This document provides information on ectopic pregnancy, including its definition, types, risk factors, diagnosis, and management. Some key points: - Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It can seriously endanger a woman's health if not promptly recognized and treated. - Risk factors include previous pelvic inflammatory disease, previous ectopic pregnancy, infertility, and certain contraceptive methods. Diagnosis involves clinical history, examination, ultrasound, and beta-hCG levels. - Management options depend on the clinical situation and include expectant management for stable patients, medical management using methotrexate, and surgical management including laparoscopy

1. Dr. PRIYADHARSHINI M

2. Definition
Any pregnancy where the fertilized
ovum gets implanted & develops in a site
other than the normal endometrial cavity.
 Serious hazard to a woman’s health and
reproductive potential, requiring prompt
recognition & early aggressive intervention

3. Ovulation ovum picked up by
fimbria swept by ciliary action
towards ampulla fertilization.
Zygote cleavage division in (3 -4
days)  morula (8-32 cell stage)
embryo to uterine cavity for up to 72
hours D6 enters uterus
implantation- uterine cavity in
normal positioned pregnancy .
hCG (trophoblast)mother’s serum 1
week after implantation, level
doubles every 36-48 hours
Delay or
obstruction of the
passage of
fertilized egg
down the fallopian
tube to the
uterus
implantation in
tube or ovary or
peritoneal cavity
ectopic pregnancy
Eventually fails to
develop
hCG fails to raise
dramatically

5.  1-2 % of total pregnancy
 Recurrence rate – 15% after 1st, 25% after 2 ectopics
 Increasing incidence
 4th leading cause of maternal mortality overall (4%)
 MC cause of maternal mortality I trimester
 Types:
1. Tubal(95-98%)
2. Non tubal(2-5%)
3. Heterotropic(1/1000)

6. IMPLANTATION SITES
TUBAL
(97%)
AMPULLARY
70%
INFUNDIBULAR
11%
INTERSTITIAL
2%
ISTHMUS 12%
ABDOMINAL
(0.1)
SECONDARY
INTRAPERITONEAL
MC
EXTRAPERITONEAL
(broad lig)
PRIMARY
(rare)
OVARIAN
(0.5)
EXTRA
UTERINE
UTERINE
(1.5)
ANGULAR
CERVICAL <1%
CORNUAL
CS SCAR <1%

8.  Improved technology
 The rising incidence of risk factors-
 acute & chronic salpingitis
 induced abortion
 tubal ligation
 tubal reconstructive surgery
 ART
 Conservative management of tubal
pregnancy,

9.  Congenital: long narrow tube, diverticulae , accessory
ostia.
 Traumatic: operation on the tube –salpingoplasty ,tubal
reversal following ligation.
 Inflammatory: Chronic salpingitis
 Neoplastic: Narrowing of the tube by a fibroid or a broad
ligament tumor.
 Functional: As tubal spasm or antiperistaltic
contractions.
 Endometriosis in the tube. encourages embedding of the
fertilized ovum.

10. Separation of the
gestational sac from
the tubal wall
Degeneration
Fall of hCG level,
Regression of the corpus luteum
Drop in the oestrogen & progesterone
level
Separation of the uterine
decidua with uterine bleeding

11. Risk Factor Risk %
High Risk
PID *
Tubal corrective surgery
Tubal sterilization
Previous EP
In utero DES exposure
IUD **
Documented tubal
pathology
Moderate Risk
Infertility
Previous genital infection
Multiple partners
Slight risk
Previous pelvic or
abdominal surgery
Smoking
Douching
Intercourse before 18 years
25
21.0
9.3
8.5
5.6
4.2-45
3.8-21
2.5-21
2.5-3.7
2.1
0.93-3.8
2.3-2.5
1.1-3.1
1.6
Up to half of women with ectopic
pregnancy will have
no identifiable risk factors.
Use of assisted reproductive
technology (such as IVF and
GIFT)
•7 fold risk after acute pelvic
infection
** 4 times risk- increased
protection against IU pregnancy,
increased incidence of PID
RISK
FACTORS

12. Infections
chlamydia,
gonorrhoea
Damage to ciliated
surface of
endosalpinx
intratubal
adhesions 
partial tubal
obstruction
peritubal
adhesions
restricted tubal
motility
Alteration of tubal
transport
mechanisms
slow the passage of
egg time to
implant itself in
the tube

14. 1- Tubal mole:
 sac is surrounded by blood clot & retained
 chronic ectopic pregnancy/ involution
2-Tubal abortion: ampullary
 Separation of sac expulsion into peritoneal cavity through
ostium.
 Rarely, reimplantation of conceptus occurs in another
abdominal structure secondary abdominal pregnancy.
3-Tubal rupture: isthmus
 Rupture in anti-mesenteric border  profuse bleeding →
intraperitoneal haemorrhage.
 rupture in mesenteric border broad ligament
haematoma.

