Incidence of ectopic pregnancy is rising while maternal mortality from it is falling. ALWAYS suspect ectopic pregnancy in a woman of a child-bearing age c/o pain and/or p.v. bleeding

1. ECTOPIC PREGNANCY
PANEL DISCUSSION
DR JAYA KORE -TULASKAR

2. PANELISTS
Group 1 Group 2

3. Moderator

4. Under the guidance of

5. Context
 Pregnancy in fallopian tube is a black cat in a
dark night.
 It makes its presence felt in subtle ways and
leap at you or it may slip unobserved.
 Although its difficult to distinguish from cats
of other colours in darkness.
 Illumination clearly identifies it.
Mc Fadyen ,1981.

6. DEFINITION
‘Any pregnancy
where
fertilized ovum
gets
implanted and
develops
In a site other
than
Normal uterine
cavity’
Also called
eccysis

7. Incidence
 The rate of ectopic pregnancy is about 1
and 2% that of live births in developed
countries. 4% among those
using assisted reproductive technology
 The risk of death among those in the
developed world is between 0.1 and 0.3
percent while in the developing world it is
1-3 %., 10 times higher than those
reported in developed countries
 The prevalence of ectopic pregnancy
first trimester bleeding, pain, or both
ranges from six to 16 percent in world.

8.  An extrauterine gestation is 50 times more
likely to result in a maternal death than a
first-trimester abortion and 10 times more
likely than delivery in the third
trimester(FIGO 2011)
 The pregnancy rate after an ectopic
pregnancy may be decreased by 40–
70%(FIGO 2011)

9. HISTORY
 History Ectopic pregnancies were
initially described in the 10th century
(Albucasis in 963 A.D.)
 For a long time were universally fatal
events for the mother
 Initial treatments (in the old days) were
desperate primitive attempts designed
to destroy the growing pregnancy

10.  Starvation
 Bleeding
 Administration of strychnine
 Administration of electricity into the
growing gestational sac

11.  Lawson Tait, THE FATHER
OF GYNECOLOGIC
SURGERY, reported the
first successful operation
for ectopic pregnancy in
1883.
 His main difficulty lay in
establishing the diagnosis.

12. HOW DO YOU CLASSIFY
ECTOPIC PREGNANCY ?

13. CLASSIFICATION
Heterotopic pregnancy

14. SITES OF ECTOPIC PREGNANCY

15. WHAT ARE RISK FACTOR
?

16. PATHOPHYSIOLOGY
FACTORS
 Anatomic obstruction to the passage
of the zygote
 Abnormal conceptus
 Abnormalities in the mechanisms
responsible for tubal motility
 Transperitoneal migration of the
zygote.

17. 1.ANATOMIC OBSTRUCTION TO THE
PASSAGE OF THE ZYGOTE
a.Major causes
Pelvic inflammatory
diseases
 Most important cause
 Chlamydial infection leads to EP
 Pelvic TB is another cause
 Post abortal & puerperal sepsis

18. o b.Congenital
factors
 Tubal tortuosity ,
accessory ostia ,
diverticula & partial
stenosis
 In utero exposure to
diethyl stilboesterol
‘DES daughters’
c. Salpingitis
isthimica nodosa of
the tube {SIN}
 Tubal epithelium
invades myosalpinx,
forming a diverticulum

19.  d.SURGICAL PROCEDURES
◦ Tubectomy,tubal
recanalisation,tuboplasty
◦ ventrosuspension
◦ Laproscopic cauterization
◦ 1/3 rd pregnancies after tubal
sterilisation turns to be
ectopic
(FIGO 2011)

20.  II .AN ABNORMAL
CONCEPTUS
- Rapid development of
trophoblast leads to premature
implantation in the tube..
 III .TUBAL MOTILITY
- influenced by the hormonal
milieu.- high estrogen levels
- in cases of hyperstimulation
with human menopausal
gonadotropins interfere with tubal
transport.)
- In contrast, subnormal estrogen
levels.

