|Video: Ectopic Pregnancy Overview|
|Watch Video: Ectopic Pregnancy DETAILED – Overview|
Ectopic Pregnancy: A pregnancy in which the fetus develops outside the womb, typically in a fallopian tube
Amenorrhoea: Absence of mentruation
Laproscopy: A surgical procedure in which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery
Laparotomy: A surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery
Salpingectomy: Surgical removal of the fallopian tubes
Salpingostomy: Creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure
|Remember The most common site for ectopic pregnancies is a fallopian tube.|
More than half of patients with ectopic pregnancy have no risk factors.
|Remember Although pregnancy is unusual after tubal ligation, when it does occur there is a relatively high chance (1 in 6) of it being an ectopic pregnancy|
Signs and Symptoms
Clinical Presentation differs if the patient has an ectopic or an ruptured ectopic.
- Ectopic Pregnancy is often asymptomatic.
- Amenorrhea because of pregnancy
- Pelvic pain and tenderness (palpation and bimanual examination).
- Vaginal bleeding
- Faint and nauseous.
If rupture of ectopic occurs, there is blood, acute abdomen with increasing pain (+/- shoulder tip pain), abdominal distention and signs of shock.
|Ectopic Pregnancy Triad: amenorrhea, vaginal spotting, and abdominal pain.|
|Remember Rule out ectopic pregnancy in a female patient in reproductive age who presents with an acute abdomen regardless of history and examination findings.|
Differential Diagnosis for ectopic pregnancy
- Acute salpingitis
- Ruptured corpus luteum
- Acute appendicitis
- Dysfunctional uterine bleeding
- Adnexal torsion
- Degenerating leiomyomata
For any pregnant lady presenting with abdominal pain and/or vaginal bleeding the most important investigations:
- Urine analysis
- β-hCG – Pregnancy test is almost always +ve, but serum B-HCG levels are lower than expected for normal pregnancy
Other Investigations to support or rule out differentials
|Remember Levels of hCG that plateau in the first 8 weeks of pregnancy indicate an abnormal pregnancy, which may either be a miscarriage or an ectopic pregnancy.|
When the hCG level equals or exceeds 1500 to 2000 mIU/mL, an intrauterine gestational sac is usually seen on transvaginal ultrasound; in fact, when the hCG level meets or exceeds this threshold and no gestational sac is seen, the patient has a highikelihood of an ectopic pregnancy
|B-HCG levels and correlation|
|b-HCG rising normally|
|b-HCG rising but not normally|
|b-HCG is decreasing||failed pregnancy (eg, spontaneous abortion, tubal abortion, spontaneously resolving ectopic pregnancy).|
Management option depends on clinical presentation and setting. Emergency setting where the patient is haemodynamically unstable will be discussed in the next section.
- Watch and wait for resolution – if detected early and not symptomatic
- Medical treatment using Methotrexate – if β-hCG not going down
- Surgery – is symptomatic
- Laproscopy (Key hole surgery) +/- salpingectomy or salpingostomy
- Laparotomy (Open surgery) +/- salpingectomy or salpingostomy
|Remember Salpingectomy is removal of the fallopian tube (uterine tube). Salpingostomy is removing a section of the fallopian tube (uterine tube)|
|Indications for salphingectomy|
|Recurring ectopic pregnancies or are > 5 cm|
|Severely damage tubes|
|No future childbearing is planned|
Methotrexate therapy The optimal candidates for MTX treatment of ectopic pregnancy are hemodynamically stable, willing and able to comply with post-treatment follow-up, have a human chorionic gonadotropin (hCG) concentration ≤5000/mL, and no fetal cardiac activity.
Contraindications for ectopic include renal failure, immunodeficiency, allergy, heterotopic pregnancy with coexisting viable intrauterine pregnancy, breastfeeding, unable to complete methotrexate management
|Pharmacology Methotrexate is a folic acid antagonist widely used for treatment of neoplasia, severe psoriasis and Rheumatoid arthritis. Side effects of methotrexate is conjunctivitis and gastrointestinal upset.|
Haemodynamically unstable patients (ruptured ectopic)
Signs and symptoms
- Acute abdomen with worsening pain
- Abdominal distention
- Shoulder tip pain (kehr’s sign)
- Signs of shock
- Two large-bore IV line and IV fluids
- Cross match 6U blood
- Call senior help and aesthetics assistance urgently
Surgery – Laparotomy with salpingectomy