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Ectopic Pregnancy
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## **Ectopic Pregnancy : Part 1**
### **Role of Progesterone in Ectopic Pregnancy**
* **Corpus luteum** β secretes progesterone.
* **Placenta** β absent.
* **Progesterone levels in ectopic pregnancy**
* Higher than non-pregnant state.
* Lesser than intrauterine pregnancy.
**Progesterone effects:**
* Decidualization of endometrium β Decidual cast Β± (shedding of decidua).
* **USG finding:** Pseudogestational sac.
* **Decidua vera**: not differentiated into decidua basalis/capsularis/parietalis.
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### **Basics of Ectopic Pregnancy**
**Anatomy of Fallopian Tube (medial β lateral):**
Interstitium (intramural) β Isthmus β Ampulla β Infundibulum.
* Narrowest part: Interstitium > Isthmus.
* Sphincters:
* Physiological β Isthmus
* Anatomical β Interstitium
**Duration of ectopic pregnancy:**
* **Lasts longest:** Interstitium (β myometrial support).
* Most dangerous site (β bleeding).
* **Ends earliest:** Isthmus.
**Site of ectopic pregnancy:**
* **Fallopian tube**: most common
* **Commonest part:** Ampulla
* Site of fertilization
* Max. number of plicae (mucosal folds)
* **Least common part:** Interstitium
* **Most common non-tubal site:** Ovary
* **Least common overall:** C-section scar < Cervical ectopic < Abdominal ectopic.
* **Note:** Abdominal ectopic lasts longest (blood from adjacent organs).
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## **Risk Factors & Clinical Features of Ectopic Pregnancy**
### **Risk Factors**
* PID / salpingitis β most common.
* Previous ectopic or tubal surgery β highest risk.
* Cervicitis.
* Multiple partners β risk factor for PID.
* Smoking.
* Previous C-section.
* Infertility / ART (assisted reproductive techniques).
* Contraceptives.
**Contraceptives and risk of ectopic:**
* β Absolute risk (β chance of pregnancy).
* β Relative risk (if failure occurs β β chance of ectopic).
**Highest risk:**
a. Tubal ligation > Progesterone IUCD (Mirena, Progestasert) > Cu-IUCD.
b. POP > OCP (Progesterone β smooth muscle relaxant β β peristalsis).
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### **Outcome**
**Tubal abortion:**
* Occurs at fimbrial end of tube.
* Most common site: Ampulla.
**Tubal rupture:**
* Due to continuous growth of ectopic.
* Most common site: Isthmus.
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### **Criteria for various sites**
| Site | Criteria |
| -------------------------------- | ------------------------------- |
| Cervical | Paalman (New), Rubin (Obsolete) |
| 1Β° Abdominal | Studdiford |
| 2Β° Abdominal (from fimbrial end) | Studdiford |
| Ovarian | Spiegelberg |
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### **Timing of Pregnancy Termination**
| Site | Termination |
| ------------ | ----------- |
| Isthmus | 6β8 weeks |
| Ampulla | 8β10 weeks |
| Interstitium | 12 weeks |
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## **Clinical Features**
### **Triad**
1. Amenorrhea
2. Pain abdomen (most specific/consistent; localized to lower abdomen; sharp/dull, unilateral)
3. Bleeding P/V
### **Pathophysiology of Pain**
**Ruptured ectopic:**
* Due to hemoperitoneum.
* Presents with:
* Mid/upper abdominal pain
* Shoulder tip pain (Danforth sign β diaphragmatic irritation)
* Urge to defecate (blood in cul-de-sac pressing rectum)
**Unruptured ectopic:**
* Due to stretching of fallopian tube β transmitted via T11βL1.
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## **Ruptured Ectopic Pregnancy**
### **Diagnosis**
* **UPT positive**
### **Symptoms Suggestive of Rupture**
Triad of ectopic + any of:
1. Shoulder tip pain
2. Urge to defecate
3. Orthostatic hypotension
### **Examination**
* **Shock Β±**
* **Per abdomen:**
* Abdominal distension
* Rigidity
* Guarding
* Rebound tenderness
* Uterus enlarged but smaller than POG (period of gestation)
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## **Management**
**P/V Findings:**
* Most significant: **Cervical motion tenderness** (due to peritonitis).
**Note:**
* Cervical motion tenderness + PID β UPT negative.
* Cervical motion tenderness + ectopic β UPT positive / β Ξ²-hCG.
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### **Management Plan**
**Triad + UPT positive + Localizing signs β**
Perform **FAST scan** to confirm diagnosis β **Surgical management.**
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### **Surgical Management**
**Route:**
* Stable vitals β Laparoscopy
* Unstable vitals β Laparotomy
**Surgery:**
* **Unilateral salpingectomy:** Irrespective of family completion.
* **Oophorectomy:** Only for ovarian ectopic.
**Contraindicated in ruptured ectopic:**
* Expectant management
* Medical management
* Surgery other than salpingectomy
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## **Culdocentesis**
**Indication:** Ruptured ectopic.
**Principle:** Syringe introduced into cul-de-sac (pouch of Douglas) via posterior fornix.
**Findings:**
* If **blood aspirated**, wait and re-aspirate.
* **Blood clots** β needle in blood vessel.