15. Tubal abortion
OUTCOMES
Tubal Rupture

16. 16
•Extraperitoneal rupture (rupture through floor
of the tube)
broad ligament hematoma with death of the ovum,
intraligamentary pregnancy.

18. The diagnosis often presents great difficulty
Usually missed because it is NOT suspected.
“Pregnancy in the fallopian tube is a black cat on a
dark night. It may make its presence felt in subtle
ways and leap at you or it may slip past unobserved.
Although it is difficult to distinguish from cats of
other colours in darkness, illumination clearly
identifies it.”
- Mc. Fadyen - 1981

19.  Multimodality approach including
 Proper history (cycle, pregnancy, PID,infertility,
gynaecological surgery, contraception)
 Clinical examination (Proper general, abdominal,
vaginal and vital signs)
 Judicious use of investigation
 Wide spectrum of presentation from asymptomatic pt
to others with acute abdomen and in shock
 Early symptoms - either absent/ subtle.
 7.2 weeks after LMP (range 5-8 weeks)

20. ECTOPIC
ABNORMAL
VAGINAL
BLEEDING
70%
ABDOMINAL
PAIN
Most common
AMENORRHOEA
75%

21.  Apart from classical triad pt presents with
 Features of shock
 Danforth sign, cullen sign
 P/A-Abdominal tenderness,guarding,BS
decreased/absent
 P/S-Minimal bleeding
 P/V-Uterus bulky,fornix tender full,pod full,adnexal
mass, cervical motion tenderness ”JUMPING SIGN”
 Bimanual examination should be very gentle with
facilities for immediate surgical intervention if needed

22.  H/O-acute attack of pain from which she has
recovered
 O/E-ill looking without any features of shock
 P/A-irregular mass,tenderness
 P/S-vaginal mucosa pale
 P/V-uterus may be normal/bulky,ill defined mass may
be felt through fornix

23.  Difficult to diagnose and high degree of clinical
suspiscion is needed,sometimes diagnosed
accidentally during laparoscopy/laparotomy
 C/F-Delayed periods,spotting with lower abdominal
discomfort
 P/A-tenderness in lower abdomen
 P/V-Uterus normal size,small tender mass may be felt
in the fornix

24. DIFFERENTIAL
DIAGNOSISDDX

25. Appendicitis (Perforated)
Acute Pancreatities
Myocardial Infarct
Pelvic Abcess
Splenic Rupture
Perforated Gastric or Duodenal Ulcer
(1) NON GYNECOLOGICAL

26. Septic
Abortion
Threatened
Abortion
Pyosalpinx
Pelvic Abcess
Twisted
Ovarian Cyst
Acute pelvic
inflammatory
disease
Rupture of
Follicle or
Corpus Luteum
Cyst
Degenerating
leiomyoma
Retroverted
Gravid
Uterus
(2) GYNAECOLOGICAL

27. •Accuracy of initial clinical evaluation < 50%.
General investigations
 Urine pregnancy test
Culdocentesis
Transvaginal ultrasonography
Serum beta hcg
Urine beta hcg
Serum progesterone
Uterine currettage
Laparoscopy/laparotomy

28.  Presence of free flowing
nonclotting blood
intraabdominal
haemorrhage
 serous fluid negative
 Lack of fluid
return/clotted blood
non- diagnostic
 Negative culdocentesis
does not exclude chance
of ectopic

29.  UPT not always positive
 Serum β-hCG (ELISA / RIA) detects very early pregnancy
about 10 days after fertilization i.e. before the missed period.
Discriminatory zone:
 1000-2000 IU/L TVS; 5000-6000 IU/L TAS
Absence of uterine pregnancy abnormal pregnancy( ectopic,
incomplete abortion)
β-hCG levels still below the discriminatory value, serial β-Hcg
USG should be done.
Doubling sign:
 Normal : >66% increase levels every 48 hours (nearly 2X).
 Inappropriately rising serum β-hCG levels suggest (but do not
diagnose) abnormal pregnancy including ectopic
Do not identify its location.

