Ectopic Pregnancy

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Ectopic pregnancy results from implantation of fertilized ovum outside the uterine cavity, mostly in a fallopian tube.  Pre-existing disease affecting the tube (salpingitis), appendicitis, endometritis and pelvic operation) predisposes to tubal pregnancy.

PRESENTATION

  • Pain in left lower abdomen.
  • History of amenorrhoea, classically 1-2 missed periods and vaginal spotting.
  • There may be syncope dizziness, lightheadedness.

PHYSICAL EXAMINATION

 

  • Examination may reveal a pale, cold, and clammy patient with thready pulse.
  • There may be tachycardia, postural hypotension or even features of shock due to internal haemorrhage.
  • Peritonism:Tenderness, slight rigidity, guarding localized to one of the iliac fossa or to whole of the lower abdomen.
  • P/V findings, cervical changes of pregnancy, pelvic adnexal mass separate from the ovary may be palpable.

INVESTIGATIONS

 

  • Take a blood sample for Hb, blood grouping & cross matching, and pregnancy test HCG.
  • Ultrasonography is most helpful in excluding tubal pregnancy by demonstrating uterine pregnancy.  Ultrasonography can also confirm an ectopic well-formed gestational sac.

Most Common Differential Diagnosis

  1. Appendicitis
  2. Early intrauterine pregnancy with or without threatened abortion
  3. Pelvic inflammatory diseases

TREATMENT

 

A patient in haemorrhagic shock should be resuscitated in operation theatre with plasma volume expanders and blood.  Immediate laparotomy should be carried out to stop haemorrhage, even if Anaesthetist is not available.  Once bleeding is controlled, volume replacement blood transfusion and anaesthesia may be administered and operation continued when patient is haemodynamically stable.

  • Laparoscopy is preferred for diagnosis and treatment of tubal pregnancy in haemodynamically stable patients.
  • Conservative surgery, salpingotomy, linear incision along the antimesosalpinx border of tube in case of unruptured tubal pregnancy.  Salpingotomy is closed with 6-0 Prolene interrupted sutures.  Segmental resection is carried out in tubal rupture to be followed by interval re-anastomosis.
  • Bilateral Salpingectomy for tubal rupture if the patient has completed her family.