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ECTOPIC
PREGNANCY
Dr.Rafi Rozan
Obstetrician & Gynecologist
Ectopic Pregnancy
• Following fertilization and fallopian tube
transit, the blastocyst normally implants in
the endometrial lining of the uterine cavity
• Implantation anywhere else is an ectopic
pregnancy
• There is a 7-to 13-fold increase in the
risk for a subsequent ectopic pregnancy.
• The chance for a subsequent successful
pregnancy is reduced after an EP.
CLASSIFICATION
Risk Factor Risk
High Risk
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 weeks
21.0
9.3
8.3
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
Risk Factors for Ectopic Pregnancy
Increasing ectopic pregnancy rates
1. Prevalence of sexually transmitted tubal infection and damage
2. Ascertainment through earlier diagnosis of some EP otherwise
destined to resorb spontaneously
3. Popularity of contraception that predisposes failures to be
ectopic
4. Use of tubal sterilization techniques that increase the likelihood
of EP
5. Use of assisted reproductive techniques
6. Use of tubal surgery, including salpingotomy for tubal pregnancy
and tuboplasty for infertility
7. Smoking
Evolution and Potential Outcome
1. Tubal Rupture: Tubal EP usually burst spontaneously but may
occasionally rupture following coitus or bimanual examination.
common with isthmus EP.
2. Tubal Abortion: This is common in ampullary and fimbrial EP
3. Pregnancy failure with Resolution: this is documented more
regularly with the advent of B-hCG assays.
There are differences between:
Acute Ectopic Pregnancy
Chronic Ectopic Pregnancy
CLINICAL
MANIFESTATIONS
Classic triad of symptoms
• Pain
• Amenorrhea (?)
• Vaginal bleeding or spotting
Presumptive Signs:
* Delayed menstruation
* Neurovegetative imbalance
* Pigmentation
* Mammary
* Jacquemier
* Chadwick
* Berstine & Montgomery
CLINICAL MANIFESTATIONS
Probability Signs:
•Sellheim
•Kunge
•Pschyrembel
•Hegar I
•Hegar II : not recommended
•Increase size of the uterus
•Gauss
•Noble Budin
•Holzapfel (Soft mature fruit)
•Piscacek
•Oschander
CLINICAL MANIFESTATIONS
Certainty Signs:
•US
•X-ray (Not Currently Recommended
•Fetal Movements
•Presence of fetal heart Rate.
ECTOPIC PREGNANCY
CLINICAL MANIFESTATIONS
• Martin *Alder (Abd Hypersensitivity)
• Rounge Simon * Blumberg (Decp RLW)
• Laffont * Guencav Mussy (Decp Abd)
• Kustallov * Granville Chapman (Incorporate Dif)
• Oddy * Wynter (Absence Resp Mv)
• Banki * Moylan & Mosadeg (Tenesmos)
• Frankel * Solowy (Pos Fornix Resistance)
• Douglast *Hergfeld (Need to urinate rup EP)
• Proust * Monadegh (proctodynia rup EP)
• Hofstaetter Cullen Hellendal * Cattomas (Rapid relief rup EP)
• Santomanso & Salmon: Anisocoria
Passage of Decidual Cast
• Occurs in 5%-10% of women
• Their passage may be accompanied by
cramps similar to those occurring with
a spontaneous abortion
• Comes out in the shape of the uterine
cavity. Decidual Casts have a well-
known association with ectopic
pregnancies
Arias-Stella Reaction Phenomenon
It is a benign change in the endometrium due to progesterone primarily,
associated with the presence of chorionic tissue. Cytologically, it looks
like a malignancy and, historically, it was diagnosed as endometrial
cancer.
Algorithm for evaluation of EP
Culdocentesis
• A simple technique to identify
hemoperitoneum
• The cervix is pulled toward the
symphysis pubis with a tenaculum
• A long 16- or 18-gauge needle is
inserted through the posterior
fornix into the
culdesac
• Non-clotting blood aspirated:
compatible
with the diagnosis of
hemoperitoneum resulting
from an rupture EP.
