Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. It is increasingly common, affecting about 1 in 100 pregnancies. Left untreated, it can cause life-threatening bleeding if the embryo implants grow large enough to rupture the fallopian tube. Diagnosis involves serial beta-hCG tests and ultrasound imaging. Treatment options include medication with methotrexate or surgery like laparoscopy or laparotomy to remove the ectopic pregnancy. With early detection and proper treatment, ruptured ectopic pregnancies can often be avoided.

1. Ectopic Pregnancy Semyatov S. Associate professor Dep. Obtetrics&Gynaecology of PFUR

2. Definition Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.

3. Incidence 1 in 100 ( from 1:25 to 1:250) normal pregnancies 1:28 in West Indies 4,5-16,8:1000 in Russia Mortality - 0,4% in Russia The Secondary Infertility - 40% after operation

4. Incidence Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries. USA-5 fold UK-2 fold France 15/1000 pregnancies India-1in100 deliveries Recurrence rate - 15% after 1 st , 25% after 2 ectopics

5. Overview Incidence Increasing (Ќ 1:66 Pregnancies) Mortality Decreasing With Better Detection Surgical and Medical Treatment Available Recurrence Rate ~ 15%

6. History Ectopic pregnancy was first described in 963 Ad by Albucasis. 1884 -- Robert Lawson Tait of Birmingham prformed the first successful Salpingectomy operation 1953 -- Stromme – Conservative surgery of Salpingostomy 1973 -- Shapiro & Adller – Laparoscopic Salpingectomy 1991 -- Young et al – Laparoscopic Salpingotomy

7. Aetiology Any 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.

8. Aetiology CONGENITAL - Tubal Hypoplasia , Tortuosity , Congenital diverticuli , Accessory ostia , Partial stenosis

9. Aetiology Previous Ectopic Pregnancy PID Congenital Defects in Fallopian Tubes (Assesory ostia, Partial stenosis, Hypoplasia, Infantilism) Migration of the Ova Externa Pelvic Abnormalities (Fundul Fibroma, adenomiosis of Fallopian Tubes) Tubal Reconstrustive Surgery

10. Aetiology Tubectomy Operation Infertility IUD (~4% pregnancies with IUD in Situ are Ectopic, Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy) IVF Induction Ovulation with Gonadotropins Extraneous Factors (Appendicitis, Endometriosis) Kartegener’s Syndrome (zebra)

11. Sites Ampulla (78-95%) Isthmus (8-12%) Interstitial portion (2%) - very rare form Cornua (< 2%) or in accessory horn Ovary (0,5-3%, 20-30% in IUD users) Abdomen (< 2%): Primary - very rare. Secondary. Cervix (< 2%) Combined Uterine Pregnancy and Ectopic Gestation - 1-3% in IVF, 1:4 000 - 1: 30 000

12. Sites 1 - Fimbrial 2 - Ampullary 3 - Isthemic 4 - Interstitial 5) Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament 10) Primary abdominal Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Abdomen (< 2%) Cervix (< 2%)

13. Symptoms Amenorrhea ~ in 75% cases Abdominal Pain - in 95% cases. Shoulder and Epigasrtric Pain Vaginal Bleeding Syncope Pelvic Mass

14. Endometrium Under Hormonal Effect of the Ectopic Pregnancy it Hypertrophies and Converted into a Decidua

15. Clinical Course Unruptured (Progressive) - without specific sings Tubal Abortion - minimal sings Tubal Rupture (into the peritoneal cavity or between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock

16. Evaluation and Diagnosis The diagnosis of ectopic gestation often presents great difficulty and it is 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

17. Evaluation and Diagnosis Women, during the childbearing period of life complaining of pain in the lower abdomen associated with continuous vaginal bleeding should be suspected of ectopic gestation

18. Evaluation and Diagnosis History and Physical Exam Vaginal Examination CBC, T+S Serial Quantitative  -hCG (BSU) Ultrasound TAS & TVS Progesterone Level? Culdocentesis Laparoscopy D&C HSG

19. Serial BSU’s  -hCG* Levels Double Every 48 Hrs < 66% Rise / 48 Hrs Consistent With Ectopic Pregnancy Single Determination Not Helpful Best If Done Within Same Laboratory Never Rules Out Ectopic Pregnancy * generally greater than > 6 500 miu/mL

20. Ultrasound May or May Not Be Helpful Discriminatory Zone: TVS: 1500-2000 mIU/ml (5th Week of Gestation) TAS: 6500 mIU/ml +IUP: Generally Excludes Ectopic

21. Culdocentesis Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood Negative Tap Inconclusive May Obviate U/S Most Helpful in Emergent Situations to Confirm Diagnosis, But Remains Controversial

22. Progesterone Levels > 15 ng/ml a/w IUP < 15: SAb or Ectopic May Take Several Days for Result Clinical Use Not Yet Widespread

23. Differential diagnosis Appendicitis (Perforated) PID Rupture of Follicle or Corpus Luteum Cyst Threatened Abortion Splenic Rupture Perforated Gastric or Duodenal Ulcer

24. Differential diagnosis Acute Pancreatities Myocardial Infarct Pyosalpinx Septic Abortion Pelvic Abcess Retroverted Gravid Uterus Twisted Ovarian Cyst Rupture of Chocolate cyst

25. Treatment Observation Laparoscopy Laparotomy MTX Hyperosmolar Glucose KCl RU-486 Prostaglandin F2 alfa

26. Observation Many Tubal Pregnancies Abort Israeli Study: Majority of Untreated Ectopics Resolve Not Yet Acceptable Standard of Care in US

27. Laparotomy Acute Ectopic Gestation Salpingoectomy Secondary Abdominal Pregnancy Interstial Pregnancy Cornual Pregnancy Cervical Pregnancy Auto-Transfusion

28. Laparoscopy Allows Diagnosis and Treatment Salpingostomy Salpingectomy (Total / Partial) Cornual Resection Minimally Invasive, Unlike Laparotomy Few Contraindications: Unstable Patient (Possibly)

29. MTX Toxic to Trophoblast Cells Minimal Side Effects May Preserve Fertility in Cases of Cervical Pregnancy Requires Compliant Patient, Time Pain Not Uncommon BSU May Rise Initially 25-50 mg into Gestational Sac

30. MTX Tubal Patency is Restored in 82% cases Oral - 50-100 mg (toxicity on GIT) Intramusculary 1 mg/kg NB. Laparoscopic Injection of MTX, Prostaglandin F2 alfa, RU 486 (anti-progesterone), Potassium Chloride into gestational sac is possible only if the sac measures less than 3 cm, and fetal heart is absent

31. Persistent Trophoblast Most Often A/W Salpingostomy Laparoscopic ~ 3% Minilap <1% Most Easily Treated With MTX

32. Cervical Pregnancy Incidence ~1:1 000 Profuse painless bleeding following a short period of Amenorrhea PE: a patulous external os and productsmof conception in the cevical canal, internal os is closed and the uterus is firm and normal in size

33. Cervical Pregnancy US helps in the correct diagnisis Treatment: - Suction Evacuation and Tamponade by inserting a distended Foley Catheter for 24 hours - Hysterectomy - Hysteroscopic Resection using Resectoscope - MTX

34. Outcomes 15% Repeat Ectopic Rate Ќ 2 Ectopics: 33% Pregnancy Rate 25% Ectopic No Benefit To Removing Ovary Along With Tube

35. Summary Ectopic Pregnancy is a Common, Treatable Problem Sensitive BSU Assays Allow Early Detection Surgical and Medical Options Exist Ruptured Ectopics Should be Unusual with Compliant Patients and Appropriate Medical Care