Ectopic pergnancy

Ectopic pergnancy

Definition:pergnancy in abnormal site that is outside the normal uterine cavity

Types

1:tubal

2:ovarian

3:abdominal or intraperitoneal

4:cervical

5:intraligamentary

6:rudimentary horn

7:secondary abdominal pergnancy

8:broad ligament

9:primary abdominal

Aetiology

(1):causes in tube:

A:smoking at the time of conception which decreas tubal motility and ciliary movements

B:change in tubal motility causes by exogenous hormones 

C:endometriosis in the tube

D:inflammatory inflation lead to stenosis of tube and destruction of ciliary e.g(chronic salpingitis)

E:trumatic: after operation as salpingoplasty and tubal ligation

F:functional: as tubal spasm or antiperistaltic contraction

G: neoplastic narrowing of the tube by fibroid or broad ligament tumer 

H:congenital as long and marrow tube

Diagnosis

1:undisturbed tubal pregnancy

Discover during the routine examination of pregnancy 

Symptoms and sign:-

1:amenorrhoea for short period for 1or2 months

2:nausea and vomiting

3:in the iliac fossa present of full aching pain 

Sign:---

Tenderness in one iliac fossa

When it is moved from siad to siad (jumping sign _ cervical excitation _ chandelier sign)and the mass may be in one siad of uterus 

2: Subacut types(60℅)

caused by tubal mole tubal abortion peritubal or paratubal haematoma

Symptoms:

1:short period of amenorrhoea for 1 or 2 months 

2:symptoms of early pregnancy 

3: pain in one iliac fossa dull aching .sharp stabbing or colicky

4:faiting attack or shock

5:vaginal bleeding dark brown in colour and occurs after pain

Signs:

Tenderness and rigidity in one iliac fossa.cullen sign(bluish colouration around the umbilicus due to presence of blood in the peritoneal cavity

3:-acute type

Sudden severe intraperitoneal haemorrhage

Symptoms:

Sudden severe abdominal pain occuring after short period of amenorrhoea shoulder pain may be felt in lying down due to diaphragmatic irritation by blood

Signs:

Generalized tenderness and rigidity there may be shifting dullness and bluish colouration around the umbilicus 

4:-Chronic type with pelvic haematocele

Symptomes:

1:-history of amenorrhoea 

2:lower abdominal pain fainting and vaginal bleeding 

3:-pressure symptoms due to accumulation of blood in Douglas pouch as dysuria dyschezia and dyspareunia 

Signs:--

1:-pelvi abdominal swelling may be felt which is fixed and ill defined

2:-in the vaginal there is fixed .tender mass bulging through the posterior fornix it is soft firm or hard if calcified depends in duration 

Special investigation in ectopic pregnancy:

1:- compelet blood count HB decrease 

2:-urinalysis excludes pyelonephritis and renal colicky

3:-urinary pregnancy test:can detect small amount of HCG 

3:-Radioimmunoassay of beta subunit of HCG in serum is avery sensitive test and detect small amount of hormone

4:-serum progesteron :more than 25nanograms/ml alevel less than 5nanogram/ml ectopic pregnancy 

5:-ultrsound:- mor sensitive for diagnose ectopic pregnancy 

6:-laparoscopy : confirm the diagnosis in case of doubt it is not done in the presence excessive intraperitoneal haemorrhage it may be fail to diagnosis an early unruptured tubal pregnancy

Tertment:-

1:- Medical tertment:. Only undisturbed

Methoterxit and cytotoxic drugs 

DNA i.m 50mg/sec

Mypheproston 

Criteria for medical tertment

Sac <3cm

No cardiac activity

B HCG less than 3000ml/iu

2:-acute  subacut and chronic

Looking to anther tube

 if normally can do salbingectomy 

If anther tube affected seve it by doing salbingostomy

More:- if RH-ve give anti-D

Dofferential Diagnosis:-

Tubal inflammatory mass

Appendicular mass

Uterine abortion

Bleeding in to a corpus luteum

Rupture of spleen

Pregnancy with an ovarian cyst or posterior wall fibroid 

Some cases of rupture of uter