1. Ruptured ectopic pregnancy
Dr. Megha Jain
University College of Medical Sciences & GTB Hospital, Delhi

2. Ectopic Pregnancy
Definition: fertilized ovum is implanted and developes outside the normal uterine cavity.
Incidence: 20 in 1000 pregnancies
Responsible for 7% of all pregnancy related maternal deaths.
Most common cause of death: hemorrhage(92%)
Infection(3%)
Embolism(3%)
Anesthetic complication(1%)
> 30% patients with ectopic suffer from infertility and 5-20% develop recurrent ectopic.

3. Etiology
Factors preventing or delaying migration of fertilized ovum: PID Contraceptive failure - Tubal reconstructive surgery - ART(ovulation induction drugs) - Previous ectopic Prior induced abortion - Developmental defects of the tube

4. Types of Ectopic Implantation site Extrauterine Uterine
- tubal cervical
- ovarian angular
- abdominal cornual

5. Tubal Ectopic 1. Ampulla(64%) 2. Isthmus(25%) 3. Infudibulum(9%)
4. Interstitial(2%)

6. Clinical Presentation
Depends on gestational age, site of implantation and occurrence of hemorrhage
Classical features of ruptured ectopic: - Short period of amenorrhea
- Acute abdominal pain
- Vaginal bleeding
O/E - severe pallor
- features of shock
- tense and tender abdomen
- uterus smaller than expected for dates
- tender adnexal mass.

7. How to diagnose?
Positive pregnancy test with absence of intrauterine gestational sac on USG
Serum progesterone <5 ng/ml
Serial beta HCG - ↓, plateau, show a subnormal rise
Culdocentesis- aspiration of non clotting bloody fluid

8. Differential Diagnosis
Threatened, inevitable or incomplete abortion
Acute appendicitis
Perforated peptic ulcer
Ruptured ovarian cyst
Ovarian torsion
Ruptured endometrial cyst

9. Management Laproscopy Resuscitation and laprotomy
Unruptured tubal ectopic Ruptured ectopic
Expectant Medical/
Surgical mgmt Salpingectomy
Pt. hemodynamically
stable
Patient in shock

10. Anesthetic management of ruptured ectopic
Two large gauge i/v cannula with RL
Arrange blood and blood products
Routine noninvasive monitoring, consideration of invasive hemodynamic monitoring(arterial line,CV line)
Foleys catheterisation
General anesthesia
RSI with cricoid pressure

11. GA (contd….)
Ketamine for induction(thiopentone or propofol if intravascular volume is restored)
Succinylcholine for endotracheal intubation
Maintenance with O2, N2O, volatile halogenated agent as tolerate
Reversal of muscle relaxant and extubation when the patient is awake and responds to verbal commands.

12. References
Obstetric Anesthesia- Principles and practice David H. Chestnut 3rd edition
Anesthesia for Obstetrics- Shnider and Levinson’s 4th edition
Miller’s Anesthesia- Ronald D. Miller 6th edition
Textbook of obstetric anesthesia- Colli’s 5th edition
Principles and practice of critical care in obstetrics – A.Bhattacharya,S.Ahuja,A.K.Saxena.
International anesthesiology clinics-2005,vol.43,no.4.
Textbook of obstetrics- D.C.Dutta 6th edition

13. Thank You