What is the highest risk of ectopic pregnancy?

1What is the highest risk of ectopic pregnancy
2Risk factors of ectopic pregnancy
3Management of ectopic pregnancy
4Differential Diagnosis of ectopic pregnancy
5Cause of increasing incidence of ectopic pregnancy

The highest risk of ectopic pregnancy are:

1) Tubal mole
-Complete abortion (rare)
-Abortion
2) Tubal abortion
-Complete
-Incomplete.
-Tubal rupture.
-Tubal perforation.
-Continuation of pregnancy

Ectopic Pregnancy: Implantation of a fertilized ovum outside the uterine cavity

Normal fertilization occure in the Ampulla of fallopian tube

Normal site of fertilization: Posterior wall of uterine cavity near the fundus

Site of ectopic pregnancy:

-Fallopian tube

-Ovary

-Broad ligament

-Abdominal cavity

-Cervix

 What is the most common site of ectopic pregnancy?and Why?

Ampulla of the fallopian tube. Because It is the site of fertilization. And Most dilated part of the fallopian tube

Parts of fallopian tube(10 cm):

– Intramural (1 cm)

-Isthmus (3 cm)

-Ampulla (5 cm)

-Infundibulum (1 cm)

Risk factors of ectopic pregnancy:

-Pelvic inflammatory disorder

-Damage cilia

-Damage peristalsis of the fallopian tube

-History of induced abortion

-History of previous ectopic pregnancy

-History of previous tubal ligation

-Contraception (IUCD, LNG-IUS) – Cu 380

-History of ART

Q. Why chance of ectopic pregnancy higher in IUCD?

-Because IUCD altered the tubal motility

Types of Ectopic pregnancy:

-Acute ruptured ectopic pregnancy

-Unruptured ectopic pregnancy

-Chronic ectopic pregnancy

Acute rupture ectopic pregnancy

Management:

Symptoms: (Classical triad)

-Severe lower abdominal pain (100%)

-Amenorrhea for 6-8 weeks (75%)

-Slight Per vaginal bleeding (70%)

-Maybe the history of fainting attack.Characteristics of abdominal pain: Acute, severe, agonizing, colicky pain in the lower abdomen. Fallopian tube is situated in the pelvis, but the pain is felt in the iliac fossa. It may be unilateral or in hypogastrium.

Q. Why does faint attack happen?

Due to the rupture of ectopic pregnancy -> Bleeding started from the site -> Blood collection within the pelvic cavity – >Hemoperitoneum – >peritoneal  irritation ->Vasovagal stimulation ->Unconsciousness

Sign:

General examination:

Appearance: III looking

Varying degree of pallor (paper white)

Features of shock present (Hypotension, tachycardia, hypovolemia, cold clammy skin)

Per abdominal examination:

Abdominal distention due to collection in the pouch of Douglas

Muscle guard absent

Shifting duliness present

Abdomen is tense and tender.

Why Collection are accumulate in abdominal cavity pouch of Douglas?

-Due to the narrowing of the uterine tube.

-Pouch of Douglas is the most descended part of the peritoneum. so any fluid accumulated here easily.

Per vaginal examination:

-Cervical excitation tests positive (Means the Fornix are tender so that severe pain in movement)

-Boggy felt in the pouch of Douglas.

Investigation:

-Urine for pregnancy test (B-HCG): Positive after 7-10 days

-Serum B-HCG (positive after 1-2 days of missed period and doubling time of serum B-HCG will be prolonged)

-USG of uterus and adnexa (transvaginal sonography).

-Blood grouping

-RH typing

-CBC

-Serum progesterone (Normally > 25 ng/ml. In case of ectopic pregnancy,<5ng/ml.)

USG finding:

> Empty uterus

> A cystic structure or mass is found in the adnexa.

>Collection of fluid in the pouch of Douglas

> Ring of fire pattern in Doppler USG

The condition where B-HCG raised in:

>Muller pregnancy++++

>Intrauterine pregnancy ++

>Ectopic pregnancy

>Abortion

(Note): B-HCG remains raised till 2 weeks In case of the abortion and D&C. So we will do one serum B-HCG test today and another one after 48 hours. In the case of normal pregnancy, it will be negative. pregnancy doubling time will be positive even after 48 hours but in the case of ectopic pregnancy, it will be negative.

