PREGNANCYECTOPIC

AREZ ESMAIL QADR

SHAMAL M. AZIZ

Normal pregnancy implantation

Pregnancy is the period during which a

woman carries a developing fetus normally

in the uterus, starting from conception

(fertilization of ova) until the baby born.

After ovulation the ovum is picked up by the

fimbria of fallopian tubes and then swept

by ciliary action towards the ampulla where

fertilization occurs.

As soon as the zygote develops it begins

dividing very rapidly, it remains in the fallopian

tube for 3 -4 days untill reaches morula stage

(8-32 cell stage)

Normal pregnancy implantationThe embryo proceeds through the isthmus to the uterine cavity for up

to 72 hours, by the sixth day it enters the uterus and begins to penetrate the decidua (endometrium) this is called implantation which takes place within the uterine cavity in normal positioned pregnancy .

Then hCG is produced by trophoblast, which can be detected in the serum of the mother in the first week after implantation, its level doubles every 36-48 hours in normal healthy pregnancy starting from 5 to 50 ,100, till reaching 1000 IU/L

Delay or obstruction of the passage of fertilized egg down the fallopian tube to the uterus may result in implantation in the fallopian tube or ovary or peritoneal cavity, this known as ectopic pregnancy which eventually most fails to develop , and the hCG fails to raise dramatically as happens in the normal intra uterine pregnancy.

Normal pregnancy implantation

Ectopic pregnancy ?

Ectopic pregnancy Definition:

An ectopic pregnancy, or eccysis , is a complication of pregnancy Occurs when the site of implantation is outside of the womb (uterine cavity) either in the tubes,ovaries or abdominal cavity, With rare exceptions, ectopic pregnancies are not viable, Pregnancy can even occur in both the womb and the tube at the same time (heterotopic pregnancy).

Classification:

1- tubal pregnancy:

The vast majority of ectopic pregnancies 95-98 % implant in the Fallopian tube, among these:

80% in the ampulla

10% in isthmus

5 % in fimbria

2% interstitial

2% in a rudimentary horn of a bicornuate uterus

classification 2-Nontubal ectopic pregnancy

Rare sites (2-5%) are;

The ovaries,

broad ligaments,

Abdominal cavity and peritoneum

cervix.

3-Heterotopic pregnancy

in rare cases of ectopic pregnancy 1/1000, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy.

Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies.

classification Since ectopic pregnancies are normally discovered and removed very

early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound

Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF.

Common sites for ectopic pregnancy

epidemiologyIncidence;

22/1000 live births

16/1000 pregnancies

In USA from 1970 – 1992 , the risk 5x increased from 4 to 19 / 1000 pregnancies

fatality rate :

fatality rate from ectopic pregnancies dropped almost 90% (from 35.5 per 1000 ectopics to 3.8 per 1000 ectopics).

Despite the sharp improvement in the fatality rate by the end of this period of time, ectopics were still the second leading cause of maternal mortality in the USA (accounting for 12% of all maternal deaths in 1987).

Why? The reason for the increase in ectopic pregnancy during this time

period is not entirely clear, but it was thought that the increase of risk factors were responsible for a significant portion of the increased number of cases of ectopic pregnancy.

Risk factors

Any mechanism that interferes with the normal function of fallopian tube increases the risk of ectopic pregnancy

The mechanism canbe:

Anatomical; scarring that blocks transport of the egg

Functional; impaired tubal mobility

Risk Factor Risk %

High Risk PID

Tubal corrective surgery

Tubal sterilization

Previous EP

In utero DES exposure

IUD

Documented tubal pathology

Moderate Risk Infertility

Previous genital infection

Multiple partners

Slight risk Previous pelvic or abdominal surgery

Smoking

Douching

Intercourse before 18 weeks

25

21.0

9.3

8.5

8.3

5.6

4.2-45

3.8-21

2.5-21

2.5-3.7

2.1

0.93-3.8

2.3-2.5

1.1-3.1

1.6

Risk factors1-History of pelvic infection

PID is the most common risk factor for ectopic pregnancy

8 folds increases the risk, due to destruction of the fallopian tubes. Chlamydia (a common sexually transmitted disease) and Gonorrhea are both able to grow within the fallopian tubes and cause;

1-tremendous damage to the endosalpinx (lining of the inner tubal lumen),

2-agglutination (sticking together) of the mucosal folds in the tube

3-peritubal adhesions (scar tissue).

