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Comprehensive Overview of Ruptured Ectopic Pregnancy Management and Anesthesia Protocols

Ruptured ectopic pregnancy, where a fertilized ovum implants outside the uterine cavity, occurs in 20 per 1000 pregnancies and accounts for 7% of maternal deaths, primarily due to hemorrhage. Diagnosis is confirmed via positive pregnancy tests and ultrasound, with management strategies varying depending on patient stability. Key anesthetic considerations include rapid intravenous access, appropriate monitoring, and induction using agents like ketamine. This comprehensive guide provides insights into clinical presentation, diagnostics, differential diagnoses, and effective management strategies.

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Comprehensive Overview of Ruptured Ectopic Pregnancy Management and Anesthesia Protocols

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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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