30.  Specificity 94%,sensitivity 38%
 TVS superior to TAS
 Failure to see Gestational sac at 4-5 wks gestation and
at beta hcg 1500iu/l i.e. the discriminatory zone
 Observation of g.sac, embryo, cardiac activity outside
the uterus
 In some cases no sac is found either
intrauterine/extrauterine

31.  7-20% proved to be ectopic
 25% of ectopic presents with PUL
 Intrauterine pregnancy in which the sac is not
developed, collapsed or aborted.
 Ectopic too small to be detected

32. Transvaginal USG
Positive β-hCG test + empty uterus by sonar ±
adnexal mass Ectopic pregnancy.

33.  Endometrial cavity shows trilaminar echo pattern
 Identification of double decidual sac sign(DDSS) is the
best method to differentiate true sacs from pseudosacs
Pseudogestational sac seen formed by the sloughing of
decidua creating an intracavitary fluid collection.it differs
from true g.sac in having only one layer and midline
location where as true sac is usually eccentric
 Decidual cast sometimes seen
 Decidual cyst anechoic area at the endometrium-
myometrium border
 Pouch of douglas may contain free fluid

34.  Presence of corpus luteal cyst in ipsilateral ovaries is a
useful marker
 Appx 60%-seen as inhomogenous mass/blob sign
adjacent to ovary, moving separetely from it
 Appx 20%-as adnexal hyperechoic ring/bagel sign
(fluid sacs with thick echogenic ring)
 Appx 13%-as obvious gestational sac with fetal
pole/cardiac activity
 Doppler improve the accuracy & identify the placental
shape ( ring of fire pattern) & blood flow outside the
uterine cavity

37.  Value >25ng/ml  normal intrauterine pregnancy
 Value<5ng/ml nonviable intrauterine pregnancy/
extrauterine pregnancy
 Most of ectopic pregnancy value ranges 10-25 ng/ml

38. Diagnostic laparoscopy
Gold standard
for diagnosis of
ectopic pregnancy
Diagnosis &
removal of ectopic
mass can be done
at the same time

39.  Presence of villi excludes ectopic
pregnancy not heterotopic
pregnancy
 Absence of villi and presence of
Ariastella reaction suggests
ectopic pregnancy
 OTHERS- VEGF, CA125, creatine
kinase, fetal fibronectin,
placental protein, Estradiol,
maternal AFP, relaxin

40. Suspected
ectopic
UPT+
S/SSTABLE
ECTOPIC Non
diagnostic
Serum beta
HCG
>1500
CURETTAGE
VILLI
ABORTION
NO VILLI
<1500
Repeat B
HCG
Intrauterin
e pregnancy
ABORTION
TVS
UNSTABLE
SURGICAL
MANAGEMENT

41. 1
• EXPECTANT MANAGEMENT
2
• MEDICAL MANAGEMENT
3
• SURGICAL MANAGEMENT
4
• EMERGENCY MANAGEMENT

42. EXPECTANT
MANAGEMENT
1

43. Criteria for selection (RCOG-green top-21-guideline)
 Asymptomatic pt
 Hemodynamically stable
 <100 ml fluid in the pouch of Douglas
 Lower beta hcg value<1000 IU/ml
 Adnexal mass <3cm without cardiac activity
 Pregnancy of unknown location
They must be fully compliant and must be willing to accept
the potential risks of tubal rupture.
• Success rate is 60% with decreasing beta hcg titre

44.  Initial follow up
 twice weekly with serial Hcg measurements
 weekly by TVS
 By the first week
 drop in HCG level
 Adnexal mass size
Otherwise reassess the options (Medical/Surgical)
 If the fall of HCG & reduction in size of adnexal
mass satisfatory
 weekly hCG & TVS till HCG falls <20 IU
MONITORING