• In gestations longer than 5.5 weeks, a transvaginal ultrasonographic
examination should identify an intrauterine pregnancy with almost
100% accuracy.
• Approximately 25 to 50% of women with an ectopic pregnancy initially
present with a pregnancy of unknown location, and approximately 7 to
20% of women with a pregnancy of unknown location ultimately receive
a diagnosis of an ectopic pregnancy.
Ultrasonographic Examination
Ectopic (tubal)
pregnancy
Ultrasonographic
Findings
Comments
Viable extrauterine
pregnancy
Extrauterine gestational
sac with fetal pole and
cardiac activity
Presence of a yolk sac or
fetal pole has positive
predictive value of almost
100% for identifying ectopic
pregnancy
Nonviable extrauterine
gestation
Extrauterine gestational
sac with a fetal pole,
without cardiac activity
Fetal pole with or without
cardiac activity seen in 13%
of ectopic pregnancies
diagnosed by
ultrasonography
Ring sign Adnexal mass with a
hyperechoic ring around
a gestational sac
Seen in 20% of ectopic
pregnancies diagnosed by
ultrasonography
Nonhomogeneous
mass
Adnexal mass separate
from the ovary
Seen in 60% of ectopic
pregnancies diagnosed by
ultrasonography; positive
predictive value ranges from
80 to 90%
Early gestational sac in the uterus without a yolk sac or fetal pole in anEarly gestational sac in the uterus without a yolk sac or fetal pole in an
intrauterine pregnancy. The gestational sac has a diameter of 0.65 cm andintrauterine pregnancy. The gestational sac has a diameter of 0.65 cm and
is consistent with a gestational age of 5 weeks 2 days.is consistent with a gestational age of 5 weeks 2 days.
A
Pseudo-gestational sac that resembles the gestational sac, but it is centrallyPseudo-gestational sac that resembles the gestational sac, but it is centrally
located, it is not symmetric, and it is associated with septation.located, it is not symmetric, and it is associated with septation.
B
C
A gestational sac and a yolk sac with evidence of associated free fluid.A gestational sac and a yolk sac with evidence of associated free fluid.
Ring sign — a hyperechoic ringRing sign — a hyperechoic ring around an extrauterine gestational sac.
D
E
Ectopic pregnancy characterized by an extrauterine adnexal mass,Ectopic pregnancy characterized by an extrauterine adnexal mass,
separate from the ovary, without any evidence of a gestationalseparate from the ovary, without any evidence of a gestational sac.
The mass is 2.2 by 2.2 cm.
Laboratory tests
• hCG assays
• EP cannot be diagnosed by a positive pregnancy test alone
• hCG assays positive in over 99% of EPs
• Sensitive to levels of chorionic gonadotropin of 10-20 mIU/ml
• The hCG pattern that is most predictive of EP is one that has reached a
plateau (doubling time of more than 7 days)
The “discriminatory hCG value” has been reported to be 1500, 2000
and 3510 mIU/ml, which can be used to determine the level of hCG
at which the sensitivity of ultrasonography for the detection of
intrauterine pregnancy approaches 100% and at which the absence
of an intrauterine pregnancy suggests abnormal or ectopic gestation.
Correlation of Ultrasonographic
Findings with hCG Values
Change in the hCG
Level in Intrauterine
Pregnancy, Ectopic
Pregnancy, and
Spontaneous Abortion.
An increase or decrease in the
serial hCG level in a woman
with an ectopic pregnancy is
outside the range expected for
that of a woman with a
growing intrauterine
pregnancy or a spontaneous
abortion 71% of the time.
However, the increase in the
hCG level in a woman with an
ectopic pregnancy can mimic
that of a growing intrauterine
pregnancy 21% of the time,
and the decrease in the hCG
level can mimic that of a
spontaneous abortion 8% of
the time.
