Ectopic Pregnancy😍

ECTOPIC PREGNANCY

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M/c site

  • Fallopian tube
    • Ampulla.

Earliest rupture

  • Isthmus

Late rupture

  • Interstitial/intramural
    • Cornual pregnancy

M/c nontubal site

  • Ovary

L/c site

  • Caesarean scar/cervix

Heterotopic pregnancy

  • Twin pregnancy;
    • one intrauterine, other ectopic.
  • Mx: Always surgical.

Risk Factors

  • Maximum risk:
    • Previous H/O ectopic pregnancy >
    • Previous H/O tubal ligation >
    • MIRENA > IUCD > POP
  • M/C risk factor:
    • PID/salpingitis.
  • Contraceptives:
    • Decrease absolute risk of ectopic.
    • If failure of contraception occurs, ectopic pregnancy risk is increased.

Presentation

  • Female with 6-8 weeks amenorrhea.
  • Pain in abdomen, spotting.
  • Vitals unstable, UPT+ve.

Triad of Symptoms

  • Amenorrhea (6-10 weeks), pain in lower abdomen and bleeding P/V.

Symptoms To Suspect Ruptured Ectopic

  1. Orthostatic hypotension.
  1. Shoulder tip pain.
  1. Urge to defecate
    1. D/t blood at pouch of Douglas

Signs: Ruptured Ectopic

  1. Shock (↑PR, ↓BP).
  1. P/A: Abdominal distension, rebound tenderness.
  1. If localizing signs.
  • Hemoperitoneum.
    • Guarding +.
    • Rigidity +.

P/V Finding

  • Most important: Adnexal mass.
  • Cervical movement tenderness:
    • Due to peritonitis (Also seen in PID).
  • Uterus is soft and enlarged.
  • Size is less than POG.

Next Step

  • If on P/A, guarding and rigidity present:
    • Confirms hemoperitoneum.
    • No need for further imaging and confirmation
    • Mx: Sx of ruptured ectopic.
  • If guarding and rigidity are not present:
    • FAST → confirm diagnosis.

Site Criteria.

  • Cervical:
    • Palman (new) , Rubin criteria (old)
    • Mnemonic: Palm in cervix
    • D/d → abortion products from uterus
      • Diff by sliding sign
    • Rubin’s diagnostic criteria
      • Uterine bleeding
        • After a period of amenorrhea
        • No pain
      • Cervix
        • Equal to or larger than the uterine fundus
      • Products of conception
        • Completely confined within the endocervix
        • Firmly attached to the endocervical wall
      • Closed internal cervical os
      • Partially opened external cervical os
        • notion image
  • Abdominal:
    • Studdiform criteria
    • ↑ risk of adherent to other structures
    • Can retain placenta if adherent
      • Mnemonic: Stud in abdomen
  • Ovarian:
    • Spiegelberg criteria
      • Mnemonic: Oval (Ovarian) shaped eagle (Spiegel)
          • notion image

Investigation

  • Culdocentesis
    • For ruptured ectopic
    • Blood does not clot on standing: Hemoperitoneum.
    • Blood which clots on standing: Entered into vessel.
        • notion image
 

Management of Ruptured Ectopic

  • Always surgical.
  • No role of conservative management or medical management.
  • Route of surgery:
    • If vitals stable: Laparoscopy.
    • If unstable vitals: Laparotomy.
  • Surgery of choice:
    • U/L salpingectomy.
    • Never Salpingostomy
  • Surgeries never done for ruptured ectopic:
    • Salpingo-oophorectomy.
    • Linear salpingostomy (Done for unruptured ectopic).

Note

  • Salpingectomy
    • Ruptured ectopic
    • Family complete
    • Sac ≥ 5 cm

Unruptured Ectopic

Note:
  • Late rupture of tubal pregnancy commonly observed in
    • Interstitium

Investigations done in Unruptured Ectopic

  • IOC for ectopic
    • TVS >
    • Serial β HCG
  • Gold Standard
    • Diagnostic Laparoscopy

Ix which may be done:

  • S. progesterone.
    • < 5 ng d/d
      • Ectopic
      • Abortion
    • 20 - 25 ng
      • Normal viable pregnancy
  • Culdocentesis (Ruptured ectopic).

Ix never done:

  • Hysteroscopy.
  • HSG.
  • Colpotomy (Drainage of pelvic abscess).

1. TVS:

Heterotropic Pregnancy

  • Ectopic + Uterine pregnancy

Confirmed sign of ectopic pregnancy:

  • Gestational sac + yolk sac ± cardiac activity
  • seen in fallopian tube.

Suspicion of ectopic if seen on USG:

  • Adnexal mass (M/c finding on USG).
  • Tubal ring / Bagel / Blob sign: (Only gestational sac +).
    • Echogenic tubal ring surrounding ectopic sac.
        • notion image

Empty uterus.

Ring of fire appearance.

  • Shows surrounding peripheral vasculature.
      • notion image
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Ruptured ectopic pregnancy:

  • Fluid accumulation in POD and paracolic gutters.
  • Patient presents with shock.
  • History of early trimester PV bleed.

2. Beta-hCG:

  • Critical value of hCG:
    • Value of hCG above which in all intrauterine pregnancies, gestational sac is visible inside uterus.
    • TVS: 2000 IU.
    • TAS: 6500 IU.

Algorithm for Diagnosis of Unruptured Ectopic

Do TVS.

  • Gestational sac + yolk sac in fallopian tube:
    • Confirms unruptured ectopic.
    • Next step: Medical Mx of ectopic.
  • Signs suspicious of ectopic seen on USG:
    • Next step: b-hCG.
        1. Value above critical level (≥2000 IU):
            • Next step: Medical Mx.
        1. Value below critical level (<2000 IU):
            • Next step: Repeat hCG after 48 hours.
              • hCG decreases:
                • Abortion.
              • hCG increases by ≥66% (Nearly double):
                • Viable intrauterine pregnancy.
              • hCG increases by <33% (Slow rise):
                • Ectopic pregnancy.

Management of Unruptured Ectopic

Medical Mx:

  • Best Mx
  • DOC: Methotrexate (MTX).
    • C/I
      • Hepatotoxicity
      • P. Fibrosis
  • Frequency:
    • Single dose therapy → NO FOLINIC ACID
  • Dose:
    • 1 mg/kg OR 50 mg/m sq
  • Route: IM.

Prerequisites for MTX (Absolute requirement):

  • If any not met → Surgical management
    • Patient: Vitally stable.
    • No rupture/ hemoperitoneum
    • Family: Not complete.
    • Size of ectopic: <4 cm.
    • Subsequent Beta-hCG: 5000 IU.
    • Cardiac activity: absent

Treatment algorithm:

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  • Day 1: Baseline b-hCG + Inj. MTX.
  • Check b-hCG between day 4 & day7.
    • Value ↓by ≥15%: Successful medical Mx.
    • Value ↓but <15%: Repeat Inj. MTX (Max. 3 times).
    • Value ↑: Failed medical Mx.
  • Desired results not obtained: Laparoscopic sx.

Laparoscopic sx:

  • Size of ectopic: ≥ 5 cms.
  • Failed medical Mx.
  • Any prerequisite not fulfilled
  • Family:
    • Complete: U/L salpingectomy.
    • Not complete: Linear salpingostomy.