45.  45–70% of PUL resolve spontaneously with
expectant management
 Ectopic pregnancy was subsequently diagnosed in
14–28% of PUL
 Intervention(laparoscopic salpingostomy) has
been shown to be required in 23–29% of cases

46. MEDICAL
2

47. CRITERIA FOR MEDICAL MANAGEMENT
Selectioncriteria
Minimal symptoms/
hemodynamically stable
No signs or symptoms of active
bleeding / haemoperitoneum.
HCG<3000(RCOG)
Normal CBC,RFT,LFT
Size<4cm
Absence of cardiac activity
Persistent ectopic after
conservative surgery
Good compliance and follow up
can be assured(RCOG)
Women should be given clear
information(preferably
written)about the possible need
for further Tt and adverse effects
following Tt (RCOG)
Exclusioncriteria
Any hepatic dysfunction,
thrombocytopenia
(<100,000), blood
dyscrasia(WBC <2000).
Difficulty/unwillingness
of patient for prolonged
follow-up (avg follow-up
35days).
Ectopic mass >4cm
presence of cardiac
activity
Women on concurrent
corticosteroid therapy

48. • Methotrexate
SYSTEMIC
( IV, IM or
orally )
• RU-486
• PgF2 alpha, MTX
• KCl , hyperosmolar glucose
• Actinomycin D
LOCALLY
SALPHINGOCENTESIS
(laparoscopic direct
injection, retrograde
salpingography)
Other agents- not recommended because their safety & accuracy are not
well documented

49. Advantage:
 Increased conc at local site
 lesser systemic s/e
 Increased fertility
 Shorter hospital stay
Follow up:
 Beta hcg twice wkly till<10iu/l
 TVS weekly till 4-6 wk
 Hcg after 6 month

50. Methotrexate:
folic acid antagonist inhibits DHFR
enzyme thus depleting the stores needed
for DNA/RNA synthesis during
trophoblast proliferation
first used by Tanaka et al(1982)-
interstitial ectopic pregnancy
Methotrexate-IM(buttock or lateral thigh)
Prior tests- CBC,LFT,RFT,CXR repeated
after 1 week

52. 1.Multidose regimen –
MTX 1mg/kg IM on 1,3,5,7 days
Leucovorin 0.1mg/kg on 2,4,6,8 days
Measure B-hCG levels on days 1,3,5,7 until 15% decrease
between 2 measurement
Once B-hCG level drops 15%, stop MTX & monitor B-hCG
weekly until non pregnant level

53. 2.Single dose regimen:
MTX 50mg/m2 on day 0
Measure B-hCG level on days 4 & 7
If level drops by 15%, monitor B-hCG weekly until non
pregnant level. If levels do not drop by 15%, repeat dose
of MTX & measure B-hCG on days 4 & 7
87% success rate
Advantages:
Increased pt compliance
Simplified administration
Safe & effective
Less expensive
Less monitoring

54. 3.Two dose regimen:
MTX 50mg/m2
on days 0 & 4
Measure B-hCG levels on days 4 & 7
 If levels drop by 15%, monitor B-hCG weekly until
non pregnant level
If level do not drop by 15%, repeat dose of MTX on
days 7 & 11 & measure B-hCG on days 7 & 11. If
levels drop 15%, monitor B-hCG level weekly until
non pregnant level

55. UNTOWARD EFFECTS:
Dose & frequency dependent
(30-40%)
nausea, vomiting
Stomatitis,
abdominal pain
bone marrow suppression
Alopecia
dermatitis & pneumonitis.
Deranged LFT

56. Rest up to one hour after the injection.
local reaction- anti-histamine/ steroid cream (v.rare)
use reliable contraception for 3 months after MTX (barrier or
hormonal)
Avoid
 sexual intercourse during treatment
 exposure to sunlight.
 alcohol , vitamin preparations containing folate until the
hormone level is back to zero.
 aspirin or drugs such as Ibuprofen for one week after
treatment.
FOLLOWED UP for signs of tubal rupture-( severe
pain/unstable/falling Hct)- surgical intervention

57.  90% successful treatment with single dose regime.
 10 – 20%. Recurrent ectopic pregnancy rate
 80%. Tubal patency rate
 75% abdominal pain-separation pain.(D3-D7)
 14 % of medical management 2nd dose of MTX
 10% finally require surgical management
Risk of subsequent ectopic 10% following either
MTX(MD)/salpingostomy.
similar reproductive outcomes
Success rates(time to resolution ) correlates with initial
serum B HCG
OUTCOME