21.  IV.Transperitoneal
migration of the zygote.
 SART data from 2011 show that ectopic
pregnancy occurs in 1.8% of recipients
of embryo transfer during in
vitro fertilization and up to 4.3% in
patients undergoing zygote
intrafallopian transfer (ZIFT).Indeed,
the first pregnancy reported in humans
with this technique was an ectopic
pregnancy.

22. V.OTHERS;
 CONTRACEPTIVE METHODS
IUCD prevents intrauterine
pregnancy more effectively than
tubal pregnancy
Progesterone containing IUCD and
progesterone only pills-delay tubal
peristalsis and motility
 PREVIOUS ECTOPIC
- chance of second ectopic – 12%
 AGE
- Elderly age-more at risk

23.  ASSISTED REPRODUCTIVE TECHNOLOGIES-
IVF
- IVF involves multiple egg transferred with fluid
medium.
- leads to flushing of one egg into tubular lumen
- can also lead to implantation in uterus along with
tubal implantation-heterotopic pregnancy
 INDUCTION OF OVULATION
- by gonadotrophins
- multiple pregnancy and ectopic pregnancy
 SMOKING

24. The trophoblast develops in the
fertilized ovum and invades deeply
into the tubal wall.
Following implantation, the
trophoblast produces hCG which
maintains the corpus luteum.
Produces oestrogen and
progesterone.
Which change the secretory
endometrium into decidua. The
uterus enlarges up to 8 weeks and
becomes soft

25. The tubal pregnancy does not usually proceed
beyond 8-10weeks due to:
> lack of decidual reaction in the tube
> the thin wall of the tube
> the inadequacy of tubal lumen
> bleeding in the site of implantation as
trophoblast invades.

26. Changes in uterus
 enlarged – myohyperplasia & hypertrophy
 endometrium shows typical histological pattern
– arias stella phenomenon –Hyperplasia of
glands with loss of polarity,cytoplasmic
vacuolisation,hyperchromatic nucleus.
 absence of chorionic villi in the endometrial
curettage
 arias stella reaction along with absence of
chorionic villi
ectopic pregnancy

27. WHAT IS FATE
OF TUBAL
ECTOPIC
PREGNANCY?

28. Separation of the gestational sac from the tubal wall
leads to
• Its degeneration, and fall of hCG level,
• Regression of the corpus luteum and
• Subsequent drop in the oestrogen and progesterone
level.
This leads to separation of the uterine decidua with
uterine bleeding.
Fate of tubal pregnancy
Tubal mole
Tubal abortion
Tubal rupture

29. Fate of tubal pregnancy
1- Tubal mole:
The gestational sac is
surrounded by a blood clot
and retained in the tube.
 may remain for long period
in the tube- chronic ectopic
pregnancy
 may be gradually absorbed-
involution
 May be expelled out
through the ostia-tubal

30. 2-Tubal abortion:
 Common in ampullary
pregnancy
 Complete expulsion
blood collected in
pouch of douglas-
pelvic hematocele
 Incomplete expulsion
diffuse intraperitoneal
haemorrhage

31. 3-Tubal rupture:
 More common in isthmic and
interstitial implantation
 Isthmic rupture---6-8 weeks
 Ampullary rupture---8-12
weeks
 Interstitial rupture---4 months
 Rupture may occur in the anti-
 mesenteric border of the
tube→ intraperitoneal
haemorrhage.
 If rupture occurs in the
mesenteric border of the tube,
broad ligament haematoma
→intraligamentous pregnancy

32. CASE….
 A 22-year-old G2P1L1 was admitted with mild
vaginal bleeding after 7 weeks of
amenorrhoea. She had had a positive home
pregnancy test. Ultrasound scan showed an
empty uterus, with an adnexal mass around 2
cm. quantitative β-hCG was 2000 iu/ml
On examination p-84/m and bp-120/70 mm Hg

33. CASE….
 An 33-year old woman G4P3L3, was
brought In emergency collapsed with lower
abdominal pain. On admission she was in
shock with blood pr. Of 80/60, a pulse of
120 bpm and tender rigid abdomen. Vaginal
exam. Revealed a slight red loss, bulky
uterus and marked cervical excitation with a
tender mass in the right fornix.

