1. ECTOPIC PREGNANCY Tayebeh gharibi

2. Ectopic Pregnancy Occurs when the conceptus implants either outside the uterus (Fallopian tube, ovary or abdominal cavity) or in an abnormal position within the uterus (cornua cervix).

3. Epidemiology & Risk Factors: Between 95% and 98% occur in the fallopian tube.Between 95% and 98% occur in the fallopian tube. More than 50% of tubal pregnancies are situated in the ampulla.More than 50% of tubal pregnancies are situated in the ampulla. Approximately 20% occur in the isthmus.Approximately 20% occur in the isthmus. Around 12% are fimbrial.Around 12% are fimbrial. Approximately 10% are interstitial.Approximately 10% are interstitial.

4. Understanding The Pathophysiology

5. In theory, any mechanical or functional factors that prevent or interfere with the passage of the fertilized egg to the uterine cavity may be aetiological factors for an ectopic pregnancy.In theory, any mechanical or functional factors that prevent or interfere with the passage of the fertilized egg to the uterine cavity may be aetiological factors for an ectopic pregnancy. 50% operated for ectopic pregnancy have evidence of chronic pelvic inflammatory disease.50% operated for ectopic pregnancy have evidence of chronic pelvic inflammatory disease.

6. Implantation occurs into a site of the tube that offers a sufficient area for placentation.Implantation occurs into a site of the tube that offers a sufficient area for placentation. The process is very similar to that of an intrauterine pregnancy.The process is very similar to that of an intrauterine pregnancy. For the conceptus penetrates the tubal mucosa and becomes embedded in the tissues of the wall.For the conceptus penetrates the tubal mucosa and becomes embedded in the tissues of the wall. The extravillous trophoblast will penetrate the full thickness of the muscular layer of the tube to reach the subserosa and the tubo-ovarian circulation.The extravillous trophoblast will penetrate the full thickness of the muscular layer of the tube to reach the subserosa and the tubo-ovarian circulation.

7. Due to its limited distensibility, the tube will ruptureDue to its limited distensibility, the tube will rupture Although this event is usually accompanied by fetal death.Although this event is usually accompanied by fetal death. Occasionally following rupture the fetus retains sufficient attachment to its blood supply to maintain viability and secondary abdominal pregnancy can proceed to term.Occasionally following rupture the fetus retains sufficient attachment to its blood supply to maintain viability and secondary abdominal pregnancy can proceed to term.

8. In an ectopic pregnancy, the uterine endometrium usually responds to the hormonal changes of pregnancy and undergoes focal decidua changes (Arias-Stella reaction).In an ectopic pregnancy, the uterine endometrium usually responds to the hormonal changes of pregnancy and undergoes focal decidua changes (Arias-Stella reaction). If the ectopic pregnancy miscarries, the uterine decidua may slough off as a cast, but more commonly as fragments mixed with small blood clots.If the ectopic pregnancy miscarries, the uterine decidua may slough off as a cast, but more commonly as fragments mixed with small blood clots.

9. mechnical AnatosalpingitisyAnatosalpingitisy Pelvic surgeryPelvic surgery IudIud TumorTumor Preferal adheisionPreferal adheision endosendos

10. functional Hormonal(minipill,iud,ocp)Hormonal(minipill,iud,ocp) SmokingSmoking endometriosisendometriosis

11. Clinical Features

12. Vaginal bleeding - (usually old blood in small amounts) and chronic pelvic pain (iliac fossa, sometimes bilateral) are the most commonly reported symptoms.

13. General Examination Shoulder pain which may occur secondary to blood irritating the diaphragm and vascular instability characterized by low blood pressure, fainting, dizziness and rapid heart rate may be noted.Shoulder pain which may occur secondary to blood irritating the diaphragm and vascular instability characterized by low blood pressure, fainting, dizziness and rapid heart rate may be noted. Symptoms are present in about 59% of patients and most typical patients whose ectopic pregnancy has ruptured (intra-abdominal bleeding).Symptoms are present in about 59% of patients and most typical patients whose ectopic pregnancy has ruptured (intra-abdominal bleeding).

14. Gynaecological Examination Speculum or bimanual examination must be performed in an environment where facilities for resuscitation are available, as this examination may provoke the rupture of the tube.Speculum or bimanual examination must be performed in an environment where facilities for resuscitation are available, as this examination may provoke the rupture of the tube.

15. Laparoscopy & Uterine Curettage The mere absence of placental villi in the curretage does not completely exclude a diagnosis of ectopic pregnancy because an ectopic pregnancy in a tube, cornu or the cervix may partially abort.The mere absence of placental villi in the curretage does not completely exclude a diagnosis of ectopic pregnancy because an ectopic pregnancy in a tube, cornu or the cervix may partially abort.

19. Human chorionic gonadotrophin and transvaginal ultrasound One of the most important parameters is the discriminatory hCG level above which the gestational sac of an intrauterine pregnancy should be detectable by ultrasonography (usually 1000iu/L).One of the most important parameters is the discriminatory hCG level above which the gestational sac of an intrauterine pregnancy should be detectable by ultrasonography (usually 1000iu/L). An empty ectopic sac or a hetero genous adnexal mass is a more common ultrasound feature.An empty ectopic sac or a hetero genous adnexal mass is a more common ultrasound feature.

20. The presence of fluid in the pouch of Douglas is a non-specific sign of ectopic pregnancy.The presence of fluid in the pouch of Douglas is a non-specific sign of ectopic pregnancy. 10-20% ectopic pregnancies, a pseudogestational sac is seen as a small, centrally located endometrial fluid collection surrounded by a single echogenic rim.10-20% ectopic pregnancies, a pseudogestational sac is seen as a small, centrally located endometrial fluid collection surrounded by a single echogenic rim. Laparoscopy should be considered in women with hCG above the discriminatory level and absence of an intrauterine gestational sac on ultrasound.Laparoscopy should be considered in women with hCG above the discriminatory level and absence of an intrauterine gestational sac on ultrasound.

21. Management

22. Treating ectopic pregnancy has always been surgical (salpingectomy or salpingotomy), either by laparotomy or laparoscopy.Treating ectopic pregnancy has always been surgical (salpingectomy or salpingotomy), either by laparotomy or laparoscopy. Non-surgical (medical) therapeutic approaches have been introduced, such as puncture and aspiration of the ectopic sac, local injections of prostaglandins, potassium chloride, hyperosmolar glucose or methotrexate.Non-surgical (medical) therapeutic approaches have been introduced, such as puncture and aspiration of the ectopic sac, local injections of prostaglandins, potassium chloride, hyperosmolar glucose or methotrexate.