58.  Medical management- cheap initially
 but considering the cost of follow up & the loss of work
time for patient & carers no cost saving was seen at
serum hCG levels above 1500 iu/l

59. SURGICAL
3

60.  Not a suitable candidate for medical therapy.
 Failed Medical therapy.
 heterotropic pregnancy with viable intrauterine
pregnancy.
 hemodynamically unstable & needs immediate treatment.
Surgical approachlaparoscopy or laparotomy
 hemodynamic stability
 size & location of ectopic mass
 surgeons expertise
Quick in and Quick out - principle
Conservative & extirpative

61. Linear salpingostomy:
 <2cm size, in distal third of tube
 Antemesenteric border incised –heals by secondary intention
 FOLLOW UP
iNDICATIONS
• unruptured ampullary
ectopic pregnancy(toc),
• wishes to retain potential
for future fertility
• affected fallopian tube
otherwise normal
• Contralateral tube
appears damaged
CONTRAINDICATIONS
Ruptured tube
use of extensive cautery
to obtain hemostasis
severely damaged tube
recurrent ectopic
pregnancy in same
tube.

62. Salpingotomy
 Conservative surgical management
 Incision – closed with vicryl7-0
 ectopic has not ruptured
 the tube appears normal
Segmental resection and anastomosis: for unruptured
isthmic pregnancy
Milking /fimbrial expression: infundibular pregnancy,
best reserved when products protrude out.
2X recurrence

63. EXTIRPATIVE
Salpingectomy (PARTIAL/TOTAL)
 Salpingectomy (tubal removal) is the principle treatment
especially where there is tubal rupture
 wedge area of outer 3rd of interstitial portion of tube is also
resected ,known as cornual resection to minimise occurence of
pregnancy in tubal stump
Total salpingectomy is the procedure of choice:
 completed childbearing and no longer desires fertility
 history of an ectopic pregnancy in the same tube.
 severely damaged tubes
 Cumulative inrauterine pregnancy rates and also incidence
of recurrent ectopic – higher with salpingostomy

66. Salpingectomy Salpingotomy
• There may be a higher
subsequent intrauterine
pregnancy rate associated with
salpingotomy but the
magnitude of this benefit may
be small
• Trend towards higher
subsequent ectopic pregnancy
• small risk of tubal bleeding in
the immediate postoperative
period
• potential need for further
treatment for persistent
trophoblast

67. Salpingostomy
 Chance of intrauterine
pregnancy- 73%
 Chance of recurrent
ectopic- 15%
Laparoscopy
Tubal patency: 80-90%
Intrauterine preg: 55-75%
Recurrent ectopic: 10-15%
 57%
 10%
Laparotomy
 80-90%
 55-75%
 10-15%
Salpingectomy

68. Laparotomy -
 hemodynamically unstable and an expedited abdominal
entry is required
 patients with cornual , interstitial ectopics
 Extensive pelvic/abdominal adhesive disease
 surgeons inexperienced & patients where laparoscopic
approach is difficult
 An alternative to laparoscopy is the use of
minilaparotomy incision.-success rate similar

69. Laparoscopy
• Less intraoperative blood
loss
• Shorter operation time
• Shorter hospital stay
• Lower analgesic requirement
• Future intrauterine
pregnancy rate same
• Lower repeat ectopic
pregnancy rate
Laparotomy
• Future intrauterine
pregnancy rate same
• Preferable in the
haemodynamically unstable
patient

70. LAPROSCOPY

71.  Tubal patency, future intrauterine pregnancy, future
ectopic rates - no differences in laparoscopic
salpingotomy and salpingostomy (recent cochrane
review)
 COMPARING systemic methotrexate with tube-
sparing laparoscopic surgery, randomized trials
have shown no difference in overall tubal
preservation, tubal patency, repeat ectopic
pregnancy, or future pregnancies(ACOG 2008)