34. CASE 2
 A 22-year-old woman G2P1L1, was admitted
with vaginal bleeding after 8 weeks of
amenorrhoea. She had had a positive home
pregnancy test, and described passing some
tissue per vaginum. Ultrasound scan showed
an empty uterus, although urinary B-hCG was
still positive. A presumptive diagnosis of
incomplete abortion was made, and evacuation
of the uterus carries out uneventfully. She was
discharged the following day. Was readmitted
that night with lower abdominal pain;

35. WHAT ARE SIGNS AND
SYMPTOMS OF TUBAL
ECTOPIC PREGNANCY?
WHAT ARE SIGNS AND
SYMPTOMS OF TUBAL ECTOPIC
PREGNANCY?

36. Presentation
Early symptoms are either
absent or subtle.
CLINICAL TRIAD OF 3A’s
1.Ammenorrhoea
2.Abdominal pain
3.Abnormal uterine bleeding

37. Symptoms
1.Pain and discomfort
 Mainly due to intraperitoneal bleeding
 In the Lower back , abdomen, or pelvis.
 Acute agonizing/colicky
 Usually unilateral
 Shoulder pain – accumulation of blood in
subdiaphramatic regions → stimulate phrenic
nerve→shoulder tip pain
 Pain while urinating and passing bowels

38. 2.Bleeding
 Vaginal bleeding usually mild.
Withdrawal bleeding due to decreased progesterone from
corpus
luteum in the failing ectopic pregnancy
 Internal bleeding (haemaoperitoneum) is due to hemorrhage
from the affected tube.
 Dizziness, headache, weakness, fainting all may happen due
to bleeding
3.Amenorrhea
Not always present
4.Retention of urine
5.Fever,vomiting,fainting attacks

39.  Irregular bleeding in a sexually
active women should always
suggestive of ectopic, until proved
otherwise

40. Signs
General examination:
 Weakness, pallor, hypotension,thready pulse with
tachycardia, tachypnea,cold extremities-features of
shock
 Signs of early pregnancy (breast tenderness, nausea
and vomiting, change of apettite …)
Abdominal examination:
 Lower abdominal tenderness and rigidity especially on
one side may be present.
 No mass felt
 Shifting dullness
 Distended bowels
 Muscle guarding-usually absent

41. Vaginal examination:
1.RUPTURED
 Vaginal spotting with blanched white mucosa
 Bluish vagina and bluish soft cervix.
 Uterus is slightly enlarged and soft.
 Extreme tenderness on fornix palpation or on
movement of cervix
 No mass usually felt
 Uterus floats as in water
2.UNRUPTURED
 Ill-defined mass with arterial pulsations

42. In a woman of child bearing age with pelvi-
abdominal pain and/ or vaginal bleeding
…… ALWAYS….think
ECTOPIC PREGNANCY

43. WHAT IS EPAC ?

44. Early Pregnancy Assessment
Clinic {EPAC}:
.
“ONE-STOP CLINIC” for
women who have
complications of
pregnancy before 20
weeks’ gestation
First established at North
York General Hospital in
August 2005
To offer women with
earlypregnancy
complications prompt
diagnosis, options for

45. The clinic is run by a
-team of dedicated gynaecologists and
-experienced obstetrical nurses, with on-site
ultrasound (both transabdominal and transvaginal)
services performed by the gynaecologists,
-easy access to laboratory services,
-readily available operating services and blood bank
In UK almost all hospitals have EPAC

46. DIAGNOSIS
 D/t 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%.
 AIM has changed from " saving the mother's
life " to recently " saving the woman's fertility
"

47. METHODS OF EARLY
DIAGNOSIS
 Immunoassay utilising monoclonal
antibodies to beta HCG
 Ultrasound scanning – Abdominal &
Vaginal including Colour Doppler
 Laparoscopy
 Serum progesterone estimation not
helpful
A combination of these
methods may have to be
employed.

