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Ectopic Pregnancy
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Denition
• It is the implantation of the fertilisedovum outside the normal uterinecavity.
* Common site (9!"# the tu$es.
* %are sites (!"# &he ovaries' arudimentary horn of a $icornuateuterus' $road ligaments' peritoneumand cervi.
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&)+,P%E-+C/0+etiology
• &he following ris1 factors have $eenimplicated#
2.3echanical factors
4.Premature implantation
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&)+,P%E-+C/0+etiology
2.3echanical factors
* Previous in5ammatory disease#* Previous pelvic surgery#
* Developmental a$normalities#
* Previous ectopic pregnancy#* Intrauterine contraceptive device#
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&)+,P%E-+C/0+etiology
4.Premature implantation#
a. Premature shedding of the 6onapellucida
$.&ransperitoneal migration of thefertilised ovum to the contralateraltu$e
c.Presence of ectopic endometriumin the tu$e.www.freelivedoctor.com
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&)+,P%E-+C/0Pathogenesis
* &he tropho$last develops in the fertilisedovum and invades deeply into the tu$al wall.
* 7ollowing implantation' the tropho$last
produces hC- which maintains the corpusluteum.
* &he corpus luteum produces oestrogen andprogesterone which change the secretory
endometrium into decidua. &he uterusenlarges up to 8 wee1s si6e and $ecomessoft.
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&)+,P%E-+C/0Pathogenesis
• &he tu$al pregnancy does not usuallyproceed $eyond 82:wee1s due to#
0 lac1 of decidual reaction in the
tu$e'
0 the thin wall of the tu$e'
0 the inade;uacy of tu$al lumen'
0 $leeding in the site ofimplantation as tropho$last invades.
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&)+,P%E-+C/0Pathogenesis
•
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7ate of tu$al pregnancy
• &u$al mole#
• &u$al a$ortion#
•
&u$al rupture#
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7ate of tu$al pregnancy
• &u$al mole#
o &he gestational sac issurrounded $y a $lood clot andretained in the tu$e.
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7ate of tu$al pregnancy
&u$al a$ortion#
&his occurs more if ovum had $een implanted in theampullary portion of the tu$e.
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7ate of tu$al pregnancy
&u$al rupture#
3ore common if implantation occurs in thenarrower portion of the tu$e which is the
isthmus.%upture may occur in the antimesenteric
$order of the tu$e. )sually profuse $leedingoccurs = intraperitoneal haemorrhage.
If rupture occurs in the mesenteric $order ofthe tu$ea $road ligament haematoma willoccur.
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Clinical Picture0tu$alpregnancy
-eneral symptoms
aginal $leeding#
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Clinical Picture0tu$alpregnancy
• -eneral signs
0 -eneral eamination#
o reast signs of pregnancy.
o +$dominal eamination#
o ,ower a$dominal tenderness and rigidity especially on oneside may $e present.
0 >aginal eamination#
o luish vagina and $luish soft cervi.
o )terus is slightly enlarged and soft.
o 3ar1ed pain in one iliac fossa on moving the cervi fromside to side.
o Ill dened tender mass may $e detected in one adnea inwhich arterial pulsation may $e felt.
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Clinical Picture0&u$al+$ortion
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Clinical Picture0&u$al+$ortion
0
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Clinical Picture0&u$al+$ortion
+$dominal eamination#
o Cullen@s sign# a perium$ilical$luish discoloration may $e presentdue to a$sorption of the $lood in theperitoneal cavity $y lymphatics. It isa late sign.
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Clinical Picture0&u$al+$ortion
,ocal eamination#
oggy swelling in the culdesacif pelvic haematocele is present.
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Clinical Picture0&u$al%upture
• &he most dramatic although not themost common.
•
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Clinical Picture0&u$al%upture
-eneral eamination#
* %apidly developed shoc1' with pallor'sweating' air hunger' rapid threadypulse and hypotension.
*
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Clinical Picture0&u$al%upture
+$dominal eamination#
•
&he a$domen is distended' rigid withgeneralised tenderness.
•
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Clinical Picture0&u$al%upture
,ocal eamination#
•
&he same as in general signs ofectopic' although it is undesira$le asit may induce more disruption and$leeding.
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Investigations of Ectopic
Pregnancy
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)ltrasonography
• In general' a positive BhC- test with emptyuterus $y sonar indicates ectopic pregnancy.
• Discriminatory hC- 6ones#
0 Diagnosis of ectopic pregnancy is made if thereis#
2. +n empty uterine cavity $y a$dominalsonography with $ hC- value a$ove A:::
mI)ml.4. +n empty uterine cavity $y vaginal sonography
with $ hC- value a$ove 4::: mI)ml.
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• Progesterone in ectopic pregnancy
•
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Culdocentesis
• If nonclotting $lood is aspirated fromthe Douglas pouch througha widepored needle' intraperitoneal
haemorrhage is diagnosed. ut if not'ectopic pregnancy cannot $eecluded.
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)ncommon
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Cornual angular pregnancy
• It is implantation in the interstitialportion of the tu$e.
• It is uncommon $ut dangerous
$ecause when rupture occurs$leeding is severe and disruption isetensive that it needs hysterectomy.
• In some cases' the pregnancy isepelled into the uterus and rupturedoes not occur.
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Pregnancy in a rudimentaryhorn
* Pregnancy occurs in the $lindrudimentary horn of a $icornuateuterus.
* +s such a horn is capa$le of somehypertrophy and distension' rupture
usually does not occur $efore 2A4:wee1s.
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Pregnancy in a rudimentaryhorn
• &reatment#
• Ecision of the horn. Duringoperation' pregnancy in a
rudimentary horn can $edierentiated from interstitial cornualtu$al pregnancy $y nding the
attachment of the round ligamentlateral to the rst and medial to thelater.
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Cervical pregnancy
• Implantation in the su$stance of thecervi $elow the level of uterine vessels.
• 3ay cause severe vaginal $leeding.
• &reatment#
0 Evacuation and cervical pac1ing withhaemostatic agentas $rin glue and
gau6e.0If $leeding continues or etensive
rupture occurs hysterectomy is needed.
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varian pregnancy
+etiology#
* Pelvic adhesions.
* 7avoura$le ovarian surface for implantation
as in ovarian endometriosis.
Pathogenesis#
* 7ertilisation of the ovum inside the ovary or'
* implantation of the fertilised ovum in theovary.
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varian pregnancy
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varian pregnancy
&reatment#
•
,aparotomy and inoculation of theectopic pregnancy andreconstruction of the ovary ifpossi$le. therwise' removal of the
aected ovary is indicated.
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+$dominal (peritoneal"pregnancy
&ypes#
* Primary# implantation occurs in the peritonealcavity from the
start.
*
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+$dominal (peritoneal"pregnancy
• Diagnosis#
* Fistory# of amenorrhoea followed$y an attac1 of lower a$dominal painand slight vaginal $leeding whichsu$sided spontaneously.
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+$dominal (peritoneal"pregnancy
0+$dominal eamination#
o )nusual transverse or o$li;ue lie.
o 7oetal parts are felt very
supercial with no uterine muscle wallaround.
0>aginal eamination#
o &he uterus is soft' a$out 8 wee1sand separate from the foetus.
• o o presenting part in the pelvis.
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+$dominal (peritoneal"pregnancy
•
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• &reatment#
• &he condition should $e terminatedsurgically through laparotomy oncediagnosed
f li d t