Risk factors for ectopic pregnancy:

Related to genital tract:

•           History of PID (pelvic inflammatory disease); present salpingitis.

•           Contraceptive failure (progesterone containing pills ,copper containing IUCD)

•           Previous H/O ectopic pregnancy.

•           History of infertility treatment

•           ART (artificial reconstruction technology)

•           Development defect of the tube.

•           Transperifonal migration of the ovum.

•           Previous induced abortion. Salpingitis isthmica nodosa.

Unrelated to genital tract:

•           Current cigarette smoking.

•           Multiple partners

•           Intercourse before 18 years.

•           In utero DES exposure.

•           Age >4oyears.

Surgical:

•           Tubal constructive surgeries.

•           Tubal sterilization.

Acute ectopic:

LESS COMMON (30%)

It is associated with cases of tubal rupture or tubal abortion with massive intraperitonal haemorrhage

Symptoms

Classic triad of disturbed tubal pregnancy are: amenorrhea (75%), followed by abdominal pain (10) and vaginal bleeding (70%)

The above triad may be accompanied by nausea, vomiting, fainting attacks (even syncope in 1 cases).

Examination:

General examination:

•           Patient lies quiet and conscious, perspires and looks blanched.

•           Pallor present.

•           Features of shock: rapid and feeble pulse, fall of blood pressure, cold clammy extremities.

Per abdomen -

•           Abdomen is tense, tumid and tender.

•           Shifting dullness may be present.

•           Rigidity/ guarding +1-

•           Cullen's sign - bluish discolouration around the umbilicus may be present.

On Bimanual examination:

•           Vaginal mucosa appears blanched.

•           Uterus- normal size/ slightly bulky.

•           Extreme tenderness on cervical movement.

•           Forn ices -tender.

•           Unilateral adnexal mass: is palpable in one third to half of patients.

Culdocentesis:

It is a simple technique used to identify haemoperitoneum. Fluid is aspirated from cul-de-sac via posterior fornix with the help of a needle. If non-clotted is obtained, it is indicative of an intraperitoneal bleed. (Probably a ruptured ectopic)

On USG:

•           Fluid in cul-de-sac.

•           Empty gestational sac.

Diagnosis: Classic history of acute abdominal catastrophe with fainting attack and collapse associated with features of intra-abdominal haemorrhage in woman of child bearing age points to a certain diagnosis of acute ectopic.

lnvestigations:ABO-Rh,Hb, BT, CT, Urine C/E.

Management:

•           The principle in management of acute ectopic is resuscitation and laparotomy.

•           Antishock treatment started simultaneously with preparation for urgent laparotomy. Ringer's solution (crystalloid) is started.

•           Arrangement is made for blood transfusion.

•           Colloid administration after withdrawing samples for grouping and cross matching. Urgent laparotomy: principle is 'quick in quick out'.

•           Indications for laparofomy: 1) Patient is haemodynamically unstable.

1.   Laproscopy is contraindicated.

2.   Evidence of rupture.

•           Salpingectomy is the definite surgery. The excised tube should be sent for hisfopathological examination.

•           The ipsilateral ovary and its vascular supply arepreserved.

Unruptered tubal ectopic:

High suspicion is required in sexually active female with abnormal bleeding and/or abdominal pain.

Symptoms:

•           Presence of delayed periods or spotting with features suggestive of pregnancy.

•           Uneasiness in one of the flanks.

Signs: On bimanual examination-

•           Uterus is slightly smaller than the period of amenorrhea.

•           Small, well circumscribed tender mass may be felt through one fornix, separate from the uterus.

Diagnostic modality:

•           Blood test: aborh and Hb, TIC and DLC, ESR.

•           Serum progesterone—level >25ng/ml is suggestive of viable intrauterine pregnancy. Whereas level <5ng/ml suggests an ectopic or abnormal intrauterine pregnancy.

•           Estimation of ß HCG: UPT(urine pregnancy test)will be positive in 95% of cases but single estimation of hcg either in the serum or in urine confirm pregnancy but cannot determine its location

Suspicious finding in serum ßhcg measurement are:

1)    Abnormally low level of ßhcg for gestational age.

2)    Doubling time in plasma fails to occur in 2 days(48 hrs).

•           Sonograpy: TVS is more informative. Diagnostic features are:

1)    Absence of intrauterine pregnancywith positive pregnancytest.

2)    Fluid in pouch of Douglas.

3)    Adnexal mass clearly separated from the uterus.

4)    Rarely cardiac motion may be seen in an unruptured tubal ectopic pregnancy.

•           Doppler sonography: Gestational sac in the adnexa surrounded by a hyper echoic ring (tubal ring sign).

•           Combination of ß HCG and sonography- ß HCG levels above the discriminatory zone (>1500 miu/ ml) and no intrauterine gestational sac suggestive of ectopic pregnancy.

Rise in HCG <66% in 48 hrs.

•           Laparoscopy- Gold standard for identification of ectopic pregnancy. But only feasible in hemodynamically stable patient. Therapeutic management can also be done at the same time.

•           Culdocentesis- Unfortunately negative culdocentesis does not rule out on ectopic pregnancy neither a positive result is very specific. Management of unruptured tubal pregnancy:

*Refer patient to tertiary care hospital for management after diagnosis.

Expectant management: only observation is done in hope of spontaneous resolution

i.e. Falling serial HCG titres.

Indications:

1)    Diameter of ectopic mass <4 cm.

2)    No evidence of bleeding or rupture assessed by vaginal sonography.

Conservative management:

A .Medical management: No. Of chemotherapeutic agents have been used either systemic or direct local.

Drugs used are - methotrexate, potassium chloride, prostaglandin (PGF 2 a), hyperosmolar glucose or actinomycin.

Requirements:

The patient must be

1)    Hemodynamically stable.

2)    Tubal diameter <4 cm without any fetal cardiac activity.

3)    No intraabdominal haemorrhage.

4)    Reliable commitment to complywith required follow up care.

Most commonly used drug is methotrexate (systemic therapy).

•           Protocol of administration and follow up:

•           For systemic therapy, a single dose of methotrexate 50mg/m2is given intramuscular. Monitoring: done by measuring serum ß hcg on day 4 and 7.

•           If decline in HCG between day 4 and 7 is >15 %., patient is followed up weekly with serum HCG

•           until HCG <10 iu/ml. If decline is <15% a second dose of methotrexate is given on day 7.

A.   Conservative surgery:

•           It is done in patients who do not fulfil the criteria laid down for medical management.

•           The procedure is either done laparoscopically or by microsurgical laporotomy.

1)  Linear salpingostomy

2)  Linear salpingotomy

3)  Segmental resection

4)  Plucking out of distal tube. (Fimbrial expression)

Radical surgery: salpingectomy

Indications:

•           The patient has completed her family;

•           Tubes grossly damaged;

•           Ectopic pregnancy has recurred in a tube already treated conservatively.

Chronic ectopic:

Symptoms: amenorrhea of 6-8 weeks, lower abdominal pain. Vaginal bleeding.

On examination: patient looks ill, pallor present, high pulse rate, no features of shock.

Management: all cases of chronic or suspected ectopic are to be admitted as an emergency. Patient is kept under observation, all required investigation are done and patient planned for laparotomy. Usually pelvic haematocele is found. Blood clots are removed. The affected tube is identified and salpingectomy is commonly done.