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🩺 ECTOPIC PREGNANCY - Easy Notes

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📌 DEFINITION

Implantation of a fertilized ovum outside the endometrial cavity of the uterus.

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⚠️ WHY IT MATTERS

• #1 cause of maternal death in the 1st trimester
• Early diagnosis = prevents rupture, hemorrhage, and loss of fertility

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📊 EPIDEMIOLOGY

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🔬 HOW IT HAPPENS (Etiopathogenesis)

Tubal damage / impaired transport
        ↓
Delayed migration of fertilized ovum
        ↓
Premature implantation
        ↓
Ectopic Pregnancy

Note: ~50% of women have NO identifiable risk factor

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📍 SITES & CLASSIFICATION

Tubal Pregnancy (95-97%)

Non-Tubal Pregnancy

• Ovarian
• Cervical
• Caesarean scar (most common non-tubal site)
• Abdominal
• Intramural
• Rudimentary horn
• Heterotopic pregnancy

3 Key Points to Remember:

• ✅ Most common site = Ampulla
• 🔴 Most dangerous site = Interstitial (Cornual)
• 📍 Most common non-tubal = Caesarean scar

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🔄 NATURAL HISTORY

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🩻 DIAGNOSIS

Classical Triad (present in only 30-40%)

1. Amenorrhoea
2. Abdominal pain
3. Vaginal bleeding

Symptoms

• Amenorrhoea
• Lower abdominal pain
• Vaginal bleeding/spotting
• Shoulder-tip pain (diaphragm irritation from blood)
• Dizziness or syncope
• Rectal pressure

Signs

• Pallor, Tachycardia
• Hypotension (if ruptured)
• Abdominal tenderness + guarding + rigidity
• Cervical motion tenderness (hallmark)
• Adnexal tenderness or mass
• Fullness in Pouch of Douglas

Differential Diagnosis

• Threatened/incomplete abortion
• Ruptured corpus luteum cyst
• Ovarian torsion
• PID
• Acute appendicitis
• Ureteric colic

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🔭 INVESTIGATIONS

Step-by-Step Approach:

Amenorrhoea ± Pain ± Bleeding
         ↓
Urine Pregnancy Test
         ↓ (if positive)
Assess Hemodynamic Status
    ↙              ↘
UNSTABLE           STABLE
   ↓                  ↓
Emergency        Serum β-hCG + TVS
Surgery

Key Investigations

β-hCG Discriminatory Zone: 1500-3500 IU/L

• If β-hCG above this level and uterus empty on TVS → likely ectopic

TVS Findings

• Empty uterine cavity
• Adnexal mass / Tubal ring sign
• Extrauterine gestational sac ± fetal pole
• Free fluid in Pouch of Douglas

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💊 MANAGEMENT

Decision Tree:

Suspected Ectopic
        ↓
  Hemodynamic Status?
   ↙             ↘
UNSTABLE         STABLE
Resuscitate →    Choose from:
Emergency        1. Expectant
Surgery          2. Medical (MTX)
                 3. Surgical

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1. EXPECTANT MANAGEMENT

• Hemodynamically stable
• Minimal/no symptoms
• Falling β-hCG
• Ectopic mass <3 cm
• No fetal cardiac activity
• Reliable follow-up

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2. MEDICAL MANAGEMENT - Methotrexate (MTX)

• Stable, unruptured ectopic
• Ectopic mass <3.5-4 cm
• β-hCG <5000 IU/L
• No fetal cardiac activity (preferred)
• No contraindications

• Single dose: MTX 50 mg/m² IM
• Multi-dose: MTX + folinic acid (selected cases)

• Hemodynamic instability / suspected rupture
• Liver or renal disease
• Blood dyscrasias
• Immunodeficiency
• Breastfeeding
• Cannot comply with follow-up

• Measure β-hCG on Day 4 and Day 7
• ≥15% decline between Day 4-7 = successful treatment ✅

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3. SURGICAL MANAGEMENT (Tubal)

• Hemodynamic instability / ruptured ectopic
• Failed medical treatment
• Contraindications to MTX
• Persistent pain or bleeding

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4. NON-TUBAL ECTOPIC - Surgical Options

Preferred approach: Laparoscopy when hemodynamically stable

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🚨 COMPLICATIONS

Acute:

• Tubal rupture
• Massive intraperitoneal hemorrhage
• Hemorrhagic shock
• Maternal death

Long-term:

• Persistent trophoblastic tissue
• Pelvic adhesions
• Infertility
• Recurrent ectopic pregnancy
• Psychological distress

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📋 FOLLOW-UP

1. Serial β-hCG until undetectable
2. Anti-D immunoglobulin for all Rh-negative, non-sensitized women
3. Early TVS at 6-7 weeks in next pregnancy to confirm intrauterine implantation

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🔮 PROGNOSIS

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🧠 QUICK MEMORY TRICKS

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