Ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in one of the fallopian tubes. Symptoms can include abdominal pain, vaginal bleeding, and gestational symptoms. Diagnosis is usually made through pregnancy tests, ultrasound showing no intrauterine pregnancy but an extrauterine sac, and laparoscopy for definitive diagnosis. Treatment depends on severity, with acute ruptured ectopic pregnancies requiring emergency surgery while unruptured cases can sometimes be treated through laparoscopic or medical management. Prompt diagnosis and treatment are important to prevent life-threatening complications from tubal rupture.

1. Ectopic pregnancy
Implantation of the fertilized ovum either
outside the uterus or in an abnormal
position within the uterus.
Sites of ectopic pregnancy:
1. Tubal (commonest 95%)
ampullary, isthmus, fimbrial,interstitial
2. Ovarian. - direct implantation
- reimplantation after tubal
abortion

2. 3. Cervical3. Cervical
4. Abdominal - primary: implants initially4. Abdominal - primary: implants initially
on abdominal organson abdominal organs
- secondary: primary- secondary: primary
implantation in tubes, ovaries or uterusimplantation in tubes, ovaries or uterus
5. Ligamentory5. Ligamentory
6. Cornual6. Cornual
7. Rudimentary horn7. Rudimentary horn

4. Causes of Ectopic PregnancyCauses of Ectopic Pregnancy
1. Tubal abnomalities impeding the progress of fertilized1. Tubal abnomalities impeding the progress of fertilized
ovumovum
a. developmental errors: hypoplasia, diverticula, accessorya. developmental errors: hypoplasia, diverticula, accessory
lumina, undue tortuositylumina, undue tortuosity
b. distortion of the tube: by adjacent large tumors orb. distortion of the tube: by adjacent large tumors or
endometriosisendometriosis
c. previous pelvic inflammatory disease:c. previous pelvic inflammatory disease:
chronic PID, gonorrhoea, postabortal, secondary tochronic PID, gonorrhoea, postabortal, secondary to
pelvic peritonitis, TB, IUCD, infection from adjacent organspelvic peritonitis, TB, IUCD, infection from adjacent organs
eg: appendicitis, diverticulitiseg: appendicitis, diverticulitis

5. d. surgical obstruction
after partial salpingectomy, tubal ligation
e. tubal surgery:
microsurgery, reversal of sterilization, previous tubal
pregnancy
2. Assisted conception: in-vitro fertilization if tubes are
damaged but patent
3. Overdevelopment of the ovum: external migration
4. Endometriosis of the tubes and ovaries

6. Diagnosis of Ectopic PregnancyDiagnosis of Ectopic Pregnancy
1. Chronic Ectopic Pregnancy1. Chronic Ectopic Pregnancy
Symptoms: short period of amenorrhoeaSymptoms: short period of amenorrhoea
: pain- aching in one or both iliac fossa: pain- aching in one or both iliac fossa
(due to distention or contraction of the(due to distention or contraction of the
tube)tube)
- sharp stabbing pain- sharp stabbing pain
(bleeding into peritoneal cavity due to(bleeding into peritoneal cavity due to
choriodecidual haemorrhage)choriodecidual haemorrhage)
- shoulder tip pain or pain in epigastrium- shoulder tip pain or pain in epigastrium
(due to diaphragmatic irritation by blood)(due to diaphragmatic irritation by blood)

7. : slight vaginal bleeding, brownish discharge: slight vaginal bleeding, brownish discharge
: syncope: syncope
: other symptoms of pregnancy: other symptoms of pregnancy
: acute retention of urine due to: acute retention of urine due to
large pelvic haematocoelelarge pelvic haematocoele
SignsSigns
General : pallor, increase in pulse rate, slight pyrexiaGeneral : pallor, increase in pulse rate, slight pyrexia
Abdomen: distention, tenderness, muscle guardingAbdomen: distention, tenderness, muscle guarding
Cullen`s sign(bluish discolouration around theCullen`s sign(bluish discolouration around the
umbilicus)umbilicus)