Management
- Medical
Use of Methotrexate, a folic antagonist which tightely binds to
dihydrofolate reductase blocking the reduction of dihydrofolate
to tetrahydrofolate which is the active form of the folic acid.
As a result the new purine and pyrimidine synthesis is halted which
leads to arrested DNA, RNA and protein synthesis.
- Surgical
Surgical diagnosis
• Laparoscopy
• Offers a reliable diagnosis in most
cases of suspected EP and a ready
transition to definitive operative
therapy
• Laparotomy
• Open abdominal surgery is preferred
when the woman is
hemodynamically unstable or when
laparoscopy is not feasible
Ectopic Pregnancy
Type of EP Definition
Tubal pregnancy A pregnancy occurring in the fallopian tube – most often these
are located in the ampullary portion of the fallopian tube
Interstitial pregnancy A pregnancy that implants within the interstitial portion of the
fallopian tube
Abdominal
pregnancy
Primary – the 1st
and only implantation occurs on a peritoneal
surface
Secondary – implantation originally in the tubal ostia,
subsequently aborted and then reimplanted into the
peritoneal surface
Cervical pregnancy Implantation of the developing conceptus in the cervical canal
Ligamentous
pregnancy
A secondary form of EP in which a primary tubal pregnancy
erodes into the mesosalpinx and is located between the leaves
of the broad ligament
Heterotopic
pregnancy
A condition in which ectopic and intrauterine pregnancies coexist
Ovarian pregnancy A condition in which an EP implants within the ovarian cortex
Table 2. Definitions of Types of Ectopic Pregnancies
Tubal Pregnancy
• The fertilized ovum may
lodge in any portion of the
oviduct, giving rise to ampullary,
isthmic, and interstitial tubal
pregnancies
• Ampulla is the most frequent site, followed by
the isthmus
• Interstitial pregnancy accounts for only 3% of all
tubal gestations
Tubal Pregnancy
• Treatment
• Anti-D immunoglobulin
• D-negative women with an ectopic pregnancy who are not sensitized to D-antigen
should be given anti-D immunoglobulin
Tubal Pregnancy
• Treatment
• Surgical Management
• Laparoscopy is preferred over laparotomy unless the patient is unstable
• Tubal surgery for EP is considered conservative when there is tubal salvage
(salpingostomy, salpingotomy, fimbrial expression of the EP)
• Radical surgery is defined by salpingectomy
Tubal Pregnancy
• Salpingostomy
• Used to remove a small pregnancy that is
usually less than 2 cm in length and
located in the distal third of the fallopian
tube
• A linear incision, 10-15 mm in length or
less, is made on the antimesenteric
border, immediately above the EP
• POC extruded out; small bleeding sites
controlled with needlepoint
electrocautery or laser
• Incision is left unsutured and to heal by
secondary intention
Tubal Pregnancy
• Salpingotomy
• Essentially the same as salpingostomy except that the incision is closed
with 7-0 Vicryl or similar suture
Tubal Pregnancy
• Salpingectomy
• May be performed through an operative laparoscope and may be used
for both ruptured and unruptured EP
• When removing the oviduct, it is advisable to excise a wedge of the outer
third (or less) of the interstitial portion of the tube (cornual resection)
• To minimize the rare recurrence of pregnancy in the tubal stump
Tubal Pregnancy
• Segmental resection and anastomosis
• Resection of the ectopic mass and tubal reanastomosis is sometimes
used for an unruptured isthmic pregnancy because salpingostomy may
cause scarring and subsequent narrowing of the small isthmic lumen
Tubal Pregnancy
• Medical Management
• Systemic MTX
• MTX acts as a folic acid antagonist and is highly effective against rapidly proliferating
trophoblasts
• Active intraabdominal bleeding is contraindicated
• May not be used if the EP is > 4 cm
• Success is greatest if the AOG is < 6 weeks, the tubal mass is not > 3.5 cm in
