Professional Documents
Culture Documents
MANAGEMENT OF
ECTOPIC PREGNANCY
Ectopic Pregnancy
In normal pregnancy, the blastocyst (fertilized ovum) implants
in the endometrial lining of the uterine cavity
Interstitial: gestation
implants in the interstitial
portion of the fallopian
Cervical tube.
Vaginal
Angular: A gestation that Broad ligament
extends beyond the interstitium
into the adjacent uterine cavity
Tubal Pregnancy
Commonest site of ectopic pregnancy (99%)
Medication: none
NKDA
Social hx:
married
Smoker (pack years unknown) *risk factor
Other important facts that are not known:
Sexual history ( coitrache, # of partners, etc.)
Past menstrual hx
Examination
General appearance: comfortable, no pallor
Vitals signs: within normal limits
BP 95/60mmHg
CVS exam: heart sounds 1 and 2 present, no added sounds
or murmurs
Resp exam: normal vesicular breath sounds
Abdominal:
Normal on inspection, no visible swellings, scars, etc.
No pain on palpation
5. Potential Complications
1. Short Term Injury
2. Long term Injury
6. Pre-op Instructions
I. Rx/lifestyle/nutritional needs or changes
II. Psychological management
7. Legal issues
Initial Investigations
Monitor βhCG levels
βhCG- hormone produced by the placenta (and fetal kidney)
Detectable in plasma and urine following blastocyst implantation
Blood levels rise rapidly, doubling every 2d and plateaus at 8-10
weeks gestation
Serum βHCG levels correlate with the size and gestational age in
normal embryonic growth
900
800
700 LOW!!!!!
600
BhCG (U/L)
500
400
300
200
100
0
12/23/2005 12/25/2005 12/27/2005 12/30/2005 1/4/2006 1/6/2006 1/9/2006
DATE
Other Labs:
Complete blood count
Leukocytosis
Advantages:
Less blood loss, decreased number of transfusions, less recovery time,
less post-op analgesia, cost effective
Contraindications:
Absolute: ruptured EP, haemodynamic instability, surgeon’s lack of
experience Relative: previous multiple pelvic surgeries, Unruptured
interstitial EP, morbid obesity
Surgical options (cont’d)
2. Laparotomy
Salpingectomy (Radical)
Tubal resection
Video monitor
Laparoscopic Tools
1.Bipolar grasper
2.Atraumatic
grasper
3.Grasping forceps
4.Toothed forceps
5.Sharp-tipped
monopolar
device
6.5-10mm suction-
Patient Positioning
Low lithotomy
position
30 degree
Trendelenburg
Urinary catheter
NG tube (?)
Uterine cannulation
Trocar Placement for
Surgery
Anteversion (exposure of
rectouterine pouch)
Displaced to contralateral side of
ectopic
Exposure
1st Assistant:
• Holds laparoscope
• Pushes intestinal loops
cephalically using
grasping forceps
2nd Assistant:
• Anteverts uterus and
pushes it CL to the
ectopic pregnancy
Exploration
To determine the precise location of the ectopic
pregnancy
To evaluate the extent of Hemoperitoneum
To determine the condition of the adnexa
Visualize active bleeding
Rule out any other associated pathology
Examine contralateral tube to rule out
retrograde reflux and haematosalpinx
Anatomical Review
1. Medial tubal A.
2. Lateral tubal A.
3. Uterine A.
4. Ovarian A.
Laparoscopic Salpingectomy
Smoking cessation
Folic acid