73. Algorithm for the diagnosis of unruptured
ectopic pregnancy without laparoscopy

74. ECTOPIC
RUPTURED
EMERGENCY

75. PRINCIPLE: Quick Resuscitation and simulataneous arrangement for
laparotomy definitive surgery
ANTI SHOCK TREATMENT: ABC of resuscitation
 give facial oxygen
 Site two IV lines (at least 16g), commence IV fluids (crystalloid)
 Send blood for CBC, Clotting screen and cross-match at least 4 units of
blood.
 - Folleys catheterization done
 - colloids for volume replacement
whilst awaiting transfer to theatre continue fluid resuscitation and ensure
intensive monitoring of haemodynamic state

76. LAPAROTOMY
 - Rapid exploration of abdominal cavity done
- Salpingectomy (definitive surgery)
peritoneal toileting
record operative findings including the state of the
remaining tube/pelvis
 Blood transfusion done
 Anti D Ig (250 IU)given to Rh negative women
RCOG Guideline

77. factors affecting future pregnancy:
 prior h/o of infertility (the most
important)
 treatment choice history ( whether
surgical or nonsurgical)
 For example, the rate of intrauterine
pregnancy may be higher following
methotrexate compared to surgical
treatment.
 Rate of fertility may be better
following salpingostomy than
salpingectomy.

78.  Resorption/ tubal abortion- obviates need for further
or medical management
 Falling HCG(caution: tubal rupture can occur even
with falling levels)
 Low BHCG(<200mU/ml) 88%
 Follow up with beta HCG

79.  Complication of salpingotomy / salpingostomy(4-15%) when
residual trophoblast continues to survive because of incomplete
evacuation of ectopic pregnancy.
 Mostly ruptures in post op
 So serial monitoring of beta hcg.(D1, every 3-7 days thereafter till
undetectable)
 Risks are small size<2cm, early preg<6wk, preop high
Bhcg>3000iu/l
 Diagnosis : raised postoperative serum HCG
 If untreated, can cause life threatening hemorrhage

TREATMENT -
 IM / oral Methorexate single dose of 50 mg/m2 -TOC
 Reoperation and further evacuation / Salpingectomy

80.  Pregnancy does not completely resolve after expectant
mgt
 Persistence of chorionic villi with bleeding into tubal
wall slow distension , no rupture
 Amenorrhoea, symptomatic pelvic mass, BHCG-
low/absent, bowel/ureteral obstructive symptoms
 DIAGNOSIS: USG
 TREATMENT: Removal of affected tube, ovary
removed

81. Non tubal pregnancy –types
 Cervical(0.1-1%)
 Ovarian(0.5-2%)
 Abdominal(0.3-0.5%)
 Interstitial(2-3%)
 Angular
 Cornual(1:1lakh)
 Heterotropic
 Multiple ectopic pregnancy
 Ectopic in caesarean scar<1%)
 Pregnancy after hysterectomy

82. Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.
As such a horn is capable of some hypertrophy and distension, rupture
usually does not occur before 16-20 weeks.
Management -
affected cornual
pregnancy is
removed
hysteroscopic
resection,
hysterectomy

83.  Thick section of tube- expands max capacity before
rupture(7-16w)
 2.4% of all ectopics
 Late presentation rate
 Most dangerous –torrential haemorrhage(dual supply)
mgt:
 MTX – stable
 Laparoscopic cornuostomy -unstable .
 Hysteroscopic resection with selective arterial
embolisation, Inj kcl
 Hysterectomy(rupture)

84. • Uterus smaller than the surrounding
distended cervix
• External os may be open
• Visible cervical lesion often blue or
purple in colour
• Profuse bleeding on manipulation of
cervix
Rubin1911
(following
hysterectomy)
• Amenorrhoea  painless bleeding
• Softened enlarged cervix to the size of
uterine corpus
• Products of conception entirely confined
& firmly attached to endocervix
• Closed internal os and partially open
external os
Paalman
McElin 1959
(Before
hysterctomy)

85.  Gestatational sac /placental tissue visualizd within
cervix
 Cardiac motion noted below the level of internal
os
 No intrauterine pregnancy’
 Hourglass uterine shape with ballooned cervial
canal
 No movement of sac with pressure from
transvaginal probe(no sliding sign)
 Closed internal os