diameter, the fetus is dead, and the B-hCG <15,000 mIU/mL
Cervical Pregnancy
• 1 in 2,400 to 1 in 50,000 pregnancies (US)
• Conditions that predispose:
• Previous therapeutic abortion
• Asherman’s syndrome
• Previous CS
• DES exposure
• Leiomyomas
• IVF
Cervical Pregnancy
• Diagnostic Criteria
1. The uterus is smaller than the surrounding distended cervix
2. The internal os is not dilated
3. Curettage of the endometrial cavity is non-productive of placental tissue
4. The external os opens earlier than in spontaneous abortion
Cervical Pregnancy
• Preoperative preparation should include blood typing and cross-
matching, IV access, and detailed informed consent which include
the possibility of hysterectomy in the event of hemorrhage
• Non-surgical management: intraamniotic and systemic MTX
administration
Ovarian Pregnancy
Criteria for diagnosis (Spiegelberg’s Criteria)
1. The fallopian tube on the affected side must be
intact
2. The fetal sac must occupy the position of the ovary
3. The ovary must be connected to the uterus by the
ovarian ligament
4. Ovarian tissue must be located in the sac wall
Ovarian Pregnancy
• 0.5% to 1% of all ectopic pregnancies
• Most common type of non-tubal pregnancy
• Misdiagnosis common because it is confused with a
ruptured corpus luteum in up to 75% of cases
• Ovarian cystectomy is the preferred treatment
• Treatment with MTX and prostaglandin injection has
also been reported
Abdominal pregnancy
• Classified as primary and secondary
• Secondary abdominal pregnancies are by far the most common and
result from tubal abortion or rupture or, less often, from subsequent
implantation within the abdomen after uterine rupture
• 1 in 372 to 1 in 9,714 live births
• Incidence of congenital anomalies: 20%-40%
Abdominal pregnancy
• Clinical presentation
• In the 1st
and early second trimester, the symptoms may be the same as a tubal
EP
• In advanced pregnancy:
• Painful fetal movement
• Fetal movements high in the abdomen or sudden cessation of movements
• Persistent abnormal fetal lies, abdominal tenderness, displaced cervix, fetal superficiality
• No uterine contractions after oxytocin infusion
Abdominal pregnancy
Criteria for diagnosis – Studdiford’s Criteria
1. Presence of normal tubes and ovaries with
no evidence of recent or past pregnancy
2. No evidence of uteroplacental fistula
3. The presence of a pregnancy related
exclusively to the peritoneal surface and
early enough to eliminate the possibility of
secondary implantation after primary tubal
abortion
Abdominal pregnancy
• Surgical intervention
• Placenta can be removed if its vascular supply can be identified and
ligated; otherwise it is left behind, packing is done which is removed
after 24 to 48 hours
• MTX treatment appears to be contraindicated because of the high
rate of complications due to rapid tissue necrosis
Interstitial pregnancy
• Represent about 1% of EPs
• Patients tend to present later in gestation than those with tubal
pregnancies
• Often associated with uterine rupture – represent a large proportion
of fatalities from EP
• Treatment: cornual resection by laparotomy
Heterotopic pregnancy
• Occurs when there are coexisting intrauterine and ectopic
pregnancies
• 1 in 100 to 1 in 30,000 pregnancies
• Higher in patients who undergo ovulation induction
• Treatment is operative
Ectopic pregnancy (Dr.Rafi Rozan)

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Ectopic pregnancy (Dr.Rafi Rozan)

  • 2. Ectopic Pregnancy • Following fertilization and fallopian tube transit, the blastocyst normally implants in the endometrial lining of the uterine cavity • Implantation anywhere else is an ectopic pregnancy • There is a 7-to 13-fold increase in the risk for a subsequent ectopic pregnancy. • The chance for a subsequent successful pregnancy is reduced after an EP.
