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1. CASE PRESENTATION ON ECTOPIC PREGNANCY BY DR. SHREYA PURI FIRST YEAR OBG PG

2. NAME: MRS ABC AGE:35 YEARS ADDRESS:CHANDAKA, BHUBANESWAR RELIGION:HINDU OCCUPATION:HOUSEWIFE DOA:13/4/2022

3. CHIEF COMPLAINT: C/O MISSED PERIOD, SEVERE PAIN IN LOWER ABDOMEN ASSOCIATED BLEED P/V SINCE 3 DAYS H/O UPT POSITIVE 8 DAYS BACK MTP KIT TAKEN 7 DAYS BACK

4. HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY WELL 8 DAYS BACK WHEN SHE FOUND SHE WAS PREGNANT FOLLOWING WHICH SHE TOOK MTP KIT AFTER WHICH SHE DEVELOPED PAIN IN LOWER ABDOMEN, AND BLEED P/V PAIN WAS SUDDEN IN ONSET, ACUTE IN NATURE, IN LEFT LOWER ABDOMEN ,SHARP IN CHARACTER, NON RADIATING PATIENT WAS RE FERRED FROM OUTSIDE HOSPITAL AND REACHED CASUALTY AT 1:30 PM WITH FOLEYS CATHETER AND CENTRAL IV LINE IN SITU FOLEYS CATHETER IN SITU: 60 ML HIGH COLOURED URINE IN UROBAG . PATIENT HAD ALREADY RECIEVED- IVF: 1 PINT RL AND 1 PINT NS GIVEN RAPID INJ TRAMADOL 100MG IN 100ML NS INJ NORADRENALINE @ 10ML/HR STARTED AT 12:40PM

5. EFAST REPORT : UTERUS NORMAL SIZE:8.6X4.7X3.2CM, ET:5.6MM , EMPTY CAVITY B/L OVARIES APPEAR NORMAL MILD ASCITES SEEN( FREE FLUID IN MORRISON POUCH, SPLENORENAL POUCH AND POD )

6. MENSTRUAL HISTORY: MENSTRUAL CYCLE: REGULAR, FOR 3-4 DAYS /28-30 DAYS CYCLE, NORMAL FLOW (USED 2-3 PADS/DAY) , LMP- 11/3/2 NO H/O PAIN DURING MENSTRUATION OR PASSAGE OF CLOTS

7. OBSTETRIC HISTORY: MARRIED FOR 12 YEARS ;NON CONSANGUINOUS ,G3 P2L2 1 PREGNANCY: 6 YEARS AGE F EMALE CHILD /TERM /BIRTH WEIGHT 2.8KG /LSCS (INDICATION:FETAL DISTRESS) / BABY CRIED IMMEDIATELY AFTER BIRTH BREASTFED WITHIN 1/2 HOUR OF DELIVERY, NO PRELACTEAL FEEDS GIVEN NO ANTENATAL OR POSTNATAL COMPLICATIONS IN THIS PREGNANCY CHILD IS IMMUNISED TILL DATE CHILD IS ALIVE AND HEALTHY WITHOUT ANY DEVELOPMENTAL MILESTONE DELAY 2 PREGNANCY: 3 YEARS OF AGE MALE CH ILD /TERM/ BIRTH WEIGHT 3.1 KG/ LSCS / BABY CRIED IMMEDIATELY AFTER BIRTH BREASTFED WITHIN 1/2 HOUR OF DELIVERY, NO PRELACTEAL FEEDS GIVEN NO ANTENATAL OR POSTNATAL COMPLICATIONS IN THIS PREGNANCY CHILD IS IMMUNISED TILL DATE CHILD IS ALIVE AND HEALTHY WITHOUT ANY DEVELOPMENTAL MILESTONE DELAY

8. 3 PREGNANCY: PRESENT PREGNANCY, SPONTANEOUS CONCEPTION DETECTED 8 DAYS BACK BY UPT , TOOK MTP KIT 7 DAYS BACK. CONTRACEPTIVE HISTORY: H/O USAGE OF CONDOMS

9. PERSONAL HISTORY REGULAR BOWEL AND BLADDER NORMAL SLEEP WAKE CYCLE MIXED INDIAN DIET GOOD APPETITE NO KNOWN ALLERGIES NO H/O SUBSTANCE ABUSE

10. MEDICAL/SURGICAL HISTORY: NOT SIGNIFICANT

11. FAMILY HISTORY NOTHING SIGNIFICANT

12. GENERAL PHYSICAL EXAMINATION PATIENT WAS CONSCIOUS, ALERT AND ORIENTED TO TIME, PLACE AND PERSON MODERATELY BUILT AND NOURISHED BMI: 25.6 KG/METRE SQUARE PALLOR++ NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA PR:120BPM BP:80/64MMHG WITH NORADRENALINE SPO2:98%IN RA