. the risk of an ectopic pregnancy is greater when the woman with the infection is younger

Other pelvic or lower abdominal infections can also result in pelvic adhesions and an increase in the ectopic pregnancy rate (such as appendicitis).

The chances of another ectopic in the same fallopian tube also in the other tube are increased 5x

Risk factors

2-History of surgery on the fallopian tubes or within the pelvis:

Tubal ligation in the past 2 years,When a bilateral tubal ligation (tubes tied) is followed by either an unexpected pregnancy (failed tubal ligation) or is "reversed" with a tubal reanastomosis (tubal reconstruction) there is an increased risk of a tubal ectopic pregnancy.

When a woman has a history of pelvic surgery that is associated with significant adhesion formation (such as myomectomy) there is also an increased risk of an ectopic pregnancy.

Risk factors

3- Prior history of ectopic pregnancy. 

When an ectopic pregnancy in the fallopian tube is treated conservatively (by preserving the tube), there is a roughly 10 fold increase the risk of recurrence in the same tube

4-History of IUD use. The use of an IUD is a classic "risk factor" for ectopic pregnancy. Actually, all but the progesterone containing IUDs are relatively protective against ectopic pregnancy while the IUD is in place. That is, the number of ectopic pregnancies in women using an IUD for contraception is about one half that of women using no contraception. However, of IUD pregnancies there is a greater chance of an ectopic location (3-4%) since the number of intrauterine pregnancies with an IUD in place is markedly reduced.

Risk factors

Additionally, IUDs can be associated with infections of the uterine cavity and fallopian tubes (especially just after insertion) which can independently increase the chance for an ectopic pregnancy..

The reason for this increase in the nomber of EPs with progesterone IUD is not clear. A theory is that somehow the progesterone enhances tubal implantation.

Risk factors

5-History of Diethylstilbestrol (DES )exposure in utero. This drug is a  is a synthetic nonsteroidal estrogen that was used for

certain conditions, including breast and prostate cancers  ,From about 1940 to 1970, DES was given to pregnant women under the mistaken belief it would reduce the risk of pregnancy complications and losses

Later researches has shown that this drug has many bad medical effects and female babies of women who used it were at risk of developmental abnormalities of the genital system

Their tubes are more likely to be abnormal and predispose to ectopic pregnancy, these females were known as DES daughters

Risk factors

6-History of destruction of the uterine cavity or lining. 

Such as history of uterine synechiae (scar tissue) from previous surgery (like endometrial ablation for dysfunctional bleeding ) or presence of multiple submucosal fibroid tumors this cause a larger percentage of the pregnancies to implant in a space other than the uterine cavity.

Similar to the situation with IUDs, the total ectopic pregnancy rate may not be increased but when a pregnancy does occur the reduced likelihood of an intrauterine pregnancy increases the relative percentage of ectopic pregnancies.

Risk factors

7-History of non-infectious pelvic inflammation (endometriosis, foreign body).

 Inflammation of the delicate tubal structures can result in adhesion formation (scar tissue), which will then increase the risk of an ectopic pregnancy. This inflammation may be due to endometriosis or the presence of a foreign body, either of which are strongly associated with scar tissue formation.

Risk factors 8-Use of assisted reproductive technology (such as IVF (in vetro

fertilization) and GIFT (gamete intrafallopian transfere). 

When multiple embryos or gametes are placed into the uterus or the fallopian tubes, the risk for multiple pregnancy rises significantly. The risk of twins and heterotopic pregnancy is generally thought to be about 1 / 30,000 pregnancies .

with ARTs the rates of ectopics and dizygotic twins have increased to 1/10,000 .

the incidence of heterotopic pregnancy may increase to as frequently as 1 /100 pregnancies.

Tubal pregnancy

Pathophysiology The trophoblast develops in the fertilized ovum and invades deeply

into the tubal wall.

Following implantation, the trophoblast produces hCG which maintains the corpus luteum.

The corpus luteum produces oestrogen and progesterone which change the secretory endometrium into decidua. The uterus enlarges up to 8 weeks and becomes soft.

