Pregnancy that grows outside of the uterine cavity
Most commonly within the Fallopian tubes. Otherwise ovary, cervix, broad ligament, abdominal cavity.
Incidence
11 per 1000 pregnancies
Risk factors
Previous PID
Smoking
Infertility
Use of IUCD
Previous ectopic
Previous abdominal/pelvic surgery
Previous tubal surgery
Endometriosis
Symptoms
Pain
Vaginal bleeding
GIT symptoms
Dizziness, fainting, syncope
Shoulder tip pain
Asymptomatic
Signs
Pelvic, abdominal and/or adnexal tenderness or fullness
Peritonism
Cervical motion tenderness
Tachycardia/hypotension
Investigation
Transvaginal ultrasound - look for absence of intra-uterine gestational sac (especially with B-hCG >1500) with positive pregnancy test. More likely if free fluid in PoD or an adnexal mass is seen.
Serial B-hCG - rise in 63% over 48 hours is more indicative of a viable intra-uterine pregnancy, while static or sub-optimal increase suggests ectopic.
Management:
Expectant
Medical
Methotrexate
Surgical
Laparoscopic salpingectomy or salpingostomy
Salpingectomy is preferred if healthy contra-lateral tube
Use LigaSure to resect the tube
Stay close to the tube and won't need to take much broad ligament with you
Salpingostomy carries an 8% risk of persistent trophoblastic tissue, intra-abdominal bleeding and an increased risk of repeat ectopic.
Should be followed up with monitoring of B-hCG until a negative restult is obtained
Laparotomy if unstable
Pfannenstiel is just as good access as laparotomy, if you can do it quickly
More complex ectopics, such as intra-abdominal, are best managed in a tertiary centre
Post-op management
Will still be able to become pregnant, however higher risk of future ectopics and miscarriages. Reduced overall fertility but >50% of women will still be able to become pregnant.
Future pregnancy attempts should be under the care of an obstetrician
Give anti-D immunoglobulin within 48 hours to women whose blood group is Rh-negative