48. Diagnosis of ruptured ectopic
o Patient may be in shock with pallor ,
tachycardia , hypotension & cold clammy
extrimities
o Abdominal examination - all signs of intra
abdominal haemorrhage
o cullens sign may be present
o Abdomen – distended with tenderness ,
guarding , rigidity& shifting dullness
o Vaginal examination – normal or bulky
uterus with tenderness on moving the
cervix

49. Culdocentesis
 Determines if there is blood in the space behind the
uterus,
 The results of a culdocentesis can be classified
 A negative culdocentesis - by the presence of clear
fluid.
 A positive - free flow of nonclotting blood-
intraperitoneal haemorrhage is diagnosed. But if not,
ectopic pregnancy cannot be excluded.
 Nondiagnostic -No fluid
 Hematocrit of the aspirate is helpful.
-Hematocrits of more than 15% -a/w ectopic
-Lower hematocrits frequently indicate the presence
of cystic fluid

50. Diagnosis of unruptured
ectopic
 pregnancy test is +ve
1. - Pregnancy test.
a) Urinary B-hCG… sensitive, detects 25-50 ml
I.U/ml.. Positive before missing the next period
b) Serum B-hCG…… Mainly used for quantitative
rather than qualitative purposes
 TVS
 β hCG
 Curettage
 laproscopy

51. 1.TVS
 Intrauterine gestational sac with
a yolksac and double decidual
sign---INTRAUTERINE
PREGNANCY
 Psuedosac---ECTOPIC
PREGNANCY
 Transvaginal. A wk earlier than
abdo… empty bladder
 Diagnosis made by
1. An empty uterus
2. An empty uterus with adnexal
mass
3. Bagel sign
4. Presence of a gestational sac in
adnexa with fetal heart

52. 2.Serum β-hCG
 If the test is negative (generally less than 5 IU/L),
normal and abnormal pregnancy including ectopic
are excluded.
 Test positive with 1500IU/L WITH
1. and an intrauterine gestational sac seen—
intrauterine pregnancy
2. w/o any intrauterine sac---ectopic pregnancy
 If β-hCG < 1500IU/L, second assay after 48hrs
1. If doubling after 48hrs---intrauterine pregnancy
2. No doubling---failing/ectopic pregnancy

53. 3.Curettage
 Curettage of the uterus
 Flotation test---floating of
chorionic villi in water
 Confirmed by microscopic
examination of presence of
villi
 CHORIONIC VILLI ABSENT
IN ECTOPIC PREGNANCY
4-Laparoscopy
 Allows you to see the
fallopian tubes and other
organs
 Gold standard

54.  An 33-year old woman G4P3L3, was
brought In emergency collapsed with
lower abdominal pain. On admission she
was in shock with blood pr. Of 80/60, a
pulse of 120 bpm and tender rigid
abdomen. Vaginal exam. Revealed a
slight red loss, bulky uterus and marked
cervical excitation with a tender mass in
the right fornix.
 WHAT WILL BE YOUR MODEL ACTION
?

55. • Patient usually in shock-resusciation done
• Immediate arrangements of laparotomy with
necessary arrangements like blood
• If tubal rupture-immediate salpingectomy
• If rupture at isthmial region –segmental resection
of ruptured site
• Cornual rupture—hysterectomy

56. Treatment of
UNRUPTURED ECTOPIC
EXPECTANT
MEDICAL
SURGICAL

57. INDICATIONS
1. Clinically stable asymptomatic women
2. Initial ß hCG < 1000IU/L and subsequent falling levels
3. Gestational sac size <4cm
4. No fetal heartbeat on TVS
5. No evidence of rupture/bleeding
• Proper monitering of ß hCG twice weekly

58.  INDICATIONS
◦ Asymptomatic women no
evidence of rupture or
hemodynamic instability
◦ less than 100 ml fluid in the
pouch of Douglas
◦ hCG less than 1000 iu/l at initial
presentation
◦ Adnexal mass less than 3cm
◦ they should objective evidence of
resolution, such as declining
bhCG levels.
◦ They must be fully compliant -
willing to accept the potential
risks of tubal rupture.