The tubal pregnancy does not usually proceed beyond 8-10weeks due to:

> lack of decidual reaction in the tube,

> the thin wall of the tube,

> the inadequacy of tubal lumen,

> bleeding in the site of implantation as trophoblast invades.

Pathophysiology

Separation of the gestational sac from the tubal wall leads to its degeneration, and fall of hCG level, regression of the corpus luteum and subsequent drop in the oestrogen and progesterone level.

This leads to separation of the uterine decidua with uterine bleeding.

Fate of tubal pregnancy

Tubal mole

Tubal abortion

Tubal rupture

Fate of tubal pregnancy

1- Tubal mole:

The gestational sac is surrounded by a blood clot and retained in the tube.

This may remain for long period in the tube and forms so called (chronic ectopic pregnancy),or they may be gradually absorbed (involution)

2-Tubal abortion:

This occurs more if ovum had been implanted in the ampullary portion of the tube.

Separation of the gestational sac is followed by its expulsion into the peritoneal cavity through the tubal ostium.

Rarely, reimplantation of the conceptus occurs in another abdominal structure leads to secondary abdominal pregnancy.

Fate of tubal pregnancy

If expulsion was complete the bleeding usually ceases but it may continue due to incomplete separation or bleeding from the implantation site.

Fate of tubal pregnancy3-Tubal rupture:

More common if implantation occurs in the narrower portion of the tube which is the isthmus.

Rupture may occur in the

anti-mesenteric border of the tube.

Usually profuse bleeding occurs →

intraperitoneal haemorrhage.

If rupture occurs in the mesenteric border

of the tube, broad ligament haematoma

will occur.

presentation

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks

The most common presenting symptoms that are suggestive for EP are:

Clinical traid (3As)

Amenorhea

ectopic

pregnancy

Abdominal pain Abnormal vaginal

bleeding

symptoms

Pain and discomfort

In the Lower back , abdomin, or pelvis.

Usually unilateral

Pain may be confused with a strong stomach pain, it may also feel like a strong cramp

Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign.

Pain while urinating

Pain while having a bowel movement

symptoms

Bleeding

Vaginal (external)bleeding usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. 

Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube.

Dizziness, headache, weakness, fainting all may happen due to bleeding

signs General examination:

signs of early pregnancy (Breast tenderness, nausea and vomitig, change of apettite …)

Weakness, pallor, hypotension and tachycardia, tachypnoea due to bleeding

Abdominal examination:

Lower abdominal tenderness and rigidity especially on one side may be present.

signs

Vaginal examination:

Vaginal spotting

Bluish vagina and bluish soft cervix.

Uterus is slightly enlarged and soft.

Marked pain in one iliac fossa on moving the cervix from side to side.

Ill defined tender mass may be detected in one adnexa in which arterial pulsation may be felt.

Speculum or bimanual examination should not be performed unless facilities for resuscitation are available, as this may induce rupture of the tube

diagnosis

The diagnosis can be difficult

Your doctor may perform some tests to help confirm suspected ectopic pregnancy including;

Detailed history of (cycle, pregnancy, PID,infertility, gynaecological surgery, contraception…)

Proper general, abdominal, vaginal examination and vital signs

Investigations: including

Diagnosis1.hormonal assay

Serum β-hCG

Urine pregnancy tests are positive in only 50-60% of ectopic. Detection of β-hCG in the serum by ELISA or radioimmunoassay are more sensitive and can detect very early pregnancy about 10 days after fertilization i.e. before the missed period.

If the test is negative (generally less than 5 IU/L), normal and abnormal pregnancy including ectopic are excluded.

If the test is positive , and doubles every 36-48 hour till reaching 1500 IU/L which is The threshold of discrimination for intrauterine pregnancy, this indicates a normal intrauterine pregnancy,

An abnormal rise in blood β-hCG levels may indicate an ectopic pregnancy and ultrasonography is indicated.

Diagnosis

Progesterone

The second most common hormone after hCG in pregnancy is progesterone.

Generally, a progesterone concentration of greater than 25 ng/mL is highly correlated with a normal intrauterine pregnancy while a concentration of less than 5 ng/mL is highly correlated with an abnormal and nonviable pregnancy

Diagnosis

2-Ultrasound

In general, a positive β-hCG test with empty uterus by sonar ± adnexial mass indicates ectopic pregnancy.