8. Vaginal Examination:Vaginal Examination:
 pulsation in the fornix (of the affected side)pulsation in the fornix (of the affected side)
 irregular tender enlargement of appendageirregular tender enlargement of appendage
 small tender masssmall tender mass
 uterus slightly enlargeduterus slightly enlarged
 cervical excitation +cervical excitation +
 POD is full and tenderPOD is full and tender
 brownish discharge PV +brownish discharge PV +
****** If symptoms strongly suggestive of ectopic, VE isIf symptoms strongly suggestive of ectopic, VE is
not advisable.not advisable.

9. II. Acute (tubal rupture)II. Acute (tubal rupture)
• There can be sudden massive intraperitonealThere can be sudden massive intraperitoneal
haemorrhage.haemorrhage.
• Symptoms: short period of amenorrhoeaSymptoms: short period of amenorrhoea
: severe lancinating pain in one iliac fossa: severe lancinating pain in one iliac fossa
or hypogastriumor hypogastrium
: immediate profound collapse: immediate profound collapse
: bleeding or brownish discharge PV: bleeding or brownish discharge PV

10. Signs:Signs:
 General - collapse, pale, cold clammy extremities,General - collapse, pale, cold clammy extremities,
low BP, increased PRlow BP, increased PR
 Abdomen- acutely tender lower abdomenAbdomen- acutely tender lower abdomen
distension and free fluiddistension and free fluid
 Vaginal E- very tender pelvisVaginal E- very tender pelvis
cervical excitationcervical excitation
tender enlarged adnexatender enlarged adnexa
full and tender PODfull and tender POD
blood-stained discharge on VE fingerblood-stained discharge on VE finger
**** Diagnosis is missed in 20-25% of casesDiagnosis is missed in 20-25% of cases

11. Think of ECTOPICThink of ECTOPIC
 female of reproductive agefemale of reproductive age
 unexplained abdominal painunexplained abdominal pain
 + or - vaginal bleeding+ or - vaginal bleeding

12. InvestigationsInvestigations
Clinically stable patientsClinically stable patients
a. Pregnancy tests- urine for UCGa. Pregnancy tests- urine for UCG
- serum- serum ββ hCGhCG
b. Ultrasound - no intrauterine pregnancyb. Ultrasound - no intrauterine pregnancy
- extrauterine pregnancy- extrauterine pregnancy
sac can be seensac can be seen
- transvaginal scan is more- transvaginal scan is more
accurateaccurate
c. Posterior Colpotomy (POD puncture)c. Posterior Colpotomy (POD puncture)
--
non-clottable bloodnon-clottable blood
d. Laparoscopy - for definitive diagnosisd. Laparoscopy - for definitive diagnosis
--

13. Differential diagnosis
1. Threatened or Incomplete abortion
- history of amenorrhoea +
- bleeding PV
- pain varies
2. Bleeding Corpus Luteum
- diagnosis difficult
- usually no overdue
- laparoscopy necessary
3. Accidents to Ovarian Cysts
- no overdue

14. Management of Ectopic Pregnancy
Acute
a. Resuscitation: - keep quiet, flat
- injection morphia
- IV line
- blood rapidly
b. Surgery - immediate laparotomy
- autotransfusion
- salpingectomy

15. Chronic Cases
- Admission
- operative procedures
a. laparoscopic surgery
- unruptured ampullary or
infundibular
-pregnancy < 3 cm in diameter
- salpingotomy
- intratubal methotrexate injection
- salpingectomy

16. b. laparotomy
- salpingectomy
- salpingotomy
- milking of the tube
Non- operative procedure
Puncture and aspiration of gestational sac,
local PG, KCL, hyperosmolar glucose,
methotrexate
Expectant management (non interventional )

17. Cornual pregnancy
 - diagnosis difficult
 - can have profuse intraperitoneal
bleeding
 - hysterectomy may be necessary

18. THE ENDTHE END