* **Blood doesnβt clot (devoid of clotting factors)** β needle in Pouch of Douglas β **Hemoperitoneum of ruptured ectopic.**
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## **Ectopic Pregnancy: Part 2**
### **Unruptured Ectopic**
**Investigations**
Amenorrhea + bleeding P/V + pain abdomen β
**1st step:** UPT (+ve in 99% cases due to β hCG) β **Next:** TVS β Ξ²-hCG
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### **Approach**
| Diagnostic finding | Signs on TVS | Next step |
| ------------------------------------------------------------ | -------------------------------------------------------------------- | ------------------ |
| **Presence of gestational sac & yolk sac in fallopian tube** | Tubal sign/Bagel sign: Fallopian tube gestational sac + / Yolk sac β | Medical management |
| **Other findings** | - Ring of Fire sign: β Vascularity around ectopic | |
* Empty uterus
* Complex adnexal mass (most common, due to hemorrhage areas) | Ξ²-hCG measurement |
**Ring of Fire:** characteristic Doppler appearance β empty uterus + vascular ring around tube.
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### **Ξ²-hCG**
**Critical titre:** Value at which gestational sac is visible in intrauterine pregnancy.
**hCG interpretation:**
| hCG pattern | Likely diagnosis |
| ------------------------------ | ---------------------------------------------------------------------------- |
| β₯ 2000 IU + no gestational sac | Unruptured ectopic β medical management |
| < 2000 IU + empty uterus | Could be early intrauterine or ectopic pregnancy β repeat Ξ²-hCG after 48 hrs |
**Repeat after 48 hrs:**
* **Nearly doubles (β 33β60%)** β Live intrauterine pregnancy
* **Slow rise (<33%)** β Ectopic pregnancy
* **Decreases** β Abortion (nonviable intrauterine pregnancy)
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## **Other Investigations**
* **Laparoscopy** β Gold standard.
* **Serum progesterone:**
* β₯ 25 ng/mL β Live intrauterine pregnancy.
* < 5 ng/mL β Ectopic pregnancy.
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### **Contraindications**
* HSG
* Hysteroscopy
* Colpotomy (drainage of pelvic abscess)
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## **Management**
### **Types of Management**
1. **Medical (best)**
2. **Surgical**
3. **Expectant**
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### **Indications for Surgical Management**
* Ruptured ectopic
* Unruptured ectopic (if medical prerequisites not fulfilled)
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### **Prerequisites for Medical Management**
* Unruptured ectopic
* Stable vitals
* Family not completed
* hCG < 5000 IU
* Site < 4 cm
* Cardiac activity absent
**Note:** Cardiac activity +
β Not an absolute contraindication if size < 3.5 cm, but β risk of failure.
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## **Medical Management**
**Drug of choice:** Methotrexate (MTX)
**Route:** Intramuscular
**Dose:** 50 mg/mΒ² or 1 mg/kg
**Note:**
* MTX can be used for both ectopic pregnancy and GTN (choriocarcinoma).
* In ectopic β single-dose regimen
* In GTN β multidose regimen (MTX + folinic acid alternate days)
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### **Single-Dose MTX Therapy**
* **Day 1 (D1):** Measure Ξ²-hCG + give entire MTX dose
* **Day 4 (D4):** Measure Ξ²-hCG
* **Day 7 (D7):** Measure Ξ²-hCG again β assess fall between D4 & D7
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### **Interpretation of MTX Response**
| hCG Fall (D4βD7) | Interpretation | Action |
| ------------------------------------- | -------------------------- | -------------------------------------------- |
| β₯ 15% | Successful medical therapy | Continue follow-up |
| < 15% | Inadequate dose | Repeat entire MTX dose (new D1), max 3 doses |
| β hCG or <15% fall after 3 injections | Failed therapy | Surgical management |
**Note:** β hCG D1βD3 = normal (due to dying sac release).
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## **Surgical Management**
**Route:** Laparoscopy
**Choice of Surgery:**
| Condition | Procedure |
| --------------------------------- | ------------------------------------------- |
| Family not complete & size < 4 cm | Linear salpingostomy |
| Family complete or size β₯ 5 cm | Unilateral salpingectomy |
| Obsolete procedures | Milking of tube, Salpingotomy (site closed) |
**Linear salpingostomy technique:**
Hydrodissection + tube left intact + incision left open.
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## **Expectant Management**
**Wait & watch**
**Indication:** Spontaneously resolving ectopic pregnancy
**Prerequisites:**
1. hCG < 4000 IU
2. Spontaneous fall in hCG
3. USG: No gestational sac in fallopian tube
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## **Special Types of Pregnancy & Criteria**
### **Heterotopic Pregnancy**
* Coexistence of **1 intrauterine pregnancy** + **1 ectopic pregnancy**
* Methotrexate contraindicated.
* Management β **Surgical**
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## **Angular vs Cornual Pregnancy**
| Feature | Cornual Pregnancy | Angular Pregnancy |
| -------------------------- | ----------------------------------------------------------- | --------------------------- |
| Type | Ectopic pregnancy | Intrauterine pregnancy |
| Site | Interstitium of fallopian tube / rudimentary horn of uterus | Near angle/cornua of uterus |
| Relation to round ligament | Lateral | Medial |
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## **Criteria for Non-Tubal Ectopic**
| Type | Criteria | Notes |
| -------------------- | --------------------- | ----- |
| **Cervical Ectopic** | **Paalman criteria:** | |
1. Internal os closed
2. External os partially open
3. Sac attached to endocervix
4. Bleeding without uterine cramps | Diagram: internal os closed, external os partially open |
| **Ovarian Ectopic** | **Spiegelberg criteria:**
5. Sac present in ovary
6. Tubes normal
7. Gestational sac attached to uterus by ovarian ligament
8. HPE: ovarian tissue in gestational sac | |
| **1Β° Abdominal Ectopic** | **Studdiford criteria:**
9. Uteroperitoneal fistula absent
10. Tubes & ovaries normal
11. Pregnancy attached to peritoneum | Note: Secondary abdominal ectopic = most common |
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