Treatment:

>Spontaneous Resuscitation

>laparotomy followed by ipsilateral Salpingectomy

>Resuscitation:

> Start the IV fluid with Hartman’s solution.

> Blood is sent for blood grouping and RH typing and arrange at least two units of crossed-matched blood.

> IV broad-spectrum antibiotics

>Catheterization

> Monitor the vital signs.

Specific Treatment: Laparotomy followed by ipsilateral salpingectomy.

When to transfuse blood in ectopic?

-After ligation of the rupture site, ligation by catgut 1.0 (absorbable), proline, and silk are not absorbable.

 Can we do D&C and Laparoscopy Acute rupture ectopic pregnancy?

-We never do D&C and Laparoscopy in ARE due to Time consuming .Collection of blood in the peritoneum of the patient, there will be no clear view due to blood. But in the case of UP, we can do a laparoscopy

Unruptured Ectopic pregnancy:

How to diagnose unruptured ectopic pregnancy?

By History: Feeling of uneasiness in one side of the flank which may be continuous and colicky in nature.

By Bimanual examination: A pulsatile well-circumscribed tender mass in one side of the fornix.

Investigation:

1. Transvaginal sonography

Findings:

-Empty uterine cavity with pregnancy tests positive

-Fluid collection in the pouch of douglas

– An adnexal mass is present separated from the ovary.

2 Color Doppler

Findings:

-Ring of fire pattern

Treatment: (3 modalities of treatment)

-Expectant management

-Conservative management

       Medical

       Surgical

3. Definitive management

Expectant management: (Criteria)

– If the patient is asymptomatic

-If the patient is hemodynamically stable

-Gestational sac diameter < 3.5 cm

-B-HCG level s 1500 lUA.

-No cardiac activity of the fetus

Treatment:

-Only follow up with B-HCG twice weekly until the level 20 IU/Liter

 -Follow up with transvaginal sonography to see whether sac size decreasing or not

-Spontaneous resolve within (3-5 weeks)

Conservative Medical treatment:

-Methotrexate

-Hyperosmolar glucose

-Prostaglandin F2 alpha

-20% Potassium chloride

-Actinomycin D

-Vasopressin

Chemotherapeutics agent

Dose of Methotrexate:

IM 500 mg/m? body surface area, single dose.

We can give the same drug ultrasonographically or laparoscopically directly fallopian tube by direct local injection. this process is called salphingosentasis.

If you give Methotrexate today, it’s Day -0. We will compare serum B-HCG levels on the 4th and 7° day. If the declining rate of serum B-HSG is more than or equal to 15% then 2nd dose of methotrexate is given. But if the declining rate is less than 15% then 2nd dose is not given.

Criteria:

If the patient is hemodynamically stable Gestational sac diameter < 4 cm B-HCG level ‹ 3000 IU/L No cardiac activity of the fetus

Conservative Surgical treatment:

Criteria:

-Not fulfill the criteria for medical management

-No decrease in size after medical treatment Fetal cardiac activity present

Surgery Name:

-Salpingostomy (Don’t close the incision, it will heal up by the secondary healing process)

-Salpingotomy (Longitudinal incision in anterior mesenteric border and product should be removed by manipulations and finally close the incision)

-Segmental resection and end-to-end anastomosis

-Fimbrial expression

Definitive Surgery: Laparotomy followed by Unilateral salpingectomy

Q. Why it is conservative?

Because we preserve the fallopian tube

Differential Diagnosis of ectopic pregnancy:

-Acute appendicitis

-Ruptured corpus luteum cyst

-Twisted ovarian tumor

-Ruptured endometriosis

-Intestinal obstruction

Cause of increasing incidence of ectopic pregnancy:

-Rise in the incidence of ST and salpingitis

-Rise in the incidence of pregnancy following ART

-Increased tubal surgeries

-Early detection of the case by US and serum B-HCG

FAQ

Qus:-Why chance of ectopic pregnancy higher in IUCD?

-Because IUCD altered the tubal motility

Qus:-What is the definitive surgery of ectopic pregnancy?

– Definitive Surgery: Laparotomy followed by Unilateral salpingectomy

Qus:-Why Collection are accumulate in abdominal cavity( pouch of Douglas)?

-Due to the narrowing of the uterine tube. And Pouch of Douglas is the most descended part of the peritoneum. so any fluid accumulated here easily

If you want to know about biggest indicator for pre-eclampsia then click on this.

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