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Dr. Megha Jain

Ruptured ectopic pregnancy. Dr. Megha Jain. University College of Medical Sciences & GTB Hospital, Delhi. www.anaesthesia.co.in. email: anaesthesia.co.in@gmail.com. Ectopic Pregnancy. Definition: fertilized ovum is implanted and developes outside the normal uterine cavity.

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Dr. Megha Jain

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  1. Ruptured ectopic pregnancy Dr. Megha Jain University College of Medical Sciences & GTB Hospital, Delhi www.anaesthesia.co.in email: anaesthesia.co.in@gmail.com

  2. Ectopic Pregnancy • Definition: fertilized ovum is implanted and developes outside the normal uterine cavity. • Incidence: 20 in 1000 pregnancies • Responsible for 7% of all pregnancy related maternal deaths. • Most common cause of death: hemorrhage(92%) Infection(3%) Embolism(3%) Anesthetic complication(1%) • > 30% patients with ectopic suffer from infertility and 5-20% develop recurrent ectopic.

  3. Etiology • Factors preventing or delaying migration of fertilized ovum: - PID - Contraceptive failure - Tubal reconstructive surgery - ART(ovulation induction drugs) - Previous ectopic - Prior induced abortion - Developmental defects of the tube

  4. Types of Ectopic Implantation site Extrauterine Uterine - tubal - cervical - ovarian - angular - abdominal - cornual

  5. Tubal Ectopic 1. Ampulla(64%) 2. Isthmus(25%) 3. Infudibulum(9%) 4. Interstitial(2%)

  6. Clinical Presentation • Depends on gestational age, site of implantation and occurrence of hemorrhage • Classical features of ruptured ectopic: - Short period of amenorrhea - Acute abdominal pain - Vaginal bleeding O/E - severe pallor - features of shock - tense and tender abdomen - uterus smaller than expected for dates - tender adnexal mass.

  7. How to diagnose? • Positive pregnancy test with absence of intrauterine gestational sac on USG • Serum progesterone <5 ng/ml • Serial beta HCG - ↓, plateau, show a subnormal rise • Culdocentesis- aspiration of non clotting bloody fluid

  8. Differential Diagnosis • Threatened, inevitable or incomplete abortion • Acute appendicitis • Perforated peptic ulcer • Ruptured ovarian cyst • Ovarian torsion • Ruptured endometrial cyst

  9. Management Pt. hemodynamically stable Patient in shock Laproscopy Resuscitation and laprotomy Unruptured tubal ectopicRuptured ectopic Expectant Medical/ Surgical mgmt Salpingectomy

  10. Anesthetic management of ruptured ectopic • Two large gauge i/v cannula with RL • Arrange blood and blood products • Routine noninvasive monitoring, consideration of invasive hemodynamic monitoring(arterial line,CV line) • Foleys catheterisation • General anesthesia • RSI with cricoid pressure

  11. GA (contd….) • Ketamine for induction(thiopentone or propofol if intravascular volume is restored) • Succinylcholine for endotracheal intubation • Maintenance with O2, N2O, volatile halogenated agent as tolerate • Reversal of muscle relaxant and extubation when the patient is awake and responds to verbal commands.

  12. References • Obstetric Anesthesia- Principles and practice David H. Chestnut 3rd edition • Anesthesia for Obstetrics- Shnider and Levinson’s 4th edition • Miller’s Anesthesia- Ronald D. Miller 6th edition • Textbook of obstetric anesthesia- Colli’s 5th edition • Principles and practice of critical care in obstetrics – A.Bhattacharya,S.Ahuja,A.K.Saxena. • International anesthesiology clinics-2005,vol.43,no.4. • Textbook of obstetrics- D.C.Dutta 6th edition

  13. Thank You www.anaesthesia.co.in

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