Ectopic

obstetrics & gynecology,

1. Ectopic Pregnancy By Samia Manzoor 08-165 Batch : J

2. Objectives : what is ectopic pregnancy ? what are different sites, high risk groups of ectopic pregnancy ? Outcomes of tubal pregnancy clinical features, diagnosis and treatment of ectopic pregnancy.

3. Ectopic Pregnancy is Implantation of a fertilized ovum at a site other than the normal uterine cavity. What is Ectopic Pregnancy ?

4. Sites of E ctopic pregnancy (95%)

5. Risk factors of ectopic Pregnancy Major risk factors Pelvic inflammatory disease( > 50%). Previous tubal surgery. Previous ectopic pregnancy. Intrauterine contraceptive devices. Termination of pregnancy. Minor risk factors. Tuberculosis salpingitis. Cigarette smoking. Age over 35 years. Many sexual partners. Congenital anomalies of the fallopian tubes. Ovum transmigration.

6. Pelvic inflammatory disease . Intrauterine contraceptive devices. puerperal sepsis. Post abortal sepsis. Generalized or pelvic peritonitis. Gonorrhea. Past appendicitis.

7. Clinical features : Symptoms 1. Amenorrhea

8. 2. Abdominal Pain Dull ache Unruptured tubal pregnancy. Sharp Colicky pain Ruptured tubal pregnancy .

9. 3. Vaginal Bleeding May persist continuously or intermittent spotting. Its mainly uterine in origin and partly by ruptured fallopian tube. Due to breakdown of decidua after the pregnancy dies and hormones are withdrawn.

10. 4. Others shock. Syncope. Subjective symptoms of pregnancy. Shoulder pain .

11. Clinical features: Signs General physical examination patient is sweating, skin is pale, cold, clammy low blood pressure weak pulse.

12. Clinical features : Signs Abdominal examination. Abdomen tenderness. Abdominal distension. Cullen’s sign (may be positive )

13. Clinical features: Signs Pelvic examination. Bluish discoloration of vulua and vagina. On bimanual examination: Tenderness on rocking of cervix, most constant sign of ectopic pregnancy ( chandelier sign).

14. Clinical Presentation Acute ectopic pregnancy. Chronic ectopic pregnancy. Patient presents with vague history, intermittent pain and irregular bleeding. The diagnosis can easily be missed if patient is not evaluated thoroughly.

15. Outcomes of ectopic pregnancy Usually the tubal pregnancy does not proceed beyond 8-10 weeks of gestation due to Lack of decidual reaction in the tube. The thin wall of the tube The inadequacy of the tube lumen.

16. Outcomes of ectopic pregnancy 1. Tubal abortion This occurs more if ovum had been implanted in the ampullary portion of the tube

17. 2- Tubal rupture More common if implantation occurs in the narrower portion of the tube which is the isthmus.

18. 3. Tubal mole and pelvic hematoma. In tubal mole gestational sac is retained in tube and is surrounded by a blood clot.

19. 4. Secondary abdominal pregnancy.

20. 5- Spontaneous regression

21. Differential diagnosis Spontaneous abortion Ovarian pathology Corpus luteum haemorrhage. Acute pelvic inflammatory disease Appendicitis. Subserous fibroid. Retroverted gravid uterus. Perforated pelvic ulcer UTI Ureteric colic.

22. Diagnosis History General physical examination. Abdominal and pelvic examination. Investigations.

23. Investigation Most useful is Ultrasonography Empty uterine cavity, and gestational sac on side of the body of uterus. Laparoscopy. Most reliable method of making a diagnosis of ectopic pregnancy.

24. Investigation Culdocentisis . Positive only in the case of ruptured ectopic pregnancy. Repeated Blood Hemoglobin in case of atypical features. Total leukocyte count may be raised. Abnormal levels of b- hcG .

25. Treatment Surgical . Medical.

26. Surgical treatment Laparotomy Indicated for Ruptured tubal pregnancy Patient is hemodynamically unstable. Laparoscopy is contraindicated Pregnancy is in rudimentary horn of uterus. Laparoscopy Indicated for Unruptured tubal pregnancy Which cannot be treated by medical methods.

27. Surgical procedures

28. http://medical-dictionary.thefreedictionary.com/salpingostomy Salpingotomy

29. Medical Treatment Selection criteria Unruptured tubal pregnancy less than 3 cm in diameter. Absent haemoperitonium Sonographically non viable pregnancy, fetal heart sound absent. B- hcG less than 2000 IU/L. Minimal symptoms.

30. Drugs Methotrexate (50mg with 2ml aqueous sol) Actinomycin-D Prostaglandin Mifepristone Hyperosmolar glucose. 20% potassium chloride.

31. Other ectopic pregnancies Ovarian Abdominal Cervical Heterotopic

32. “Before you were conceived I wanted you. Before you were born I loved you. Before you were here an hour I would die for you. This is the miracle of Mother's Love“  By  Maureen Hawkins