Discriminatory hCG zones:

Diagnosis of ectopic pregnancy is made if there is:

An empty uterine cavity by abdominal sonography with b -hCG value above 6000 mIU/ml.

An empty uterine cavity by vaginal sonography with b -hCG value above 2000 mIU/ml.

Ultrasound

Diagnosis3-Culdocentesis

in this test, a needle is inserted into the space at the top of the vagina, behind the uterus and in front of the rectum to aspirate fluid and

Determines if there is blood in the space behind the uterus

If non-clotting blood is aspirated from the Douglas pouch , intraperitoneal haemorrhage is diagnosed. But if not, ectopic pregnancy cannot be excluded.

Diagnosis4-laparoscopy or laparotomy can also be performed to visually confirm an

ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred.

Laparoscopy: an endoscope is inserted through a small incision in the woman’s abdomen

This allows you to see the fallopian tubes and other organs

This takes place in an operating room with anaesthesia

Uncommon Sites of Ectopic Pregnancy

1-Cornual angular pregnancy

2-Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.

3-Cervical pregnancy

4-Ovarian pregnancy

5-Abdominal (peritoneal) pregnancy

Cornual angular pregnancy

It is implantation in the interstitial portion of the tube.

It is uncommon but dangerous because when rupture occurs bleeding is severe and disruption is extensive that needs hysterectomy.

In some cases, the pregnancy is expelled into the uterus and rupture does not occur.

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Pregnancy in a rudimentary horn Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.

As such a horn is capable of some hypertrophy and distension, rupture usually does not occur before 16-20 weeks.

Cervical pregnancy Implantation in the substance of the cervix below the level of uterine

vessels.

May cause severe

vaginal bleeding.

Can be diagnosed by

trans vaginal ultrasound

Ovarian pregnancy

Aetiology:

* Pelvic adhesions.

* Favourable ovarian surface for implantation as in ovarian endometriosis.

Pathogenesis:

* Fertilization of the ovum inside the ovary or,

* implantation of the fertilized ovum in the ovary.

Ovarian pregnancySpiegelberg criteria for diagnosis of ovarian pregnancy:

* The gestational sac is located in the region of the ovary,

* the ectopic pregnancy is attached to the uterus by the ovarian ligament,

* ovarian tissue in the wall of the gestational sac is proved histologically,

* the tube on the

involved side is intact.

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Abdominal (peritoneal) pregnancy

Types:

Primary: implantation occurs in the peritoneal cavity from the

start.

Secondary: usually after tubal rupture or abbortion.

Intraligamentous pregnancy: is a type of abdominal but extraperitoneal pregnancy. It develops between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the myometrium) pregnancy.

Abdominal (peritoneal) pregnancy

Diagnosis:

History: of amenorrhoea followed by an attack of lower abdominal pain and slight vaginal bleeding which subsided spontaneously.

Abdominal examination:

Unusual transverse or oblique lie.

Foetal parts are felt very superficial with no uterine muscle wall around.

Vaginal examination:

The uterus is soft, about 8 weeks and separate from the foetus.

No presenting part in the pelvis.

Abdominal (peritoneal) pregnancySpecial investigations:

Plain X-ray: shows abnormal lie. In lateral view, the foetus overshadows the maternal spines .

Ultrasound: shows no uterine wall around the foetus

Magnetic resonance imaging (MRI): has a particular importance in preoperative detection of placental anatomic relationships.

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DIFFERENTIAL

DIAGNOSISDDX

Appendicitis (Perforated)

Acute Pancreatities

Myocardial Infarct

Pelvic Abcess

Splenic Rupture

Perforated Gastric or Duodenal Ulcer

(1) NON GYNECOLOGICAL

Septic Abortion

Threatened Abortion

PyosalpinxPelvic Abcess

Twisted Ovarian Cyst

Acute pelvic inflammatory

disease

Rupture of Follicle or Corpus

Luteum Cyst

Degenerating leiomyoma

Retroverted Gravid Uterus

(2) Gynecologic disorders

Rx

TREATMENT

Ectopic

1

•EXPECTANT MANAGEMENT

2

•MEDICAL MANAGEMENT

3

•SURGICAL MANAGEMENT

Treatment options

EXPECTANTMANAGEMENT

1

• Criteria for selection– asymptomatic women no evidence

of rupture or hemodynamic instability

– less than 100 ml fluid in the pouch of Douglas

– hCG less than 1000 iu/l at initial presentation

– Adnexal mass less than 3cm– they should objective evidence of

resolution, such as declining bhCG levels.

