Ectopic pregnancy


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Ectopic pregnancy

  1. 1. Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & HospitalMahatma Gandhi Medical College, Jaipur.
  2. 2. DEFINITION“Any pregnancy where the fertilised ovumgets implanted & develops in a site otherthan normal uterine cavity”.It represents a serious hazard to a woman’shealth and reproductive potential, requiringprompt recognition and early aggressiveintervention.
  3. 3. Is one in which fertilized ovum is implanted & develops outside normal uterine cavity
  4. 4. IMPLANTATIONS SITES EXTRAUTERINE UTERINE -CERVICALTUBAL 95-96% OVARIAN ABDOMINAL (1:18,000) (1:40,000) (1:10,000) -ANGULAR-Ampulla 70% -CORNUAL-Isthmus 12% -CAESAREAN PRIMARY SECONDARY-Infundibulum 11% SCAR (<1)-Interstitial & cornual 2% Intraperitoneal Extraperitoneal Broad Ligament (rare)
  5. 5. INCIDENCE• Increased due to PID, use of IUCD, Tubal surgeries, and Assisted reproductive techniques (ART).• Ranges from 1:25 to 1:250• Average range is 1 in 100 normal pregnancies.• Late marriages and late child bearing -> 2%• ART -> 5%• Recurrence rate - 15% after 1st, 25% after 2 ectopics
  6. 6. ETIOLOGY: Any factor that causes delayed transport of the fertilised ovum through the tube. Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired.
  7. 7. ETIOLOGY CONGENITAL • Tubal Hypoplasia • Tortuosity • Congenital diverticuli • Accessory ostia • Partial stenosis • Elongation • Intamural polyp • Entrap the ovum on its way.
  8. 8.  ACQUIRED -Pelvic Inflammatory disease (6-10 times) Chlamydia trachomatis is most commonContraceptive Faliure CuT - 4% Progestasart -17% Minipills -4-10% Norplant -30%
  9. 9. Tubal sterilization faliure -40% Depends on sterilization technique and age ofthe patient Bipolar Cauterisation -65% Unipolar Cautery -17% Silicon rubber band -29% Interval Salpingectomy -43% Postpartum Salpingectomy -20%Reversal of sterilisation - Depends on method of sterilization, Site of tubal occlusion, residual tubal length. - Reanastomosis of cauterised tube -15% - Reversal of Pomeroy’s - < 3%
  10. 10. Tubal reconstructive surgery (4-5 times)Assisted Reproductive technique - Ovulation induction, IVF-ET and GIFT (4-7%) - Risk of heterotopic pregnancy(1%)Previous Ectopic Pregnancy - 7-15% chances of repeat ectopic pregnancy
  11. 11. Other Risk factors Age 35-45 yrs Previous induced abortion Previous pelvic surgeries Cigarette smoking DES Exposure in Utero Infertility Salpingitis Isthmica Nodosa Genital Tuberculosis Fundal Fibroid & Adenomyosis of tube Transperitoneal migration of ovum
  12. 12. Iffy hypothesis – “Theory of reflux” menstural fluid throw the fertilised ovum into the tubeFactors facilitating nidation of ovum in tube: - Premature degeneration of zona pellucida - Increased decidual reaction - Tubal endometriosis
  13. 13. Evolution Tubal pregnancies rapidly invade the mucosa, feeding from the tubal vessels, which become enlarged and engorged. The segment of the affected tube is distended as the pregnancy grows. Possible outcomes of such abnormal gestations are as follows:
  14. 14.  The pregnancy is unable to survive owing to its poor blood supply, thus resulting in a tubal abortion and resorption, or it is expelled from the fimbriated end into the abdominal cavity. The pregnancy continues to grow until the overdistended tube ruptures, with resulting profuse intraperitoneal bleeding. Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months Abortion is common in ampullary pregnancies,whereas rupture is in isthmic.
  15. 15.  In rare instances, a tubal pregnancy will be expelled from the tube and seed onto sites in the abdominal cavity (e.g. the omentum, the small or large bowel, or the parietal peritoneum), and gives rise to a viable abdominal pregnancy.
  16. 16. Pictures showing TUBAL ABORTION
  17. 17. CLINICAL APPROACH Dignosis can be done by history, detail examination and judicious use of investigation. H/o past PID, tubal surgery,current contraceptive measures should be asked Wide spectrum of clinical presentation from asymtomatic pt to others with acute abdomen and in shock.