  • 4. Risk Factor Risk High Risk 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 weeks 21.0 9.3 8.3 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 Risk Factors for Ectopic Pregnancy
  • 5. Increasing ectopic pregnancy rates 1. Prevalence of sexually transmitted tubal infection and damage 2. Ascertainment through earlier diagnosis of some EP otherwise destined to resorb spontaneously 3. Popularity of contraception that predisposes failures to be ectopic 4. Use of tubal sterilization techniques that increase the likelihood of EP 5. Use of assisted reproductive techniques 6. Use of tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility 7. Smoking
  • 6. Evolution and Potential Outcome 1. Tubal Rupture: Tubal EP usually burst spontaneously but may occasionally rupture following coitus or bimanual examination. common with isthmus EP. 2. Tubal Abortion: This is common in ampullary and fimbrial EP 3. Pregnancy failure with Resolution: this is documented more regularly with the advent of B-hCG assays.
  • 7. There are differences between: Acute Ectopic Pregnancy Chronic Ectopic Pregnancy
  • 8. CLINICAL MANIFESTATIONS Classic triad of symptoms • Pain • Amenorrhea (?) • Vaginal bleeding or spotting
  • 9. Presumptive Signs: * Delayed menstruation * Neurovegetative imbalance * Pigmentation * Mammary * Jacquemier * Chadwick * Berstine & Montgomery CLINICAL MANIFESTATIONS
  • 10. Probability Signs: •Sellheim •Kunge •Pschyrembel •Hegar I •Hegar II : not recommended •Increase size of the uterus •Gauss •Noble Budin •Holzapfel (Soft mature fruit) •Piscacek •Oschander CLINICAL MANIFESTATIONS Certainty Signs: •US •X-ray (Not Currently Recommended •Fetal Movements •Presence of fetal heart Rate.
  • 11. ECTOPIC PREGNANCY CLINICAL MANIFESTATIONS • Martin *Alder (Abd Hypersensitivity) • Rounge Simon * Blumberg (Decp RLW) • Laffont * Guencav Mussy (Decp Abd) • Kustallov * Granville Chapman (Incorporate Dif) • Oddy * Wynter (Absence Resp Mv) • Banki * Moylan & Mosadeg (Tenesmos) • Frankel * Solowy (Pos Fornix Resistance) • Douglast *Hergfeld (Need to urinate rup EP) • Proust * Monadegh (proctodynia rup EP) • Hofstaetter Cullen Hellendal * Cattomas (Rapid relief rup EP) • Santomanso & Salmon: Anisocoria
  • 12. Passage of Decidual Cast • Occurs in 5%-10% of women • Their passage may be accompanied by cramps similar to those occurring with a spontaneous abortion • Comes out in the shape of the uterine cavity. Decidual Casts have a well- known association with ectopic pregnancies
  • 13. Arias-Stella Reaction Phenomenon It is a benign change in the endometrium due to progesterone primarily, associated with the presence of chorionic tissue. Cytologically, it looks like a malignancy and, historically, it was diagnosed as endometrial cancer.
  • 15. Culdocentesis • A simple technique to identify hemoperitoneum • The cervix is pulled toward the symphysis pubis with a tenaculum • A long 16- or 18-gauge needle is inserted through the posterior fornix into the culdesac • Non-clotting blood aspirated: compatible with the diagnosis of hemoperitoneum resulting from an rupture EP.
