factor that causes delayed transport of the
fertilised ovum through the fallopian tube favours
implantation in the tubal mucosa itself thus giving
rise to a tubal ectopic pregnancy.
These factors may be Congenital or Acquired.
utilising monoclonal antibodies to
Ultrasound scanning – Abdominal & Vaginal
including Colour Doppler
Serum progesterone estimation not helpful
A combination of these methods may have to
At 4-5 weeks-
can visualise a gestational sac as early as
4-5 weeks from LMP.
During this time the lowest serum beta HCG is
When beta HCG level is greater than this and
there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.
In such a situation, when the value of beta HCG
does not double in 48 hours ectopic pregnancy
will be confirmed.
Distended portion of left
No evidence of rupture
1.7 x 1.6cm adjacent
and anterior to left
Tenderness over left iliac
fossa on deep palpation
with the probe
with microscopic exam
Type and Rhesus
Therefore, must give anti-D (RhoGAM) prior to surgery
on the stage of the disease and the
condition of the patient at diagnosis.
Surgery – Laparoscopy / Laparotomy
Medical – Administration of drugs at the site /
Expectant – Observation
OPTIONS: SURGICAL SURGICALLY ADMINISTERED
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 be used for
tubal pregnancy as well
Mechanism of action- Interferes with the DNA
synthesis by inhibiting the synthesis of
pyrimidines leading to trophoblastic cell death.
Auto enzymes and maternal tissues then absorb
pregnancy size should be < 3.5 cm.
Can be given IV/IM/Oral, usually along with Folinic
Recent concept is to give Methtrexate IM in a single
dose of 50mg/m2 without Folinic acid. If serum HCG
does not fall to 15% with in 4-7 days, then a second
dose of Methtrexate is given and resolution
confirmed by HCG estimation
Minimal Hospitalisation.Usually outdoor treatment
90% success if cases are properly selected
Side effects like GI & Skin
Monitoring is essential- Total blood count, LFT & serum
HCG once weekly till it becomes negative
Lie flat with the leg end raised
Helpful in Emergent Situations to Confirm
Highly Specific if performed and Interpreted
Correctly: - Presence of Free-Flowing, NON-Clotting
Negative Tap Inconclusive
should be done at the
Salpingectomy is the definitive
benefit from removing Ovary along with the tube
blood is not available, autotransfusion can be done.
out either by Laparoscopy / Laparotomy.
The procedures are:
Salpingectomy / Cornual resection / Excision
Conservative surgery (in cases of Infertility & desire for
Segmental resection and anastomosis
Milking of the tube
The debate goes on
SALPINGOSTOMY / SALPINGOTOMY?
SALPINGOSTOMY / SALPINGOTOMY
All tubal pregnancies can be treated by partial or total Salpingectomy
Salpingostomy / Salpingotomy is only indicated when:
The patient desires to conserve her fertility
Patient is haemodinmically stable
Tubal pregnancy is accessible
Unruptured and < 5Cm. In size
Contralateral tube is absent or damaged
1. Medial tubal A.
2. Lateral tubal A.
3. Uterine A.
4. Ovarian A.
Main Risk: devascularization of the ovary
Operate close to the tube, away from ovarian
vessels and suspensory ligament
Proximal tube division
Isthmus is held upwards and
Isthmus is cauterized
Take care not to cauterized the
internal ovarian A. and ovarian
branch of the uterine A.
Divide tube with scissors
Divide the mesosalpinx
Cauterize and divide the
ligaments and the lateral
Extraction of the tube
Remove tube through an
Verification of hemostasis
Removal of equipment
Suture/ Steri-strip laparoscopic
is carried out by laparoscopic
scissors and 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
The excised tissue is removed by
piece meal or in a tissue removal bag.
To reduce blood loss, first 10-40 IU of vasopressin
diluted in10 ml of normal saline is injected into the
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)
tubal pregnancy is then
evacuated by suction irrigation.
of the trophpblastic bed
tubal incision is left open.
quantitative beta HCG level by RIA
Serum progesterone level (<5 nanog/ml in
Low levels of Trophoblastic proteins such as
SPI and PAPP-, Placental protein 14 & 12
usually haematocele is found
TREATMENT – ALWAYS SURGICAL
of the offending tube
If pelvic haematocele is
infected, posterior. colpotomy is to be
done to drain the pelvic abscess
of ectopic pregnancy is rising while
maternal mortality from it is falling.
Early diagnosis is the key to less invasive
The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
The trend is towards conservative treatment.
Careful monitoring and proper counselling of
patients is mandatory.
Ruptured ectopics should be unusual with
compliant patients and appropriate medical