86. Diagnosis
 Clinical- painless vaginal bleeding/crampy pain
1/3massive harmorrhage
Very rarely>20 weeks
 Imaging- USG: true cervical pregnancy vs ongoing
spontaneous abortion: no sliding sign
 MRI pelvis
D/D:
 Carcinoma, cervical/prolapsed submucosal leiomyoma
 Trophoblastic tumor
 Placenta praevia

88. Evacuation and cervical packing with haemostatic
agent as fibrin glue and gauze.
Lateral cervical suture placement
Cervical cerclage
Angiographic Arterial embolization
Laparotomy-uterine artery& internal iliac artery
ligation
If bleeding continues or extensive rupture occurs
hysterectomy is needed.
Cervical pregnancy-Management
Medical
treatment with
MTX,KCL
surgical
dilation &
curettage
fetalcardiac
activity-
Multidose
MTX+KCL
injection

89. MC type of non tubal ectopic
Aetiology:
* Pelvic adhesions.
* Favourable ovarian surface for implantation as in
ovarian endometriosis.
Pathogenesis:
* Fertilization of the ovum inside the ovary or,
* implantation of the fertilized ovum in the ovary.

90. Spiegelberg criteria(1878)
* The gestational sac located in the region of the ovary,
* the ectopic attached to the uterus by the ovarian ligament,
* ovarian tissue in the wall of the gestational sac is proved histologically,
* the tube on the
involved side is intact.

91.  Misdiagnosis very
common(Ruptured corpus luteal
cyst75%)
 Laparotomy ovarian
cystectomy/wedge resection for
unruptured and oophorectomy for
ruptured.
 Treatment with MTX and
prostaglandin injection has also
been reported

92. primary
abdominal
pregnancy
• Studifords criteria for diagnosis
• Presence of normal tubes & ovaries with no evidence of recent or
past pregnancy
• No e/o uteroplacental fistula
• presence of a pregnancy related exclusively to the peritoneal
surface & early enough to eliminate the possibility of secondary
implantation after primary tubal nidation
Secondary
• usually after tubal rupture or abortion
• conceptus escapes out through a rent from primary site –
Intraperitoneal or Extraperitoneal broad ligament
Intraligamentous
pregnancy
• type of abdominal but extraperitoneal pregnancy. It develops between
the anterior and posterior leaves of the broad ligament after rupture
of tubal pregnancy in the mesosalpingeal border or lateral rupture of
intramural (in the myometrium) pregnancy.

93. Diagnosis:
History: amenorrhoea  an attack of lower abdominal
pain & slight vaginal bleeding which subsided
spontaneously., painful FM
Abdominal examination:
 Unusual transverse or oblique lie.
 Foetal parts are felt very superficial with no uterine muscle
wall around.
Vaginal examination:
 The uterus is soft, about 8 weeks and separate from the
foetus.
 Displaced uterine cervix
 No presenting part in the pelvis.

94. Special investigations:
Plain X-ray: shows abnormal lie. In lateral view, the
foetus overshadows the maternal spines .
Ultrasound: diagnoses only 40%,shows no uterine
wall around the foetus
(MRI): has a particular importance in preoperative
detection of placental anatomic relationships.
If pregnancy continues to term
Perinatal mortality& morbidity is also increased(IUGR,
congenital anomalies, fetal pulmonary hypoplasia, pressure
deformities)
maternal morbidity& mortality highly increased(7-8X, 50X)

95.  laparotomy with removal of
sac,fetus,placenta,membranes
 placenta if attached to vital structures -left in situ
after ligating base
 Placental involution serial USG, BHCG
 MTX treatment contraindicated -high rate of
complications due to rapid tissue necrosis

96. ANGULAR PREGNANCY
Implantation at lateral angle of
uterine cavity just medial to
uterotubal junction
In true sense not variety of
ectopic pregnancy
Confused with interstitial
pregnancyround ligament lies
medial to it.