13. SYSTEMIC EXAMINATION RS: B/L NORMAL VESICULAR BREATH SOUNDS HEARD CVS: S1S2 HEARD, NO ADDED MURMURS CNS: NO FOCAL NEUROLOGICAL DEFICIT

14. PER ABDOMEN INSPECTION: ABDOMEN APPEARED SLIGHLY DISTENDED PREVIOUS LSCS SCAR APPEARED HEALTHY PALPATION: TENDERNESS PRESENT IN LEFT ILIAC REGION N O PALPABLE ORGANOMEGALY PERCUSSION: TYMPANIC AUSCULTATION: BOWEL SOUND PRESENT

15. P/S: CERVIX AND VAGINA APPEARS HEALTHY P/V:UTERUS SIZE COULD NOT BE ELICITED, LEFT FORNIX FULL, CERVICAL MOTION TENDERNESS PRESENT

16. PROVISIONAL DIAGNOSIS RUPTURED LEFT TUBAL ECTOPIC PREGNANCY

17. INVESTIGATIONS INVESTIGATIONS SENT IMMEDIATELY: BLOOD GROUP: A POSITIVE HB: 7.7 WBC:12270 PLATELET:140 S. UREA: 17 S. CREAT: 0.57 VIRAL SEROLOGY: NEGATIVE PT:10.3 INR:0.9 NA: 134 K: 3.6

18. MANAGEMENT LAPROTOMY- LEFT SALPINGECTOMY AND RIGHT SIDED TUBAL LIGATION DONE ON 13/4/22(2:15PM) INTRA-OP: HEMOPERITONEUM SEEN RUPTURED LEFT TUBAL E CTOPIC PREGNANCY SEEN WITH BLEEDING CONTINUING FROM THE RUPTURED TUBE. LEFT SIDED SALPINGECTOMY DONE AND SPECIMEN SENT FOR HPE RIGHT TUBAL LIGATION DONE (AS REQUESTED BY THE PATIENT) B/L OVARIES APPEAR HEALTHY AND WERE PRESERVED ABOUT 1700ML BLOOD AND 1L CLOTS REMOVED. HEMOSTASIS SECURED.

19. 4 PINTS FFP AND 1 PINT PRBC WAS GIVEN INTRAOP INTRA PERITONEAL DRAIN GIVEN. ABDOMEN CLOSED IN LAYERS .SKIN WAS CLOSED WITH ETHILON AS MATRESS SUTURE POST OP : 1 PINT PRBC WAS GIVEN NEXT DAY HB: 9.2MG/DL VITALS STABLE

20. POSTOP PERIOD WAS UNEVENTFUL PATIENT WAS DISCHARGED ON POD 7 AFTER SUTURE REMOVAL WITH HB 9.2G/DL

21. DISCUSSION

22. ECTOPIC PREGNANCY IMPLANTATION OF THE BLASTOCYST OCCURING OUTSIDE ENDOMETRIUM IS CALLED ECTOPIC PREGNANCY. MOST COMMON SITE:FALLOPIAN TUBE (AMPULLA>ISTHMUS>FIMBRIA>INTERSTITIUM)

23. RISK FACTORS PREVIOUS H/O ECTOPIC PREGNANCY SALPINGITIS PID IVF/ART SMOKING CONTRACEPTIVE FAILURES: IUCD, STERILISATION H/O GENITAL TUBERCULOSIS

24. SYMPTOMS: 4.SHOULDER TIP PAIN 5. FEATURES OF SHOCK 6. PASSAGE OF DECIDUAL CAST

25. SIGNS CERVICAL MOTION TENDERNESS PRESENCE OF ADNEXAL MASS PASSAGE OF DECIDUAL CAST

26. INVESTIGATIONS LEUCOCYTOSIS UPTO 30,000/MICROLITRE LOW HEMOGLOBIN RAISED ESR RAISED BHCG CULDOCENTESIS: HEMOPERITONEUM

27. ULTRASONOGRAPHY EMPTY UTERUS Complex adnexal mass DOPPLER : RING OF FIRE APPEARANCE IN TUBE

28. MANAGEMENT

29. UNRUPTURED ECTOPIC: MEDICAL MANAGEMENT: DOC: METHOTREXATE DOSE:50MG/METRE SQUARE REPEAT BHCG ON DAY4,DAY7 – FALL IN B HCG >15% IF LESS THAN 15% REPEAT METHOTREXATE INJECTION IF STILL LESS THAN 15% , GO FOR SURGICAL MANAGEMENT. 2 . SURGICAL MANAGEMENT:LAPROSCOPY IS PREFERRED IF FAMILY NOT COMPLETE: SALPINGOSTOMY, SALPINGOTOMY FAMILY COMPLETE: SALPINGECTOMY

30. RUPTURED ECTOPIC: STABLIZE THE Vitals of the PATIENT SURGICAL MANAGEMENT: SALPINGECTOMY

31. THANK YOU