  • 16. • In gestations longer than 5.5 weeks, a transvaginal ultrasonographic examination should identify an intrauterine pregnancy with almost 100% accuracy. • Approximately 25 to 50% of women with an ectopic pregnancy initially present with a pregnancy of unknown location, and approximately 7 to 20% of women with a pregnancy of unknown location ultimately receive a diagnosis of an ectopic pregnancy. Ultrasonographic Examination
  • 17. Ectopic (tubal) pregnancy Ultrasonographic Findings Comments Viable extrauterine pregnancy Extrauterine gestational sac with fetal pole and cardiac activity Presence of a yolk sac or fetal pole has positive predictive value of almost 100% for identifying ectopic pregnancy Nonviable extrauterine gestation Extrauterine gestational sac with a fetal pole, without cardiac activity Fetal pole with or without cardiac activity seen in 13% of ectopic pregnancies diagnosed by ultrasonography Ring sign Adnexal mass with a hyperechoic ring around a gestational sac Seen in 20% of ectopic pregnancies diagnosed by ultrasonography Nonhomogeneous mass Adnexal mass separate from the ovary Seen in 60% of ectopic pregnancies diagnosed by ultrasonography; positive predictive value ranges from 80 to 90%
  • 18. Early gestational sac in the uterus without a yolk sac or fetal pole in anEarly gestational sac in the uterus without a yolk sac or fetal pole in an intrauterine pregnancy. The gestational sac has a diameter of 0.65 cm andintrauterine pregnancy. The gestational sac has a diameter of 0.65 cm and is consistent with a gestational age of 5 weeks 2 days.is consistent with a gestational age of 5 weeks 2 days. A
  • 19. Pseudo-gestational sac that resembles the gestational sac, but it is centrallyPseudo-gestational sac that resembles the gestational sac, but it is centrally located, it is not symmetric, and it is associated with septation.located, it is not symmetric, and it is associated with septation. B
  • 20. C A gestational sac and a yolk sac with evidence of associated free fluid.A gestational sac and a yolk sac with evidence of associated free fluid.
  • 21. Ring sign — a hyperechoic ringRing sign — a hyperechoic ring around an extrauterine gestational sac. D
  • 22. E Ectopic pregnancy characterized by an extrauterine adnexal mass,Ectopic pregnancy characterized by an extrauterine adnexal mass, separate from the ovary, without any evidence of a gestationalseparate from the ovary, without any evidence of a gestational sac. The mass is 2.2 by 2.2 cm.
  • 23. Laboratory tests • hCG assays • EP cannot be diagnosed by a positive pregnancy test alone • hCG assays positive in over 99% of EPs • Sensitive to levels of chorionic gonadotropin of 10-20 mIU/ml • The hCG pattern that is most predictive of EP is one that has reached a plateau (doubling time of more than 7 days)
  • 24. The “discriminatory hCG value” has been reported to be 1500, 2000 and 3510 mIU/ml, which can be used to determine the level of hCG at which the sensitivity of ultrasonography for the detection of intrauterine pregnancy approaches 100% and at which the absence of an intrauterine pregnancy suggests abnormal or ectopic gestation. Correlation of Ultrasonographic Findings with hCG Values
  • 25.
  • 26. Change in the hCG Level in Intrauterine Pregnancy, Ectopic Pregnancy, and Spontaneous Abortion. An increase or decrease in the serial hCG level in a woman with an ectopic pregnancy is outside the range expected for that of a woman with a growing intrauterine pregnancy or a spontaneous abortion 71% of the time. However, the increase in the hCG level in a woman with an ectopic pregnancy can mimic that of a growing intrauterine pregnancy 21% of the time, and the decrease in the hCG level can mimic that of a spontaneous abortion 8% of the time.
  • 27. Management - Medical Use of Methotrexate, a folic antagonist which tightely binds to dihydrofolate reductase blocking the reduction of dihydrofolate to tetrahydrofolate which is the active form of the folic acid. As a result the new purine and pyrimidine synthesis is halted which leads to arrested DNA, RNA and protein synthesis. - Surgical
  • 28.
