of pregnancy & its levels are significantly lower in ectopic pregnancies. c) Maternal AFP: levels are elevated in ectopic pregnancies d) Serum progesterone: With ectopic pregnancies is lower than 5 ng /mL .

39. Management Of Ectopic Pregnancy Management may be expectant medical or surgical Management approach depends on clinical circumstances, site of ectopic pregnancy & the available resources

40. Mx of unruptured tubal pregnancy : Expectant management: Indications 1 . Initial HCG level<1000 mIU /ml 2 . Falling HCG titre 3 . Gestational Sac <4cm 4 . No evidence of bleeding or rupture 5. No fetal heartbeat on TVS

41. Expectant Mx : Contd # Protocol Hospitalisation with strict monitoring of clinical symptom Daily Hb estimation Serum B- hCG monitoring 3-4 days until it is <10 IU/L TVS to be done twice a week Spontaneous resolution occurs in 72%, while 28% will need laparoscopic salpingostomy

42. Mx Of Ectopic Pregnancy: Contd Medical Treatment: Methotrexate-commonly used drug Other agents – KCL, hyperosmolar glucose &PG2 α ROUTE- IV, IM or orally or locally (laparoscopic direct injection or retrograde salpingography ).

43. Medical Treatment Contd: Methotrexate: It is a folic acid analogue that inhibits dehydrofolate reductase & thereby prevents synthesis of DNA Candidates for Methotrexate – patients with confirmed or high suspicion for ectopic pregnancy who are hemodynamically stable with no evidence of rupture Contraindications: hemodynamically unstable ruptured ectopic pregnancy unable to comply with medical management follow up Breastfeeding Immunodeficiency Preexisting blood dyscrasias active pulmonary disease

44. Medical Treatment Contd: Methotrexate treatment regimens Multidose regimen – MTX 1mg/kg IM on 1,3,5,7 days Folinic acid 0.1mg/kg on 2,4,6,8 days Measure B-hCG levels on days 1,3,5,7 until 15% decrease between two measurements. Once B-hCG level drops 15%, stop MTX & monitor B-hCG weekly until non pregnant level(< 5.0 mIU /ml)

45. Medical Treatment Contd: Single dose regimen: MTX 50mg/m 2 on day 0 by IM route Measure B-hCG level on days 4 & 7 If level drops by 15%, monitor B-hCG weekly until non pregnant level. If levels do not drop by 15%, repeat dose of MTX is given on day 7

46. Surgical treatment : It can be accomplished by laparoscopy or laparotomy. LAPROTOMY:- Principle- Quick in quick out Indications of laparotomy Pt haemodynamically unstable Laproscooy contraindicated Evidence of rapture

47. Surgical management: Contd Laparotomy: Indicated when the patient becomes hemodynamically unstable & an expedited abdominal entry is required Advantages of laparoscopy: decreased cost, operative time ,blood loss & hospital stay An alternative to laparoscopy is the use of minilaparotomy incision .

48. Linear salpingostomy :

49. Surgical management: contd Linear salpingostomy : Unruptured ectopic pregnancy Retain future fertility Affected fallopian tube appears normal Contralateral tube appears damaged

50. LINEAR SALPINGOTOMY Same as salpingostomy . but incision line is closed in 2 layers with 7-0 interrupted vicryl sutures

51. Segmental Resection Choice in isthmic pregnancy End to end anastomosis is done

52. Fimbrial expression Ampullary pregnancy Done digitally

53. Salpingectomy Affected tube is damaged Contralateral tube normal Future fertility not desired

54. Management of ruptured ectopic PRINCIPLE: Resuscitation & Laparotomy ANTI SHOCK TREATMENT: - IV line opened, crystalloid started - Folleys catheterization done - colloids for volume replacement LAPAROTOMY: - Rapid exploration of abdominal cavity done - Salpingectomy is the definitive surgery - Blood transfusion done Subtotal hysterectomy(Interstitial)

55. Cervical Ectopic Rubin Clinical criteria Enlarged cervix equal to or larger than fundus Uterine bleeding following amenorrhoea without pain External os may be open Product of conception confined within endocervix Profuse bleeding on manipulation of cervix Management methotrexate therapy hysterectomy

56. Ovarian ectopic Spiegelberg’s Criteria for ovarian pregnancy diagnosis: 1.The fallopian tube on the affected side must be intact 2.The fetal sac must occupy the position of the ovary 3.The gestational sac must be connected to the uterus by the ovarian ligament 4.Ovarian tissue must be located in the sac wall Treatment: Ovarian cystectomy &/or wedge resection Salpingo -oophorectomy Successful treatment with Methotrexate is reported

57. Abdominal ectopic pregnancy It can be classified Primary Secondary Studdifords criteria for diagnosis of primary abdominal pregnancy are Presence of normal tubes & ovaries with no evidence of recent injury No evidence of uteroperitoneal fistula The presence of a pregnancy related exclusively to the peritoneal surface & early enough to eliminate the possibility of secondary implantation after primary tubal nidation

58. Secondary – conceptus escapes out through a rent from primary site – Intraperitoneal or Extraperitoneal broad ligament Clinical features History suggestive of disturbed tubal pregnancy is present Minor ailments of normal pregnancy exaggerated Uterine contour not well defined Fetal parts are easily palpable with increased fetal movements Abnormal attitude and position of fetus on repeated examination Braxton hick contraction absent

59. On examination – uterus may not felt separate from abdominal mass , cervix is not soft and displaced depending upon the position of sac Diagnosis – USG,MRI,X ray Management - Hospitalisation -Immediate laparotomy – Ideal surgery is to remove entire sac-fetus ,placenta and membranes. If placenta is attached to vital organs or where vessels can not be ligated easily better to remove fetus and leaving behind placenta with sac. In such cases HCG and pregestrone level should be monitored.

60. Nursing diagnosis Anxiety Acute pain Impaired tissue perfusion Deficient fluid volume Anticipatory grieving Situational low self esteem Risk for infection Fear Risk for complication Knowledge deficit

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