97.  intrauterine+ extrauterine
pregnancy coexist
 1:1001:30000
 ART patients
 Delayed diagnosis
 Serial B HCG NOT useful
 Surgical treatment of
ectopic & intrauterine if
desired Continue
 Spontaneous abortion high

98.  Newly highlighted
 Prior CS csar, outside normal uterine cavity
 Completely surrounded by myometrium & fibrous
 I: 1:800-1:2200
Imaging: sac well perfused(i/c/t avascular aborting GS)
USG criteria:
 Trophoblast located b/w blader and anterior abdominal wall
 Fetal pole absent in uterine cavity
 Sagittal view through amniotic sac no myometrium b/w GS and
bladder
 Lack of continuity of anterior uterine wall
Management: no role of expectant mgt –risk- uterine rupture
 MTX, Hysteroscopic resection, uterus preserving wedge resection,
hysterectomy

99. Pregnancy after
hysterectomy
 Supracervical
hysterectomy provides
cervical canal
intraperitoneal access
 Pregnancy in periop period
with implantation of
already fertilized ovum in
tube
 After TAH secondary to
vaginal mucosal defect
that allows sperm into
abdominal cavity
 Twin/multiple ectopic
pregnancies- less
frequent
 Variety of locations and
combinations
 ART
 Treatment: similar to
others
Multiple ectopic
pregnancy

100. • In comparing systemic methotrexate with tube-sparing
laparoscopic surgery, randomized trials have shown no
difference in overall tubal preservation, tubal patency,
repeat ectopic pregnancy, or future pregnancies
good and consistent
evidence
(Level A):
• An increase in serum hCG of < 53% in 48 hr confirms an
abnormal pregnancy.
• With an hCG level of > 5,000 mIU/mL, multiple doses MTX
may be appropriate.
• MTX can be considered in those women with a confirmed, or
high clinical suspicion of, ectopic pregnancy who are
hemodynamically stable with an unruptured mass.
• Failure of the hCG level to decrease by at least 15% from day 4 to
day 7 after MTX administration  treatment failure requiring
therapy with either additional MTX / surgical intervention.
• Post-treatment hCG levels monitored until a nonpregnancy
level is reached
limited or inconsistent
evidence
(Level B):
• If the initial hCG level is less than 200 mU/mL,
88% of patients experience spontaneous
resolution.
consensus and expert
opinion (Level C):

101. Surgical management of tubal pregnancy
 laparoscopic approach to the surgical management of tubal
pregnancy, in the haemodynamically stable patient, is preferable
to an open approach.( A: evidence Ia)
 Management of tubal pregnancy in the presence of
haemodynamic instability should be by the most expedient
method. In most cases this will be laparotomy.( C:evidenceIV)
 In the presence of a healthy contralateral tube there is no clear
evidence that salpingotomy should be used in preference to
salpingectomy(B:EvidenceIIa).
 Laparoscopic salpingotomy should be considered as the primary
treatment when managing tubal pregnancy in the presence of
contralateral tubal disease and the desire for future fertility.
(B:EvidenceIIa).

102. Medical management of tubal pregnancy
 Medical therapy should be offered to suitable women, and units
should have treatment and follow-up protocols for the use of
methotrexate in the treatment of ectopic
pregnancy(B:EvidenceIIa)..
 If medical therapy is offered, women should be given clear
information (preferably written) about the possible need for
further treatment and adverse effects following treatment.
Women should be able to return easily for assessment at any
time during follow-up. (B:EvidenceIIa).
 Women most suitable for methotrexate therapy are those with a
serum hCG below 3000 iu/l, and minimal symptoms.
(B:EvidenceIIa).
 Outpatient medical therapy with single-dose methotrexate is
associated with a saving in treatment (A: evidenceIb)

103. Expectant management of pregnancy of unknown location
 Expectant management is an option for clinically stable women with minimal
symptoms and a pregnancy of unknown location. (C:EvidenceIII)
 Expectant management is an option for clinically stable asymptomatic women
with an ultrasound diagnosis of ectopic pregnancy and a decreasing serum
hCG, initially less than serum 1000 iu/l. (C:EvidenceIII)
Persistent trophoblast
When salpingotomy is used for the management of tubal pregnancy, protocols
should be in place for the identification and treatment of women with
persistent trophoblast.( EvidenceIV)
Anti-D immunoglobulin
 Nonsensitised women who are rhesus negative with a confirmed or suspected
ectopic pregnancy should receive anti-D immunoglobulin. .( EvidenceIV)
Patient involvement
 Women should be carefully advised, whenever possible, of the advantages and
disadvantages associated with each approach used for the treatment of ectopic
pregnancy. They should participate fully in the selection of the most
appropriate treatment. .( EvidenceIV)

104. THANK YOU