Ectopic Pregnancy: May Cost A life

The normal place of implantation of a fertilized ovum is posterior wall of uterus. But often implantation occurs in other places like fallopian tube, ovary etc rather than the uterus.

Implantation and development of a fertilized ovum in outside the uterine cavity proper, is called Ectopic Pregnancy.

There are so many places inside the female genital organ where ectopic implantation may occur resulting in ectopic pregnancy. And if it is not identified and removed properly it may endanger life.

Extra-uterine:

• Tubal (97%)
  • Ampulla (55%)
  • Isthmus (25%)
  • Infundibulum (18%)
  • Interstitial (2%)
• Ovarian (1.5%)
• Abdominal (0.1%)

• Cervical
• Angular
• Cornual

Among these, the Cornual Ectopic Pregnancy is more fatal as because it ruptures in early stage, causing profuse hemorrhage. Management is a bit complicated and patient may die within 3 hours of rupture.

• History of previous ectopic pregnancy
• Intrauterine contraceptive device (IUCD) or sterilization failure
• Sexually Transmitted Disease (Salpingitis)
• History of Infertility
• Previous pelvic surgery (appendicectomy, tubal surgery)
• Ovulation induction methods
• Developmental defects in the tube (such as : undue curves, diverticula, distortion of fallopian tube)
• Smoking: Nicotine alter or damage tubal epithelial ciliary motility

Symptoms:

• Pain: (100% cases) Acute agonizing colicky pain. It may be pelvic or abdominal, unilateral or bilateral and localized or generalized.
• Short period of Amenorrhea: (70% cases) Occurs in 6th to 8th week and may extend up to 10th to 12th week.
• Bleeding: (75% cases) Vaginal bleeding. Varies from spotting to frank irregular expulsion of decidual casts.
• Syncopal attack: (34% cases) Nausea, vomiting & dizziness.

First Three are called Classical Triad of Symptoms of Ectopic Pregnancy.

• Pallor
• Features of shock
• Per vaginal examination: Extreme tenderness of cervix on movement & uterus is bulky, soft, and tender on movement.
• Per vaginal bleeding may be present.

• Ultrasonography (USG): It is more informative. It shows gestational sac outside the uterine cavity and fluid in the Pouch of Douglas in case of rupture ectopic pregnancy.
• Serum beta-HCG: Slow rising of this is a positive sign which indicates ectopic pregnancy.
• Pregnancy Test: Positive in 50% cases. Other may remain undetected.
• Examination under anesthesia.
• Laparoscopy: It may be diagnostic or therapeutic.
• Laparotomy.
• Colpopuncture.

• Tubal abortion
  • Complete absorption
  • Complete abortion
  • Incomplete abortion
  • Missed abortion resulting in tubal mole
• Tubal rupture

• Death of fetus and may be absorbed.
• Secondary abdominal pregnancy may proceed to the full term arising many complications.

• Expectant management: Observation and wait till spontaneous resolution in early cases. It is indicated by:
  • Falling of HCG titer of initial beta-HCG< 1600mIU/ml
  • Haemoperitonium.
• Surgical treatment:
  • Definitive: Salpingectomy, Salpingoopgorectomy or TAH.
  • Conservative: Salpingotomy, Salpingostomy, segmental resection with end to end anastomosis or milking.
• Medical management: Single dose of Methotrexate. Selection criteria:
  • No intrauterine gestation sac or fluid on TVS
  • HCG level less than 200mIU/ml
  • Ectopic pregnancy mass is less than 3.5 cm
  • No evidence of haemoperitonium on USG
  • Minimal clinical symptoms.

Ectopic pregnancy is a clinical condition where a woman needs medical support along with emotional support from family. Early detection of this may save a life. Ignoring this may cause death.