Ectopic Pregnancy By Rohan Kulkarni

Defination. Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity. 1 in 100 ( from 1:25 to 1:250) normal pregnancies (incidence)

Recurrence rate - 15% after 1st, 25% after 2 ectopics Recent evidence shows that the incidence of ectopic pregnancy has been rising in many countries. USA-5 fold UK-2 fold France 15/1000 pregnancies India-1in100 deliveries Recurrence rate - 15% after 1st, 25% after 2 ectopics

Overview. Incidence Increasing (Ќ 1:66 Pregnancies) Mortality Decreasing With Better Detection Surgical and Medical Treatment Available Recurrence Rate ~ 15%

Aetiology Any factor that causes delayed transport of the fertilised ovum through the. Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired. CONGENITAL - Tubal Hypoplasia, Congenital diverticuli , Accessory ostia , Partial stenosis Previous Ectopic Pregnancy PID

Migration of the Ova Externa Pelvic Abnormalities (Fundul Fibroma, adenomiosis of Fallopian Tubes) Tubal Reconstrustive Surgery Tubectomy Operation Infertility IUD (~4% pregnancies with IUD in Situ are Ectopic, Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy) IVF Induction Ovulation with Gonadotropins Extraneous Factors (Appendicitis, Endometriosis)

Sites Ampulla (78-95%) Isthmus (8-12%) Interstitial portion (2%) - very rare form Cornua (< 2%) or in accessory horn Ovary (0,5-3%, 20-30% in IUD users) Abdomen (< 2%): Primary - very rare. Secondary. Cervix (< 2%) Combined Uterine Pregnancy and Ectopic Gestation - 1-3% in IVF, 1:4 000 - 1: 30 000

1 - Fimbrial 2 - Ampullary 3 - Isthemic 4 - Interstitial 5) Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament 10) Primary abdominal

Tubal Pregnancy at USG Detailed view of ectopic (thick, brightly echogenic, ringlike structure outside the uterus) Tubal pregnancy circled in red 4.5 mm fetal pole (between cursors) in green Pregnancy yolk sac in blue

Tubal Pregnancy After laparoscopic resection of the tube, the tubal stump is seen at S Close view of the same ectopic

Tubal Pregnancy Right tubal ectopic pregnancy in 11 th Same situation after rupture Right tubal ectopic pregnancy in 11 th week of gestation

Ovarian Pregnancy Ovary is the white structure in the middle Pregnancy is implanted on the far right side of the ovary at the "X„ Around the ovary are seen bleeding and clotted blood

Symptoms Amenorrhea in 75% cases Abdominal Pain - in 95% cases. Shoulder and Epigasrtric Pain Vaginal Bleeding Syncope Pelvic Mass

Clinical classification. Unruptured (Progressive) - without specific sings Tubal Abortion - minimal sings Tubal Rupture (into the peritoneal cavity or between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock

Diagnosis History and Physical Exam Vaginal Examination Serial Quantitative -hCG (BSU) Ultrasound TAS & TVS Progesterone Level? Culdocentesis Laparoscopy D&C

-hCG* Levels Double Every 48 Hrs < 66% Rise / 48 Hrs Consistent With Ectopic Pregnancy Single Determination Not Helpful Best If Done Within Same Laboratory Ultrasound Never May or May Not Be Helpful Rules Out Ectopic Pregnanc

Culdocentesis Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood Negative Tap Inconclusive May Obviate U/S Most Helpful in Emergent Situations to Confirm Diagnosis, But Remains Controvers

Differential diagnosis Appendicitis (Perforated) , PID Rupture of Follicle or Corpus Luteum Cyst Threatened Abortion Splenic Rupture Perforated Gastric or Duodenal Ulcer Acute Pancreatities Myocardial Infarct Pyosalpinx Septic Abortion Pelvic Abcess Retroverted Gravid Uterus Twisted Ovarian Cyst, Rupture of Chocolate cyst

Treatment Observation Laparoscopy Laparotomy MTX (methotrexate) Hyperosmolar Glucose KCl RU-486 Prostaglandin F2 alfa

Laprotomy Acute Ectopic Gestation Salpingoectomy Secondary Abdominal Pregnancy Interstial Pregnancy Cornual Pregnancy Cervical Pregnancy

Laparoscopy Allows Diagnosis and Treatment Salpingostomy Salpingectomy (Total / Partial) Cornual Resection Minimally Invasive, Unlike Laparotomy Few Contraindications: Unstable Patient (Possibly)

mxt Toxic to Trophoblast Cells Minimal Side Effects May Preserve Fertility in Cases of Cervical Pregnancy Requires Compliant Patient, Time Pain Not Uncommon 25-50 mg into Gestational Sac Tubal Patency is Restored in 82% cases Oral - 50-100 mg (toxicity on GIT) Intramusculary 1 mg/kg

Cervical Pregnancy Incidence 1:1 000 Profuse painless bleeding following a short period of Amenorrhea PE: a patulous external os and products of conception in the cevical canal, internal os is closed and the uterus is firm and normal in size US helps in the correct diagnisis Treatment: - Suction Evacuation and Tamponade by inserting a distended Foley Catheter for 24 hours - Hysterectomy - Hysteroscopic Resection using Resectoscope , MTX

Outcomes 15% Repeat Ectopic Rate Ectopics: 33% Pregnancy Rate No Benefit To Removing Ovary Along With Tube

Ectopic Pregnancy is a Common, Treatable Problem Sensitive -hCG Assays Allow Early Detection Surgical and Medical Options Exist

Thank you for attention.