59. ◦ Initial follow up
 twice weekly with serial hCGmeasurements
 weekly by transvaginal examinations
◦ By the first week
 drop in HCG level
 Adnexal mass size
 Otherwise reassess the options (Medical/Surgical)
◦ If the fallof HCG & reduction in size of adnexalmass satisfatory
 weekly hCG andtransvaginal ultrasound examinations
 Till the HCG falls less than <20 IU
MONITORING

60.  Selection criteria
◦ Minimal symptoms &Thepatient must be hemodynamicallystable
◦ no signs or symptoms of active bleeding orhaemoperitoneum.
◦ Absence of foetal heart beat
◦ NormalFBC,U&E(urea&electrolytes),LFT(liver functiontests)
 Exclusion criteria
◦ Anyhepatic dysfunction, thrombocytopenia (platelet count<100,000),blood
dyscrasia(WCC <2000cells cm3).
◦ Difficulty or unwillingness of patient for prolonged follow-up (average follow-up
35days).
◦ Ectopic mass >3.5cm
◦ Thepresence of cardiac activity in an ectopic pregnancy
CRITERIA for MEDICAL MANAGEMENT

61. METHOTREXATE THERAPY
 WHAT IS METHOTREXATE
-Methotrexate is a folic acid antagonist that interferes
with the synthesis of DNA.
-The use of drug therapy for ectopic pregnancy was first
reported in 1982, in a patient with an interstitial
pregnancy who refused surgery
WHEN TO GIVE
 Hemodynamically stable
 NO cardiac activity in an ectopic pregnancy
 Desire future fertility.

62.  Methotrexate – destroys actively growing tissues such as the
placental tissues , (in non ruptured ectopic)
 Side effects include abdominal pain for 3 – 7 days in 50% of
cases and mild symptoms of nausea, mouth dryness and
soreness and diarrhoea,
◦ Methotrexate-Intramuscular(buttock or lateral thigh)
◦ Dose calculated from body surface area
◦ Usual dose ranges between 75-95 mg
◦ HCG checked on day 4 & day 7
 If fall is less than 15 % consider second dose of
methotrexate
 Anti-D should also be given if required
METHOTREXATE

64. ADVICES
 Patient should be given information on(preferably written)
◦ Need for further treatment
◦ Adverse effects
 Women should be able to return easily for assessment at
any time during follow-up
 Advice
◦ avoid sexual intercourse during treatment
◦ to maintain fluid intake
◦ use reliable contraception for three months after
methotrexate has been given, barrier or hormonal)
◦ Avoid exposure to sunlight.
 “- Avoid alcohol and vitamin preparations containing
folic acid until the hormone level is back to zero.
 - Avoid aspirin or drugs such as Ibuprofen for one
week after treatment.

65. ◦ 90% successful treatment with single dose
regime.
◦ Recurrent ectopic pregnancy rate 10 – 20%.
◦ Tubal patency approximately 80%.
◦ 14 % of medical management second dose
of methotrexate
◦ 75% would experience abdominal pain-
separation pain. This usually occurs between
day 3-7
◦ 10% would finally require surgical
management
OUTCOME

66.  ADVICE
1 Avoid sexual intercourse during
treatment
2 Maintain ample fluid intake
3 To use contraception for three
months after methotrexate has been
given, because of a possible
teratogenic risk.

67.  Day 1 is considered the day of administration of
methotrexate.
 Follow-up hCG levels should be obtained on
days 4 and 7, with an expected 15% drop
between the two latter values. Thereafter, hCG
values should be followed weekly until negative.
 Treatment failure -
-less than 15% drop in hCG values between days 4
and 7
-worsening abdominal pain concerning for rupture
-increasing or plateauing hCG values after the first
week of therapy
*Large uncontrolled studies have reported that about 14% of women will require
more than one dose of methotrexate and less than 10% of women treated
with this regimen will require surgical intervention(RCOG ,2014)

68. Contraindications TO MEDICAL
THERAPY
 A ruptured ectopic
 Ectopic mass greater than 3.5 cm
 Fetal cardiac activity
 High level hCG value (10,000 IU)
 Breastfeeding
 Immunodeficiency
 Elevated creatinine or liver function tests
 Alcoholism
 Active pulmonary or gastrointestinal
disease.