  • 29. Surgical diagnosis • Laparoscopy • Offers a reliable diagnosis in most cases of suspected EP and a ready transition to definitive operative therapy • Laparotomy • Open abdominal surgery is preferred when the woman is hemodynamically unstable or when laparoscopy is not feasible Ectopic Pregnancy
  • 30. Type of EP Definition Tubal pregnancy A pregnancy occurring in the fallopian tube – most often these are located in the ampullary portion of the fallopian tube Interstitial pregnancy A pregnancy that implants within the interstitial portion of the fallopian tube Abdominal pregnancy Primary – the 1st and only implantation occurs on a peritoneal surface Secondary – implantation originally in the tubal ostia, subsequently aborted and then reimplanted into the peritoneal surface Cervical pregnancy Implantation of the developing conceptus in the cervical canal Ligamentous pregnancy A secondary form of EP in which a primary tubal pregnancy erodes into the mesosalpinx and is located between the leaves of the broad ligament Heterotopic pregnancy A condition in which ectopic and intrauterine pregnancies coexist Ovarian pregnancy A condition in which an EP implants within the ovarian cortex Table 2. Definitions of Types of Ectopic Pregnancies
  • 31. Tubal Pregnancy • The fertilized ovum may lodge in any portion of the oviduct, giving rise to ampullary, isthmic, and interstitial tubal pregnancies • Ampulla is the most frequent site, followed by the isthmus • Interstitial pregnancy accounts for only 3% of all tubal gestations
  • 32. Tubal Pregnancy • Treatment • Anti-D immunoglobulin • D-negative women with an ectopic pregnancy who are not sensitized to D-antigen should be given anti-D immunoglobulin
  • 33. Tubal Pregnancy • Treatment • Surgical Management • Laparoscopy is preferred over laparotomy unless the patient is unstable • Tubal surgery for EP is considered conservative when there is tubal salvage (salpingostomy, salpingotomy, fimbrial expression of the EP) • Radical surgery is defined by salpingectomy
  • 34. Tubal Pregnancy • Salpingostomy • Used to remove a small pregnancy that is usually less than 2 cm in length and located in the distal third of the fallopian tube • A linear incision, 10-15 mm in length or less, is made on the antimesenteric border, immediately above the EP • POC extruded out; small bleeding sites controlled with needlepoint electrocautery or laser • Incision is left unsutured and to heal by secondary intention
  • 35. Tubal Pregnancy • Salpingotomy • Essentially the same as salpingostomy except that the incision is closed with 7-0 Vicryl or similar suture
  • 36. Tubal Pregnancy • Salpingectomy • May be performed through an operative laparoscope and may be used for both ruptured and unruptured EP • When removing the oviduct, it is advisable to excise a wedge of the outer third (or less) of the interstitial portion of the tube (cornual resection) • To minimize the rare recurrence of pregnancy in the tubal stump
  • 37. Tubal Pregnancy • Segmental resection and anastomosis • Resection of the ectopic mass and tubal reanastomosis is sometimes used for an unruptured isthmic pregnancy because salpingostomy may cause scarring and subsequent narrowing of the small isthmic lumen
  • 38. Tubal Pregnancy • Medical Management • Systemic MTX • MTX acts as a folic acid antagonist and is highly effective against rapidly proliferating trophoblasts • Active intraabdominal bleeding is contraindicated • May not be used if the EP is > 4 cm • Success is greatest if the AOG is < 6 weeks, the tubal mass is not > 3.5 cm in diameter, the fetus is dead, and the B-hCG <15,000 mIU/mL
  • 39. Cervical Pregnancy • 1 in 2,400 to 1 in 50,000 pregnancies (US) • Conditions that predispose: • Previous therapeutic abortion • Asherman’s syndrome • Previous CS • DES exposure • Leiomyomas • IVF
  • 40. Cervical Pregnancy • Diagnostic Criteria 1. The uterus is smaller than the surrounding distended cervix 2. The internal os is not dilated 3. Curettage of the endometrial cavity is non-productive of placental tissue 4. The external os opens earlier than in spontaneous abortion