  18. 18. ACUTE ECTOPIC PREGNANCY Classical triad is present in 50% of pt with rupture ectopic. - PAIN:- most constant feature in 95% pt - variable in severity and nature - AMENORRHOEA:- 60-80% of pt - there may be delayed period or slight spotting at the time of expected menses. - VAGINAL BLEEDING: - scanty dark brown Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to reflex vasomotor disturbance.
  19. 19.  O/E:- patient is restless in agony, looks blanched, pale, sweating with cold clammy skin. Features of shock, tachycardia, hypotension. P/A:- abdomen tense, tender mostly in lower abdomen,shifting dullness, rigidity may be present. P/S:- minimal bleeding may be present P/V:- uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain on movement of cervix. POD may be full, uterus floats as if in water.
  20. 20. CHRONIC ECTOPIC PREGNANCY It can be diagnosed by high clinical suspicion. Patient had previous attack of acute pain from which she has recovered. She may have amenorrhoea, vaginal bleeding with dull pain in abdomen,and with bladder and bowel complaints like dysuria,frequency or retention of urine, rectal tenesmus.
  21. 21.  O/E:- patient look ill, varying degree of pallor, slightly raised temperature. Features of shock are absent. P/A:- Tenderness and muscle guard on the lower abdomen. A mass may be felt, irregular and tender. P/V:- Vaginal mucosa pale, uterus may be normal in size or bulky, ill defined boggy tender mass may be felt in one of the fornix.
  22. 22. UNRUPTURED ECTOPIC High degree of suspicion & ectopic conscious clinician can diagnose. Diagnosed accidentally in Laparoscopy or Laparotomy C/F – delayed period, spotting with discomfort in lower abdomen. P/A – tenderness in lower abdomen P/V – should be done gently uterus is normal size, firm small tender mass may be felt in the fornix
  23. 23. DIAGNOSIS “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 youor 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
  24. 24. DIAGNOSIS In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate. This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease. This has resulted in early diagnosis and effective treatment. Now the rate of tubal rupture is as low as 20%.
  25. 25. DIAGNOSIS Patient with acute ectopic can be diagnosed clinically. Blood should be drawn for Hb gm%, blood grouping and cross matching, DC and TWBC, BT, CT. Should be catheterized to know urine output.Bed side test:- 1. Urine pregnancy test:- positive in 95% cases. ELISA is sensitive to 10-50 mlU/ml of β hCG and can be detected on 24th day after LMP.
  26. 26. 2. Culdocentesis:- (70-90%) - Can be done with 16-18 G lumbar puncture needle through posterior fornix into POD. - Positive tap is 0.5ml of non clotting blood. Other Investigations:- 1. Ultra Sonography-a) Transvaginal Sonography (TVS): - Is more sensitive - It detect intrauterine gestational sac at 4-5wks and at S-β hCG level as low as 1500
  27. 27.  Endometrial cavity -A trilaminar endometial pattern seen -pseudogestational sac -decidual cyst may be seen PSEUDOSAC – All pregnancies induce an endometrial decidual reaction, and sloughing of the decidua can create an intracavitary fluid collection called a pseudosac Early gestational sac Pseudosac location below the midline echo along the burried into endometium cavity line b/w endometrial layers shape usually round may change,oviod borders double ring single layer
  28. 28. DECIDUAL CYST It is identified as an anechoic area lying with in the endometrium but remote from the canal and often at the endometrial-myometrial border. Adenxa - 15-30% an extrauterine yolk sac or embryo seen in fallopian tubes confirms tubal pregnancy. - A halo or tubal ring surrounded by a thin hypoechoic area caused by subserosal edema can be seen. Rectouterine cul-de-sac Free peritonial fluid with an adnexal mass suggestive of ectopic pregnancy
  29. 29. b) Color Doppler Sonography(TV-CDS): - Improve the accuracy. -Identify the placental shape (ring- of-fire pattern) and blood flow outside the uterine cavity.c) Transabdominal Sonography: - can identify gestational sac at 5-6 wks - S-β hCG level at which intrauterine gestational sac is seen by TAS is 1800 IU/L.
  30. 30. USG PICTURE1.‘Bagel’ sign – Hyperechoic ring around gestational sac in adnexal region2. ‘Blob’ sign – Seen as small inconglomerate mass next to ovary with no evidence of sac or embryo.3. Adnexal sac with fetal pole and cardiac activity is most specific.4. Corpus luteum is useful guide when looking for EP as present in 85% cases in Ipsilateral ovary.