69. SIDE EFFECTS OF MEDICAL
THERAPY
 Nausea and vomiting, abdominal
pain, diarrhea, stomatitis, dizziness,
and rarely neutropenia or reversible
alopecia.

70. 1.Conservative surgery
 Indicated when woman not completed her
family
 5%cases—persistant ectopic noted
 hCG monitoring and single dose methotrexate
continued after surgery
 Includes--1.linear salpingostomy
2.segmental resection
3.milking of the tube
2.Radical surgery—salpingectomy
Indications-
 When the tube is not salvageable
 Recurrent ectopic
 Childbearing completed
 Previous sterilisation

71. Surgical Management
 Conservative,
Open vs laparoscopic….. Linear
salpingotomy vs milking of the tube
 Radical,
laparoscopic vs open …….
salpingectomy

73.  Salpingectomy versus Salpingo-oophorectomy
 In 1955, Jeffcoate suggested that in conjunction
with a salpingectomy an oophorectomy on the
ipsilateral side be done as well.
 The theory behind this is that all ovulations
would be into the good tube;
 this discounts the importance of transmigration.

74. MANAGEMENT OF RUPTURED
ECTOPIC
 CALL FOR HELP
 ABC of resuscitation
◦ give facial oxygen
◦ Site two IV lines , commence IV fluids (crystalloid)
◦ Send blood for FBC, Clotting screen and cross-match at least 4 units
of blood.
 insert indwelling catheter
 arrange theatre for laparotomy
 whilst awaiting transfer to theatre continue fluid resuscitation and ensure
intensive monitoring of haemodynamic state
 do not wait for BP and pulse to normalise prior to transfer-resuscitation
and surgery need to go hand in hand.
 Pfannensteil incision,
 salpingectomy and wash out of abdomen
 assess bloods /consider CVP
 record operative findings including the state of the remaining tube/pelvis
 Anti – D immunoglobulin (250 IU)to be given to Rhesus negative
women

75. Laparascopy OR
laparatomy??
 Laparoscopy has become the recommended
approach in most cases.
 Laparotomy is usually reserved for patients:
 who are hemodynamically unstable
patients with cornual ectopic pregnancies.
for surgeons inexperienced in laparoscopy
and in patients where laparoscopic approach
is difficult

76. 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

77. Salpingectomy OR
Salpingotomy ??
 Salpingectomy
 Salpingectomy (tubal removal) is the principle treatment
especially where there is tubal rupture
 Salpingotomy
 Conservative surgical management may be employed
when the ectopic has not ruptured and where the tube
appears normal
 Total salpingectomy is the procedure of
choice:
 In a patient who has completed childbearing
and no longer desires fertility
 in a patient with a history of an ectopic
pregnancy in the same tube.
 in a patient with severely damaged tubes,

78. Salpingectomy Salpingotomy
• There may be a higher
subsequent intrauterine
pregnancy rate
associatedwith 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

79. 1. Heterotopic pregnancy
◦ ectopic pregnancy coexist with intra
uterine pregnancy
◦ incidence has ↑sed due to ART
◦ Surgical management with continuation
of intrauterine pregnancy

80. 2.Interstitial pregnancy /Cornual angular
preganancy
◦ implantation – interstitial part of tube
◦ pregnancy advance to a later date – myometrium
◦ abdominal pain & collapse – rupture of uterine wall
◦ In some cases, the pregnancy is expelled into the
uterus and rupture does not occur.
◦ TREATMENT-immediate laprotomy with
salpingectomy
wedge resection of cornua
reconstruction of uterine wall
if severe uterinewall damage-
hysterectomy

