ECTOPIC PREGNANCY

Definition

An ectopic pregnancy or extrauterine

pregnancy is one in which a fertilized
ovum (the zygote) implants in an area
outside the uterine cavity.
 INCIDENCE

Between 0.20% and 1.4% of all pregnancies

Incidence of ectopic pregnancy is increasing
worldwide
Here in UPTH, we probably see a ruptured
ectopic, pregnancy every week
Combined intra & extrauterine pregnancy
(Heterotropic Pregnancy) 1:17 – 30,000
pregnancy
 SITES

99% of ectopic pregnancy occur in the

fallopian tubes
55% at the ampulla
25% at the isthmus
17% at the Fimbriae
2% at the interstitium
1% at the corna, ovary, peritoneum, cervix
 AETIOLOGY
The primary causes of ectopic pregnancy
include conditions that either prevent or
impede passage of a fertilized ovum
through the fallopian tube.
Tubal factors
PID, STD, Surgery
Developmental abnormalities of the tubes
– congenital diverticula, accessory ostia or atresia
– abnormal tubal anatomy due to exposure to
diethylstilbestrol (DES) exposure in utero
– endometriosis, Tortuosity of tube
 AETIOLOGY cont.
 Zygote abnormalities
Sperm abnormalities
 Ovarian factors
Fertilization of an unextruded ovum
Transmigration of an ovum
 Other factors
• IUCD (2 in 1000 IUD cases) (1 in 8 being
primary ovarian pregnancy)
• Endometriosis
• IVF ET
 PATHOLOGY
Trophoblast implants may invade tubal musculature to
grow
The wall becomes very thin and eventually ruptures
Growth may be predominantly intraluminal
Penetration of tubal blood vessel, haemorrhage and
separation of the product of conception from the
implantation site Leads to embryonal death, cessation
of trophoblastic activity and tubal abortion
An abdominal pregnancy is very rare (1 per 15000
pregnancies)
May be secondary to tubal rupture or abortion with
trophoblast maintaining its tubal attachment or the
entire ovum implanting again at another site
 CLINICAL FEATURES
Ectopic pregnancy remains the great mimic of
gynaecology

No specific symptoms or signs are pathognomonic

of ectopic pregnancy

There should be a high index of suspicion

patient may experience fainting attack, shoulder tip

pain and symptoms and signs of blood loss
 SYMPTOMS AND SIGNS
Abdominal pain(99% of cases)
– may be present even prior to rupture
– Extensive intraperitoneal bleeding
– decidual cast passed per vaginam will mimic products of conception
as in abortion
– Syncopy or fainting, collapse is present in 37% of cases
Evidence of blood loss. Pulse Bp
Abdominal tenderness present in 80% of cases
If ruptured with haemoperitineum, rebound tenderness, fluid in
peritoneum
Adnexal tenderness on VE. Fullness of POD Adnexal mass if
unruptured
Bimanual exam should be gentle
Fever is unusual and occurs in only 2%
 INVESTIGATIONS
Hb
+ Pregnancy Test
Culdocentesis
USS
Laparoscopy
• very useful in unruptured and ruptured ectopic
pregnancy
• Rule out differentiate diagnosis.
D&C
Exploratory laparotomy
Quantitative HcG
Transvaginal ultrasound scan
 DIFFERENTIAL DIAGNOSIS

Ruptured or twisted ovarian cyst acute

PID and tubovarian abscess
Mittleschmerz
Abortion
Ruptured corpus luteum cyst
Appendicitis
 COMPLICATION

If untreated or missed diagnosis;

– Maternal death
– Majority of these death are preventable
1:1000 ectopic.
– Infertility or sterility may follow surgery for
extrauterine pregnancy.
 TREATMENT
Emergency treatment
If there is evidence of haemoperitoneum with
clinical shock, Bp, pulse following rupture, there
is little room for delay
Withdraw blood for Hb and crossmatch
immediately and set up a plama expander to
correct shock
Take patient to theatre for a laparotomy
– Salpingostomy
– Milking
– Salpingectomy
– end/end anastomosis
 TREATMENT cont.
Autotrasfusion using the patients own citrated
and filtered blood
Other Surgical Techniques Through
Laparoscopy
Aspiration
End/end anastomosis
Salpingostomy
Fetocide injection-
Methotrexate
KCL
PG E2 or F2 &
Mifepristone
 TREATMENT cont.

Medical Treatment
Systemic Methotrexate
Response must be monitored with 48 hourly
HCG determinations and TVS
– Ru 486 mifepostone, Actinomycin D
 TREATMENT cont.

RADICAL OR CONSERVATIVE
Conservation
•Funbrial evacuation
•Linear Salpingostomy
•Mid-tubal resection

Radial Surgery
•Salpingectomy
•Oophorectomy
•Cornual resection
 PROGNOSIS

Another ectopic pregnancy will occur

in 10 – 28% of patients treated.

50% of patient treated may have

infertility.
 SUMMARY
Common life threatening emergency in gynae.
Incidence is increasing.

High index of suspicious in our practice: Commonly

ruptured ectopic present in our casualty. Commonly
diagnosed unruptured ectopic in Western world
therefore a move to more conservative surgery.

Diagnosis by quantitative HCG + TVS with

laparoscopy.