– They must be fully compliant and must be willing to accept the potential risks of tubal rupture.

– Initial follow up • twice weekly with serial

hCGmeasurements • weekly by transvaginal examinations

– By the first week• drop in HCG level• Adnexal mass size

– Otherwise reassess the options (Medical/Surgical)

– If the fall of HCG & reduction in size of adnexal mass satisfatory

• weekly hCG and transvaginal ultrasound examinations

– Till the HCG falls less than <20 IU

MONITORING

• 45–70% of pregnancies of unknown location resolve spontaneously with expectant management

• Ectopic pregnancy was subsequently diagnosed in 14–28% of cases of pregnancy of unknown location

• Intervention has been shown to be required in 23–29% of cases.

MEDICALMANAGEMENT

2

• Selection criteria– Minimal symptoms & The patient must be

hemodynamically stable– no signs or symptoms of active bleeding or

haemoperitoneum.– Absence of foetal heart beat– Normal FBC,U&E(urea & electrolytes),LFT(liver

function tests)• Exclusion criteria

– Any hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood dyscrasia(WCC <2000 cells cm3).

– Difficulty or unwillingness of patient for prolonged follow-up (average follow-up 35days).

– Ectopic mass >3.5cm– The presence of cardiac activity in an ectopic

pregnancy

CRITERIA for MEDICAL MANAGEMENT

•Methotrexate

SYSTEMIC

•injections of prostaglandins, potassium chloride OR hyperosmolar glucose OR local methotrexate

LOCALLY

• Methotrexate – a drug that destroys actively growing tissues such as the placental tissues ,is used as an injection in selected cases to avoid surgery (in non ruptured ectopic)

• Side effects include abdominal pain for 3 – 7 days in 50% of cases and mild symptoms of nausea, mouth dryness and soreness and diarrhoea,– Methotrexate-Intramuscular(buttock or lateral thigh)– Dose calculated from body surface area– Usual dose ranges between 75-95 mg– HCG checked on day 4 & day 7

• If fall is less than 15 % consider second dose of methotrexate

Anti-D should also be given if required Rest up to one hour after the injection. Check for any local reaction.

METHOTREXATE

ADVICES• Patient should be given information on(preferably written)

– Need for further treatment– Adverse effects

• Women should be able to return easily for assessment at any time during follow-up

• Advice– avoid sexual intercourse during treatment– to maintain fluid intake – use reliable contraception for three months after

methotrexate has been given, barrier or hormonal)– Avoid exposure to sunlight.

• “- Avoid alcohol and vitamin preparations containing folic acid until the hormone level is back to zero.

• - Avoid aspirin or drugs such as Ibuprofen for one week after treatment.

– 90% successful treatment with single dose regime.

– Recurrent ectopic pregnancy rate 10 – 20%.– Tubal patency approximately 80%.– 14 % of medical management second dose of

methotrexate– 75% would experience abdominal pain-

separation pain. This usually occurs between day 3-7

– 10% would finally require surgical management

OUTCOME

COST BENEFITS

• cheap in the initial period –but considering the cost of follow up & the loss of work time for patient & carers •no cost saving was seen at serum hCG levels above 1500 IU/l due to the increased need for further treatment and prolonged follow-up.

SURGICALMANAGEMENT

3

Indications for surgical treatment

• The patient is not a suitable candidate for medical therapy.

• Medical therapy has failed.• The patient has a heterotopic pregnancy with a

viable intrauterine pregnancy.• The patient is hemodynamically unstable and

needs immediate treatment.

EMERGENCY

ECTOPICPREGNANCY

RUPTURED

• Get help- call senior /Consultant on call • ABC of resuscitation

– give facial oxygen– Site two IV lines , commence IV fluids (crystalloid)– Send blood for FBC, Clotting screen and cross-match at least 4 units

of blood.• insert indwelling catheter• arrange theatre for laparotomy • whilst awaiting transfer to theatre continue fluid resuscitation and ensure

intensive monitoring of haemodynamic state• do not wait for BP and pulse to normalise prior to transfer-resuscitation

and surgery need to go hand in hand.• Pfannensteil incision, • salpingectomy and wash out of abdomen• assess bloods /consider CVP• record operative findings including the state of the remaining tube/pelvis • Anti – D immunoglobulin (250 IU)to be given to Rhesus negative women

Laparascopy OR laparatomy??