  31. 31. Hyperechoic ring aroundgestational sac in adnexal region
  32. 32. Ring sign — a hyperechoic ring around anextrauterine gestational sac.
  33. 33. 2. β-HCG Assay- a) Single β-HCG: little value b) Serial β-HCG: is required when result of initial USG is confusing. - When hCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy. -Rise of β-HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy . Biochemical pregnancy is applied to those women who have two β-HCG values >10 IU/L
  34. 34. 3. Serum Progesterone – - level >25 ngm/ml is suggestive of normal intrauterine pregnancy. - level <15 ngm/ml is suggestive of ectopic pregnancy. - level <5 ngm/ml indicates nonviable pregnancy, irrespective of its location.4. Diagnostic Laparoscopy (Gold standard)– - Can be done only when patient is haemodynamically stable. -It confirms the diagnosis and removal of ectopic mass can be done at the same time.
  35. 35. 5. Dilatation & Curettage – - Is recommended in suspected case of incomplete abortion vs ectopic pregnancy. - Identification of decidua without chorionic villi is suggestive of extra uterine pregnancy. - “Arias-Stella” endometrial reaction is suggestive but not diagnostic of ectopic pregnancy.6. Other hormonal Tests – - Placenta protein (PP14) decrease in EP - PAPPA (Pregnancy Associated Plasma Protein A), PAPPC (schwangerchaft protein 1) has low value in EP - CA-125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic pregnancy.
  36. 36. SUSPECTED ECTOPIC PREGNANCY Urine Pregnancy test positive Transvaginal USG IU sac No IU sac Quantitative S-hCG + S progesterone < 66% rise in 48 hr or >66% rise in 48 hr or S progesterone < 5-10 ng/ml S progesterone > 5-10 ng/ml D&C Repeat S-hCG in 48 hrs till USG discrimination zone Villi present Villi absentIncomplete Laparoscopy No sac IU sac abortion Continue to monitor
  37. 37. DIFFERENTIAL DIAGNOSISD/D of Acute Ectopic 1. Rupture corpus luteum of pregnancy 2. Rupture of chocolate cyst 3. Twisted ovarian cyst 4. Torsion / degeneration of pedunculated fibroid 5. Incomplete abortion 6. Acute Appendicitis 7. Perforated peptic ulcer 8. Renal colic 9. Splenic rupture
  38. 38. D/D OF CHRONIC (SUB ACUTE) ECTOPIC 1. Pelvic abscess 2. Pyosalpinx 3. Subserous uterine fibroid 4. Salpingintis 5. Retroverted gravid uterus 6. Appendicular lump
  39. 39. MANAGEMENT Expectant Medical Surgical management management management Local Systemic Radical Conservative(USG or Laparoscopic) Salpingectomy salpingocentesis Methotrexate -Salpingostomy - Methotrexate - Potassium chloride -Salpingotomy - Prostagladin(PGF2α) - Hypersmolar glucose - Segmental - Actinomycin D resection - Mifepristone -Milking or fimbrial expression
  40. 40. MANAGEMENT OF RUPTURED ECTOPICPRINCIPLE: Resuscitation and LaparotomyANTI SHOCK TREATEMENT: - IV line made patent, crystalloid is started - Blood sample for Hb, blood grouping & cross matching, BT, CT - Folley’s catheterization done - Colloids for volume replacementLAPAROTOMY: Principle is ‘Quick in and Quick out’ - Rapid exploration of abdominal cavity is done - Salpingectomy is the definitive surgery (sent for HP study) - Blood transfusion to be given - Autotransfusion only when donated blood not available.
  42. 42. EXPECTANT MANAGEMENTIDENTIFICATION CRITERIA (Ylostalo et al , 1993)- : 1. Tubal ectopic pregnancies only 2. Haemodynamically stable 3. Haemoperitoneum < 50ml 4. Adnexal mass of < 3.5 cm without heart beat. 5. Initial β HCG <1000 IU/L and falling in titreSUCCESS RATE - Upto 60%PROTOCOL: - Hospitalization with strict monitoring of clinical symptom - Daily Hb estimation - Serum β HCG monitoring 3-4 days until it is <10 IU/L
  43. 43. EXPECTANT MANAGEMENT Spontaneous resolution occurs in 72%,while 28% will need laparoscopic salpingostomy In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant level. The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2. Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low.