81. Pregnancy in a rudimentary
horn
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.

82. 3. Intraligamentous pregnancy
◦ Rare
◦ due to penetration of tubal wall by the trophoblast
& its advancement b/w the two layers of broad
ligament
◦ 2º to tubal pregnancy
◦ clinical findings are similar to abdominal
pregnancy

83. Cervical pregnancy
Implantation in the substance of the cervix below the
level of uterine vessels.
May cause severe
vaginal bleeding.
Can be diagnosed by
trans vaginal ultrasound

84. Ovarian pregnancy
Spiegelberg criteria for diagnosis of ovarian pregnancy:
* The gestational sac is located in the region of the ovary,
* the ectopic pregnancy is 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.
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85. Abdominal (peritoneal)
pregnancy
Types:
Primary: implantation occurs in the peritoneal cavity from the
start.
Secondary: usually after tubal rupture or abbortion.
Intraligamentous pregnancy: is a 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.

86. Abdominal (peritoneal)
pregnancySpecial investigations:
Plain X-ray: shows abnormal lie. In lateral view, the foetus
overshadows the maternal spines .
Ultrasound: shows no uterine wall around the foetus
Magnetic resonance imaging (MRI): has a particular
importance in preoperative detection of placental anatomic
relationships.
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87. PREGNANCY OF UNKNOWN
LOCATION
 When serum hCG levels are below the
discriminatory zone(intra- or extrauterine) visible on
transvaginal ultrasound scan, the pregnancy can
be described as being of unknown location.(RCOG
2010)
 Using an initial upper level of serum hCG of 1000–
1500 iu/l to diagnose pregnancy of unknown
location, women with minimal or no symptoms at
risk of ectopic pregnancy should be managed
expectantly with 48–72 hours of follow-up and
should be considered for active intervention if
symptoms of ectopic pregnancy occur, serum hCG
levels rise above the discriminatory level (1000 iu/l)
or levels start to plateau

88.  45–70% of pregnancies of unknownlocation resolve
spontaneously with expectant management
 Ectopic pregnancy was subsequentlydiagnosed in 14–
28% of cases of pregnancy of unknownlocation
 Interventionhas been shown to be required in 23–29%
of cases.

89.  Persistent trophoblast
- detected by the failure of serum hCG levels to fall as expected
after initial treatment.
- occurring after salpingotomy rather than following salpingectomy.
Although, even in the presence of persistent trophoblast,
Acc to DATA persistent trophoblast has been seen in 8.1–8.3%
after laparoscopic salpingotomy and 3.9–4.1% after open
salpingotomy.
.

90. Factors that have been suggested as
increasing the risk of developing persistent
trophoblast
- higher preoperative serum hCG levels (>3000 iu/l),
- a rapid preoperative rise in serum Hcg
- the presence of active tubal bleeding.
Following the elimination of all trophoblastic tissue, serum
hCG levels will fall a predictable clearance curve, but the
proportion of women treated for persistent trophoblast will in
part depend upon the frequency of postoperative
measurement and the cut off used for its definition

91.  persistent trophoblast was initiated if the serum hCG was
greater than 10% of the preoperative level ten days after
surgery.
 Another study has suggested initiating treatment if hCG
levels are above 65% of their initial level at 48 hours after
surgery
 Methotrexate at a dose of 50 mg/m2 - used as a single dose
instead of a repeat surgical procedure.
 The use of prophylactic methotrexate at the time of
laparoscopic salpingotomy has also been reported and in one
randomised trial

92. TAKE HOME MESSAGE
Incidence of ectopic pregnancy is rising while
maternal mortality from it is falling.
ALWAYS suspect ectopic pregnancy in a woman of
a child-bearing age c/o pain and/or p.v. bleeding
Early diagnosis of ectopic is the key to less
invasive treatment.
Nowadays ,trend –towards conservative treatment.
Careful monitoring and proper counselling of
patients is mandatory.
Ruptured ectopic should be unusual with
complaint patients and appropriate medical care.