• Laparoscopy has become the recommended approach in most cases.

• Laparotomy is usually reserved for patients:

who are hemodynamically unstable

patients with cornual ectopic pregnancies.

for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is difficult

Laparoscopy

• Less intraoperative blood loss

• Shorter operation time

• Shorter hospital stay

• Lower analgesic requirement

• Future intrauterine pregnancy rate same

• Lower repeat ectopic pregnancy rate

Laparotomy

• Future intrauterine pregnancy rate same

• Preferable in the haemodynamically unstable patient

Salpingectomy OR Salpingotomy ??

• Salpingectomy• Salpingectomy (tubal removal) is the principle treatment especially

where there is tubal rupture

• Salpingotomy• Conservative surgical management may be employed when the

ectopic has not ruptured and where the tube appears normal

• Total salpingectomy is the procedure of choice: In a patient who has completed childbearing and no

longer desires fertility in a patient with a history of an ectopic pregnancy in

the same tube. in a patient with severely damaged tubes,

Salpingectomy Salpingotomy

• There may be a higher subsequent intrauterine pregnancy rate associatedwith salpingotomy but the magnitude of this benefit may be small

• Trend towards higher subsequent ectopic pregnancy

• small risk of tubal bleeding in the immediate postoperative period

• potential need for further treatment for persistent trophoblast

Persistent trophoblast

• When salpingotomy is done, protocols should be in place for the identification and treatment of women with persistent trophoblast.

• Monitoring serum HCG levels would help to identify the persistent trophoblast.

• Most Easily Treated With MTX

Heterotropic

Cervical Abdom

inal

Ovarian

Other TypesMx

Evacuation and cervical packing with haemostatic agent as fibrin glue and gauze.

Arterial embolization

If bleeding continues or extensive rupture occurs hysterectomy is needed.

Cervical pregnancy

• Laparotomy and inoculation of the ectopic pregnancy and reconstruction of the ovary if possible. Otherwise, removal of the affected ovary is indicated.

• Ovarian cystectomy is the preferred treatment

• Treatment with MTX and prostaglandin injection has also been reported

Ovarian pregnancy

Abdominal (peritoneal) pregnancy

• The condition should be terminated surgically through Laparotomy once diagnosed

• MTX treatment appears to be contraindicated because of the high rate of complications due to rapid tissue necrosis

Heterotropic pregnancy

• Depends upon

the state of the

woman

and the skill of

the doctor.• .Surgical

• Laparoscopy is the ideal surgical method to remove an ectopic pregnancy before it ruptures without interrupting the viable pregnancy. Although the intrauterine pregnancy can still survive if the ectopic pregnancy ruptures, there is an increased danger of miscarriage. The surgery must be done with great skill and it is important that bleeding be addressed quickly. Medical therapies include injecting the ectopic pregnancy in order to terminate the gestation.

Anti D

• Non sensitized women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.

• In accordance with RCOG Guideline it is recommended that anti-D immunoglobulin at a dose of 250 IU (50 micrograms) be given to all non sensitized women who are rhesus negative and who have an ectopic pregnancy.

ADVICE

• Not using IUCD• Not using progesterone only pills• Treatment for any PID• Follow up by HCG that should disappear after 1

month• Do HSG after 40 day to see patency of the tube• Use barrier method of contraception• Timing of pregnancy, visit specialist in any

missed period

• Recurrence of ectopic• Infertility• Shock & death• Tubal rupture & organ damage• Psychological • Surgical Rx • Medical Rx

COMPLICATION

Prognosis

• Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior of infertility. The treatment choice history , whether surgical or nonsurgical, also plays a role. For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment. Rate of fertility may be better following salpingostomy than salpingectomy.

Reference

1.Gynecology & obstetrci by Ten teachers 19th edition2.RCOG guidelines (Royal college of obstetric & gynecology)3.ACOG(American college of obstetric & gynecology)4.ASRM(American society of reproductive medicine)5.Wikipedia .com6.Livemedicine.com7.Dr.Abraham ( laparascopy Video)

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