  44. 44. MEDICAL MANAGEMENTSurgery is the mainstay of T/t worldwideMedical M/m may be tried in selected casesCANDIDATES FOR METHOTREXATE (MTX) Unruptured sac < 3.5cm without cardiac activity S-hCG < 10,000 IU/L Persistant Ectopic after conservative surgeryPHYSICIAN CHECK LIST CBC, LFT, RFT, S-hCG Transvaginal USG within 48 hrs Obtain informed consent Anti-D Ig if pt is Rh negative Follow up on day1, 4 and 7.
  45. 45. MEDICAL MANAGEMENTMETHOTREXATE: It can be used as oral,intramuscular ,intravenous usually along with folinic acid. Resolution of tubal pregnancy by systemic administration of Methotrexate was first described by Tanaka et al (1982) Mostly used for early resolution of placental tissue in abdominal pregnancy.Can also be used for tubal pregnancy. Mechanism of action-Methotrexate is a folic acid antagonist that inactivates the enzyme dihydrofolate reductase.Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the
  46. 46. Contd…… Advantages – • Minimal Hospitalisation.Usually outdoor treatment • Quick recovery • 90% success if cases are properly selected Disadvantages- • Side effects like GI & Skin • Monitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative
  47. 47. SURGICALLY ADMINISTERED MEDICAL Tt (SAM) Aim- trophoblastic destruction without systemic side effects Technique- Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by- • Laparoscopy or • Ultrasonographically guided  Transabdominal (Porreco, 1992)  Transvaginal (Feichtingar, 1987) • With Falloposcopic control (Kiss, 1993)
  48. 48. SURGICALLY ADMINISTERED MEDICAL Tt (SAM)Trophotoxic substances used- Methtrexate (Pansky, 1989) Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486) PGF2α (Limblom, 1987) Hyper osmolar glucose solution Actinomycin DAdvantage of local MTX : - Increase tissue concentration at local site - Decrease systemic side effects - Decrease hospitalization - Greater preservation of fertilityFollow up: - Serum β HCG twice weekly till < 10 IU/L - TVS weekly for 4-6 weeks - HCG after 6 months for tubal patency
  49. 49. INSTRUCTION TO THE PATIENTS If T/t on outpatient basis rapid transportation should be available Refrain from alcohol, sunlight, multivitamins with folic acid, and sexual intercourse until S-hCG is negative. Report immediately when vaginal bleeding, abdominal pain, dizziness, syncope (mild pain is common called separation pain or resolution pain) Failure of medical therapy require retreatment Chance of tubal rupture in 5-10 % require emergency Laparotomy.
  50. 50. SURGICAL MANAGEMENT OF ECTOPIC Conservative SurgeryCan be done Laparoscopically or by microsurgical laparotomyINDICATION: - Patient desires future fertility - Contralateral tube is damaged or surgically removed previouslyCHOICE OF TECHNIQUE: depends on - Location and size of gestational sac - Condition of tubes - Accessibility
  51. 51. VARIOUS CONSERVATIVE SURGERIES1.Linear Salpingostomy: - Indicated in unruptured ectopic <2cm in ampullary region. - Linear incision given on antimesentric border over the site and product removed by fingers, scalpel handle or gentle suction and irrigation. - Incision line kept open (heals by secondary intention)2. Linear Salpingotomy : - Incision line is closed in two layers with 7-0 interrupted vicryl sutures.3. Segmental Resection & Anastomosis: - Indicated in unruptured isthmic pregnancy - End to end anastomosis is done immediately or at later date
  52. 52. 4. Milking or fimbrial Expression: - This is ideal in distal ampullary or infundibular pregnancy. - It has got increased risk of persistent ectopic pregnancy.ADVANTAGES OF LAPAROSCOPY - It helps in diagnosis, evaluation, and treatment . - Diagnose other causes of infertility. - Decreased hospitalization, operative time, recovery period, analgesic requirement.Follow up after conservative surgery - With weekly Serum β HCG titre till it is negative. - If titre increases methotrexate can be given.
  53. 53. DEBATABLE ISSUES? Salpingectomy Vs Salpingostomy? Laparotomy Vs Laparoscopy? Reproductive outcome? Risk of Recurrent Ectopic
  54. 54. SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY All tubal pregnancies can be treated by partial or total Salpingectomy Salpingostomy / Salpingotomy is only indicated when: 1. The patient desires to conserve her fertility 2. Patient is haemodinamically stable 3. Tubal pregnancy is accessible 4. Unruptured and < 5Cm. In size 5. Contralateral tube is absent or damaged
  55. 55. CONTD…… The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment. Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.
