This document discusses various types of ectopic pregnancies and their management. It begins with a brief history and then covers medical and surgical management options. Specific procedures like salpingostomy, salpingectomy and methotrexate administration are described. Criteria for different treatments are provided. Rare types of ectopic pregnancies like interstitial, cervical and ovarian are defined along with their diagnostic criteria and management approaches. Monitoring of treatment is outlined.

2. History
Lawson Tait – first successful
salpingectomy;1884
Stromme – first conservative
surgery(salpingostomy); 1953

3. Medical Management
Surgical Management
Surgically administered medical
management
Expectant Management

4.  In case of unruptured pregnancies.
 Methotrexate
Antineoplastic drug
Acts as a Folic acid antagonist
ADVANTAGES:
Avoids surgery and anaesthesia
Less expense
Less tubal damage
More chance of future fertlity

5. CRITERIA FOR SELECTION
 Haemodynamically stable
 No intrauterine pregnancy on ultrasound
 No tubal rupture
 Size of ectopic < 4cm
 If there is fetal cardiac activity use with caution
 βhCG level preferably < 3000 IU/L

6.  Investigations : Full blood count, LFT and
RFT
 Exposure to sun should be avoided
 Folic acid tablets should not be given
 ‘Seperation pain’
 If medical management fails surgery is
indicated and it becomes necessary in
about 10% women
 After methotrexate administration, βhCG is
better for monitoring and ultrasound is not
used

7.  SINGLE DOSE REGIMEN
Single dose of methotrexate
 MULTIPLE DOSE REGIMEN
Methotrexate & Leucovorin on alternate days to a
maximum of 4 doses
 TWO DOSE REGIMEN
Second dose of methotrexate on day 4

9.  Both conservative surgery & salpingectomy can
be performed at laparoscopy and laparotomy.
 Laparoscopy is preferable.
 But the laparoscopic experience of the surgeon
and the haemodynamic stability of the patient
matters.
 Conservative measures are indicated when the
woman has not completed her family.But in 5%
cases, persistent ectopic has been noted and
hence serial serum βhCG is indicated.

10.  LINEAR SALPINGOSTOMY
In ampullary ectopic
A linear incision is made on the antimesenteric border of
the tube immediately over the ectopic and the products
will extrude out.
 SEGMENTAL RESECTION
When the ectopic is at the isthmus
Segmental resection is followed by isthmoampullary
anastomosis, if necessary.

11.  SALPINGECTOMY
The safest and complete method ,provided the other tube is
normal. Ipsilateral ovary should be conserved.
INDICATIONS:
 When the tube is not salvageable
 Uncontrolled bleeding from the tube
 Recurrent ectopic occurs in the same tube
 Childbearing is complete
 Previous sterilisation
 PERSISTENT ECTOPIC
Diagnosed by plateauing or rising serum βhCG values
following salpingostomy.

12.  Under ultrasound guidance, direct injection of
a drug is given into the ectopic.
 Methotrexate, patassium chloride,
hyperosmolar glucose and PGF2α can be used.
 Direct injection of KCl into the sac can be
combined with medical management , in case
of a live ectopic otherwise suited for medical
management.
 This is not much employed today.

13. Option for clinically stable asymptomatic
women with an ultrasound diagnosis of ectopic
pregnancy and initial serum βhCG below the
discriminatory zone (preferably <1000 IU/L) and
subsequent falling levels.
These women should be counselled properly and
should be within easy reach of the hospital.
Monitoring should be with serial serum βhCG twice
weekly.

14. Infertility (fertility rate around 65%)
Repeat Ectopic (risk of a future ectopic is about
12%)

15.  Heterotopic Pregnancy
 Interstitial and Cornual Pregnancy
 Intraligamentous Pregnancy
 Abdominal Pregnancy
 Cervical Pregnancy
 Ovarian Pregnancy

17. An ectopic pregnancy coexists with an
intraabdominal pregnancy.
Incidence has increased from 1 in
30,000 pregnancies in the past to 1 in
100 pregnancies.
Serial monitoring of serum βhCG is not
helpful.
Management : Surgical

18. Interstitial : In the proximal intramural part of the
tube
Cornual : In the upper and lateral uterine cavity
Involves myometrium and advance to a
later
stage (even upto 16 weeks).
USG shows a bulge in the cornual area, with an
extremely thin myometrial mantle surrounding
gestational sac. The sac should be located more
than 1cm from the endometrial echo.
The pregnancy can also be in a rudimentary horn of
a bicornuate uterus, usually the horn is non
communicating. If diagnosed earlier, excision of
the rudimentary horn and the tube of the affected
side can be done.

19.  Within the broad ligament
 Rare; due to penetration of the tubal wall
by the trophoblast and its advancement
between the two layers of the broad
ligament.

20.  Usually secondary; after early tubal
rupture or abortion. The fertilised ovum
implants on the peritoneum and continues
to grow.
 A primary abdominal pregnancy is
extremely rare.
STUDIFORD CRITERIA
 Both tubes and ovaries should be normal
 Uteroperitoneal fistula should not be seen
 The pregnancy is related exclusively to the peritoneal
surface.

21. In abdominal pregnancy,
Nausea and abdominal pain
Malpresentations and superficial fetal parts
Braxton-Hicks contractions not felt
USG : Absence of uterine outline over the fetus
Management : Laparotomy and removal of fetus
Complications : Torrential haemorrhage due to lack of
constriction of open vessels after placental seperation
Unless placenta is implanted over vital structures or
major blood vessels it should be removed. Or else
left in situ and autolysis awaited.
Monitored by serial ultrasound and serum βhCG
levels.
Methotrexate can be given.

22.  Implantation in the endocervical canal below
the internal os.
 Predisposing factors
Previous dilatation and curettage
Previous caesarean section
 Most common symptom – Painless vaginal
bleeding
 Usually diagnosed incidentally during a
routine scan or during evacuation of a
suspected abortion.
 Blood flow around the sac is more suggestive
of a true cervical pregnancy.
Colour doppler can be used to differentiate
between a true cervical pregnancy and an
intact gestational sac passing through cervix.

23. Rubin Criteria:
 There should be cervical glands opposite the placental
attachment.
 Attachment of placenta to cervix should be below the
entrance of the uterine vessels or below the peritoneal
reflection.
 Fetal elements should not be present in the corpus uteri.
Ultrasound Criteria:
 Empty uterus
 Hourglass shape of uterus
 Ballooned out cervical canal
 Gestational sac and placental tissue
in the cervical canal
 Closed internal os

24.  First choice : Medical treatment with
multiple dose methotrexate.
 Radiological uterine artery embolisation
followed by evacuation. Bilateral internal
iliac artery ligature has also been tried.
 Hysterectomy

25.  Implantation in the ovary
 Very rare
 Usual consequence : Rupture at an early
stage
 Management : Surgery; ovariotomy
Methotrexate if
diagnosed earlier
Spiegelberg Criteria:
 The tube on the affected side should be intact.
 Fetal sac should occupy the position of the ovary.
 Ovary should be connected to the uterus by the
ovarian ligament.
 Definite ovarian tissue should be found in the sac
wall.

26. In women with a previous caesarean section.
Diagnostic criteria:
 An empty uterine cavity
 A gestational sac located anteriorly at the level of
the internal os covering the visible or presumed
site of the previous lower uterine segment
caesarean section scar
 Evidence of functional trophoblastic /placental
circulation on Doppler examination
 An absent “sliding sign” (inability to displace the
gestational sac from its position at the level of
internal os using gentle pressure applied by the
transvaginal probe)