  • 41. Cervical Pregnancy • Preoperative preparation should include blood typing and cross- matching, IV access, and detailed informed consent which include the possibility of hysterectomy in the event of hemorrhage • Non-surgical management: intraamniotic and systemic MTX administration
  • 42. Ovarian Pregnancy Criteria for diagnosis (Spiegelberg’s Criteria) 1. The fallopian tube on the affected side must be intact 2. The fetal sac must occupy the position of the ovary 3. The ovary must be connected to the uterus by the ovarian ligament 4. Ovarian tissue must be located in the sac wall
  • 43. Ovarian Pregnancy • 0.5% to 1% of all ectopic pregnancies • Most common type of non-tubal pregnancy • Misdiagnosis common because it is confused with a ruptured corpus luteum in up to 75% of cases • Ovarian cystectomy is the preferred treatment • Treatment with MTX and prostaglandin injection has also been reported
  • 44. Abdominal pregnancy • Classified as primary and secondary • Secondary abdominal pregnancies are by far the most common and result from tubal abortion or rupture or, less often, from subsequent implantation within the abdomen after uterine rupture • 1 in 372 to 1 in 9,714 live births • Incidence of congenital anomalies: 20%-40%
  • 45. Abdominal pregnancy • Clinical presentation • In the 1st and early second trimester, the symptoms may be the same as a tubal EP • In advanced pregnancy: • Painful fetal movement • Fetal movements high in the abdomen or sudden cessation of movements • Persistent abnormal fetal lies, abdominal tenderness, displaced cervix, fetal superficiality • No uterine contractions after oxytocin infusion
  • 46. Abdominal pregnancy Criteria for diagnosis – Studdiford’s Criteria 1. Presence of normal tubes and ovaries with no evidence of recent or past pregnancy 2. No evidence of uteroplacental fistula 3. The presence of a pregnancy related exclusively to the peritoneal surface and early enough to eliminate the possibility of secondary implantation after primary tubal abortion
  • 47. Abdominal pregnancy • Surgical intervention • Placenta can be removed if its vascular supply can be identified and ligated; otherwise it is left behind, packing is done which is removed after 24 to 48 hours • MTX treatment appears to be contraindicated because of the high rate of complications due to rapid tissue necrosis
  • 48. Interstitial pregnancy • Represent about 1% of EPs • Patients tend to present later in gestation than those with tubal pregnancies • Often associated with uterine rupture – represent a large proportion of fatalities from EP • Treatment: cornual resection by laparotomy
  • 49. Heterotopic pregnancy • Occurs when there are coexisting intrauterine and ectopic pregnancies • 1 in 100 to 1 in 30,000 pregnancies • Higher in patients who undergo ovulation induction • Treatment is operative

Editor's Notes

  1. Fortunately with urine and serum B HCG assays and transvaginal sonography earlier diagnosis is possible and As a result both maternal survival rates and conservation of reproductive capacity are improved.
  2. 95% are implanted in the fallopian tube in the various segments Fimbrila, ampullary, isthmic, interstitial or corneal. Ovary. Peritoneal cavity, cervix, prior cesarean scar. Ocationally a multifetus is composed of one conceptus in the uterine cavity and one implanted ectopically Known as HETEROTOPIC pregnancy (1 in 30,000 but becauser of ART its now 1 in 7000) Regardless of lacotion, D negative woman who are non sensitise should be given Anti D IgG: 1st Trimester 50 ug and standard 300ug in later gestation
  3. The Fallopian tube lack a submucosal layer and as such the fertized ovum can promply burrows through the epitelium and lie close or With in the muscularis. In EP the embryo or fetus if absent or stunted.
  4. Acute: are those with high serum B-hCG and rapid growth leading to immediate diagnosis Chronic: the abnormal trophoblast dies early and thus there is a NEAGATE or low B-hCG . They usually rupture late if at all but form a Complex mass which is often the reason prompting diagnosis surgeries.