  56. 56. Fertility reducing factor Score• Antecedent one Ectopic pregnancy 2• Antecedent each further Ectopic pregnancy 1• Antecedent Adhesiolysis 1• Antecedent Tubal micro surgery 2• Antecedent Salpingitis 1• Solitary tube 2• Homolateral Adhesions 1• Contralateral Adhesions 1 • The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy. • Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more.
  57. 57. Laparotomy Vs Laparoscopy - Laparoscopy is reserved for pt who are hemodynamically stable. - Ruptured Ectopic does not necessarily require Laparotomy, but if large clots are present Laparotomy should be considered.Reproductive outcome Is similar in pt treated with either Laparoscopy or Laparotomy. Identical rates of 40% of IUP, around 12% risk of recurrent pregnancy with either radical or conservative pregnancy.
  58. 58. LAPAROSCOPIC SALPINGECTOMYIt is carried out by laparoscopic scissors & diathermy or Endo-loop.After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch.The excised tissue is removed by piece meal or in tissue removal bag LAPAROSCOPIC SALPINGOTOMY To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal saline is injected into the mesosalpinx. Then the tube is opened through an antimesenteric longitudinal incision over the tubal pregnancy by a – Co2 laser (Paulson, 1992) – Argon laser (Keckstein et al; 1992) – Laparoscopic scissors and ablating the bleeding points with bipolar diathermy. – Fine diathermy knife (Lundorff, 1992) The tubal pregnancy is then evacuated by suction irrigation.
  59. 59. PERSISTENT ECTOPIC PREGNANACY This is a complication of salpingotomy / salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy. Diagnosis is made because of a raised postoperative β HCG If untreated, can cause life threatening hemorrhageRisk Factor: (seifer 1997) 1. Early ectopic pregnancy (< 6 wks amenorrhoea) 2. Smaller size < 2 cm (Incomplete removal) 3. Preoperative high serum β HCG (> 3,000 IU/L) and postoperative Day1 titre is < 50% of preoperative level, is predictor of persistent EP. 4. Implantation medial to the salpingostomy site. surgery Medical Treatment (selected Asymptomatic pt) Total or partial MTX + Leukovorin salpingectomy
  60. 60. OVARIAN ECTOPIC PREGNANCYIncidence: 1:40,000Risk factor: - IUCD - Endometriosis on surface of ovaryCourse:C/F are same as tubal pregnancy ruptures within 2-3 wksDiagnosis: On LaparotomySpiegelberg’s Criteria 1. Ipsilateral tube is intact and separate from sac 2. Sac occupies the position of the ovary 3. Connected to uterus by ovarian ligament 4. Ovarian tissue found on its wall on HP study Ruptured M/M Unruptured Laparotomy Ovarian wedge resection Ovarian Cystectomy Oophorectomy
  61. 61. ABDOMINAL PREGNANCYIncidence: RarestMMR : 7-8 times > tubal ectopic 90 times > Intrauterine pregnancyH/O : - Irregular bleeding, spotting - Nausea, vomiting, flatulence, constipation, diarrhoea, abdominal pain. - Fetal movement may be painful and high in the abdomenO/E : - Abnormal fetal position, easy in palpating fetal parts. - uterus palpated separate from sac - no uterine contraction after oxytocin infusion
  62. 62. Diagnosis: Confirmed by USG, CT scan, MRI, Radiography TYPE Primary Secondary Studiford’s criteria Conceptus escapes out. Both tubes and ovaries normal through a rent from primary site. Absence of Uteroperitonal fistula. Pregnancy related to Peritoneal Intraperitoneal Extraperitoneal surface & young enough to rule Broad ligament out possibility of secondary implantation
  63. 63. FATE OF SECONDARY ABDOMINAL PREGNANCY : 1. Death of ovum – complete absorption 2. Placental separation – massive intraperitoneal haemorrhage 3. Infection – fistulous communication with intestine, bladder, vagina, or umbilicus 4. Fetus dies (majority) – mummification, adipocere formation, or calcified to lithopaedion 5. Rarely – continue to term (malformation)M/M: - Urgent Laparatomy irrespective of period of gestation - Ideal to remove entire sac fetus, placenta, membrane - Placenta may be left if attached to vital organs, get absorbed by aseptic autolysis
