incidence of ectopic pregnancy has been placed between 0.25% to 1 % of all pregnancies.
Etiology of Ectopic Pregnancy :-
It is found that the incidence of ectopic pregnancy is on rise, may be due to better diagnostic fascilities available.most common etiologic factors of ectopic are:
1. pelvic inflammatory diseases (P.I.D.) : chalamydia and gonorrhoea are most common offenders. promptly and correctly treated PID does not add to the incidence of ectopic pregnancy. In developing countries genital tuberculosis is also an important factor.
2.Assisted reproductive techniques
3. Abnormal embryogenesis
4. some contraceptive methods like progesterone only pills
5. operative interventions in pelvic pathologies, like ovarian cystectomy,myomectomy,tubal recanalisation procedure etc.
The extent to which these factors do contribute in actuality is indeed debatable.
DIAGNOSIS :-
Mortality and morbity in ectopic pregnancy is directly related to early diagnosis.With the advent of high resolution endosonography and serum HCG level estimation,early diagnosis of ectopic pregnancy is very much a reality.
if serum HCG levels are more than 1000 I.U. and no intrauterine gestational sac is visible on Transvaginal Sonography ( TVS),ectopic gestation should be suspected.
following transabdominal sonography ( TAS ) intrauterine gestational sac should be visible at serum HCG levels of 6000 I.U./ L in more than 90 % of cases ( Kadar- 1981 ).
serial estimation of HCG levels alone :
It is recommended by Kadar & Colleagues ( 1981) that if HCG increased by less than 66 % over 48 hrs. in a given case than laparoscopy should be performed to rule out ectopic pregnancy. Thus 48 hrs. is considered as a “ doubling time “” for HCG levels in a given case wherein the pregnancy is intrauterine.
HCG levels versus days of conception in intrauterine pregnancy
Days from conception HCG levels
[I.U./L]
15 200
18 400
21 800
24 1600
27 3000
30 6000
42 50000
Some newer biochemical tests used for detecting ectopic pregnancy :
Human placental lactogen ( HPL )
Schwangerschafts protein ( SP-1)
Pregnancy associated plasma protein A ( PAPP -A )
Progesterone dependent endometrial protein ( P.
E.P )
Insulin like growth factor binding protein ( IGF - bp).
Active renin assay
Alpha Fetoprotein ( AFP )
These have more or less remained experimental and their use in clinical practice is limited.
Transvaginal colour Doppler: help to characterize the nature of the adnexal mass thus permitting preoperative diagnosis when the ectopic embryo and its characteristic heartbeat can not be seen
seen as an ectopic colour flow, usually very prominent and randomly dispersed inside the solid part of the adnexal mass and clearly separated from ovarian tissue and corpus luteum. Pulsed Doppler wave form analysis shows a very low impedance signal and calculated R.I. Is below 0.4 due to increased end diastolic flow. The brightness of the colour is usually high, indicating high velocity of ectopic flow
MANAGEMENT OF ECTOPIC PREGNANCY :-
expectant management : ectopic pregnancies are now diagnosed very early, many of these are expected to resolve spontaneously. this treatment is limited to those subgroup of patients who have minimal symptoms, have falling HCG levels and over a period of time shows diminishing size of the sac on TVS. Besides a frequent TVS in these cases, it is also necessary to estimate HCG levels atleast twice at a 2