  64. 64. CERVICAL PREGNANCYImplantation occurs in cervical canal at or below internal Os.Incidence: 1 in 18,000RISK FACTORS : - Previous induced abortion - Previous caesarean delivery - Asherman’s syndrome - IVF - DES exposure - Leiomyoma
  65. 65. Diagnosis:CLINICAL CRITERIA: Paulman & McEllin 1. Uterine bleeding, no cramping, following amenorrhoea 2. Cervix distended,thin walled,soft consistency 3. Enlarged uterine fundus may be palpated. 4. Internal Os is closed 5. External Os is partially openedUSG CRITERIA: American Journal of O&G 1. Echo-free uterine cavity/ pseudo-gestational sac 2. Decidual reaction 3. Hourglass uterus with ballooned cervical canal 4. Gestational sac in endocervix 5. Closed internal Os 6. Placental tissue in Cx canal
  66. 66. HISTOPATHOLOGIC CRITERIA: Rubin’s 1. Cervical glands present opposite to placenta 2. Placental attachment to the cervix must be below the entrance of uterine vessels . 3. Fetal element absent from corpus uteri.D/d : - Carcinoma Cx - Cervical submucous fibroid - Trophoblastic tumour - Placenta previa
  67. 67. MANAGEMENT Surgical Medical Mainstay therapy in past Recently proposed Single or Combination ConservativeRadical ORsurgery D&C Adjunct to surgery (risk of torrential bleeding) - MethotrexateHysterectomy - Cerclage Bernstein ≈ Mc Donald’s - Actinomycin Wharton ≈ Shirodkar’s -Transvaginal ligation of Cx branch of - KCl uterine artery - Angiographic uterine A embolisation - Etoposide - Intracervical vasopressin inj - Foley’s catheter as tamponade
  68. 68. CORNUAL PREGNANCYSITE: Implantation occurs in rudimentary horn of Bicornuate uterusCOURSE :Rupture of horn occurs by 12-20 wksD/D : 1. Interstitial tubal pregnancy 2. Painful leiomyoma along with pregnancy 3. Ovarian tumor with pregnancy 4. Asymmetrical enlargement of uterus. Implantation into cornu of normal uterus is sometime called Angular pregnancy .TREATEMENT: - Affected cornu with pregnancy is removed - Hysterectomy - Hysteroscopically guided suction curettage if
  69. 69. HETEROTYPIC PREGNANCYCo-existing intrauterine and extra uterine pregnanciesIncidence: 1 : 30,000 With ART – 1:7000 With ovulation induction – 1:900More likely: a) Ass. reproductive technique b) Rising HCG titre after D & C c) More than 1 corpus luteum at laparotomyM/M : Depends on the site. Ectopic site may be removed with continuation of IU pregnancy(Rh Immunoglobulin: dose of 50 μ gm is sufficient to prevent sensitization.)
  70. 70. INTERSTITAL PREGNANCY (2%)It ruptures late at 3-4 months gestation.Fatal rupture – severe bleeding as both uterine & ovarian artery supply.Early & Unruptured – Local or IM MTX with followup Cornual resection by Laparotomy may be done. There is high risk of uterine rupture in subsequent pregnancy.Rupture – Hysterectomy is indicated
  71. 71. CAESAREAN SCAR ECTOPIC PREGNANCY Recently reported USG slows on empty uterine cavity and gestational sac attached low to the lower segment caesarean scar.C/F : similar to threatened or inevitable abortionDiagnosis : Doppler imaging confirmsT/t : Methotrexate injection Hysterectomy in a multiparous women. In young pt resection & suturing of scar may be done (high risk of rupture).
  72. 72. OTHER RARE TYPES1. Multiple Ectopic pregnancy2. Pregnancy after hysterectomy3. Primary splenic pregnancy4. Primary hepatic pregnancy5. Rectroperitoneal pregnancy6. Diaphragmatic pregnancyMORTALITY : In general population is 10-15% mainly due to haemorrhage.
  73. 73. SUMMARY - KEY POINTS Incidence of ectopic pregnancy is rising while maternal mortality from it is falling. Ectopic pregnancy can be diagnosed early (before it ruptures) with recent advances in Immunoassay to detect S-hCG , high resolution USG, and dignostic Laparoscopy. There has been shift in the M/m from ablative surgery to conservative fertility preserving therapy Laparotomy should be done when in doubt The choice today is Laparoscopic treatment of unruptured ectopic pregnancy. Careful monitoring and proper counselling of patients is mandatory.