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Ectopic pregnancy

Dr. Sourav Chowdhury provides a detailed overview of ectopic pregnancy in 3 pages of text. Some key points: - An ectopic pregnancy is when a fertilized egg implants outside the uterus, usually in the fallopian tubes. - Risk factors include previous pelvic inflammatory disease, tubal surgery or infertility treatments. The most common site is the fallopian tube (95-96% of cases). - Clinical signs can range from asymptomatic to acute abdominal pain and bleeding. Diagnosis involves transvaginal ultrasound, serum hCG levels and laparoscopy. - Treatment depends on stability but may include expectant management, systemic or local methotrexate, or surgical

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Dr. Sourav Chowdhury Senior Resident
DEFINITION “Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity”. It represents a serious hazard to a woman’s health and reproductive potential, requiring prompt recognition and early aggressive intervention.
Is one in which fertilized ovum is implanted & develops outside normal uterine cavity
IMPLANTATIONS SITES EXTRAUTERINE UTERINE OVARIAN ABDOMINAL PRIMARY SECONDARY Intraperitoneal Extraperitoneal Broad Ligament (rare) 1. Cervical <1 2. Angular 3. Caesarean 4. CornualTUBAL 95-96% •Ampulla 70% •Isthmus 25% •Interstistial 18% •Infundibulum2%
INCIDENCE & MORTALITY • Increased • PID • IUCD • Tubal surgeries, and • Assisted reproductive techniques (ART). • Rate in India – 5.6/10000 deliveries • Late marriages and late child bearing -> 2% • ART -> 5% • Recurrence rate - 15% after 1st, 25% after 2 ectopics Innovative Journal of Medical and Health Science 4 : 1 Jan - Feb(2014) 305-309.
ETIOLOGY:  Any factor that causes delayed transport of the fertilised ovum through the tube.  Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy.  These factors may be Congenital or Acquired.
ETIOLOGY  CONGENITAL  Tubal Hypoplasia  Tortuosity  Congenital diverticuli  Accessory ostia  Partial stenosis  Elongation  Intamural polyp  Entrap the ovum on its way.
ETIOLOGY ACQUIRED - Pelvic Inflammatory disease (6-10 times) Chlamydia trachomatis is most common Contraceptive Faliure  CuT - 4%  Progestasart -17%  Minipills -4-10%  Norplant -30%
•Tubal sterilization faliure -40% Depends on sterilization technique and age of the patient •Bipolar Cauterisation -65% •Unipolar Cautery -17% •Silicon rubber band -29% •Interval Salpingectomy -43% •Postpartum Salpingectomy -20% •Reversal of sterilisation •Depends on • method of sterilization, • Site of tubal occlusion, • residual tubal length. •Reanastomosis of cauterised tube -15% •Reversal of Pomeroy’s - < 3%
ETIOLOGY Tubal reconstructive surgery (4-5 times) Assisted Reproductive technique - Ovulation induction, IVF-ET and GIFT (4-7%) - Risk of heterotopic pregnancy(1%) Previous Ectopic Pregnancy - 7-15% chances of repeat ectopic pregnancy
Other Risk factors  Age 35-45 yrs  Previous induced abortion  Previous pelvic surgeries  Cigarette smoking  DES Exposure in Utero  Infertility  Salpingitis Isthmica Nodosa  Genital Tuberculosis  Fundal Fibroid & Adenomyosis of tube  Transperitoneal migration of ovum
Iffy hypothesis – “Theory of reflux” menstural fluid throw the fertilised ovum into the tube Factors facilitating nidation of ovum in tube: - Premature degeneration of zona pellucida - Increased decidual reaction - Tubal endometriosis
EVOLUTION  Tubal pregnancies rapidly invade the mucosa, feeding from the tubal vessels, which become enlarged and engorged. The segment of the affected tube is distended as the pregnancy grows. Possible outcomes of such abnormal gestations are as follows:
MORBID ANATOMY Changes  Implantation- intercolumnar or between mucosal flods  Decidual change minimal  Muscle hyperplasia & Hypertrophy min.  Intramuscular implatation  Pseudocapsule formation  Trophoblast invasion-erosion of blood vessel  The pregnancy is unable to survive owing to its poor blood supply, thus resulting in a  tubal abortion and  resorption, (rare)  Tubal Rupture  Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months  Abortion is common in ampullary pregnancies,whereas rupture is in isthmic.
ARIAS – STELLA REACTION Arias – Stella reaction is charecterised by a benign, focal and unusual decidual changes in the presence of chorionic tissue,  Loss of polarity  Pleomorphism  Hyperchromatic nuclei  Vacuolated cytoplasm  Intraluminal budding Though seen in Ectopic Pregnancy but is not specific for it and can also be seen in uterine pregnancy
Pictures showing TUBAL ABORTION Ruptured ectopic
CLINICAL APPROACH  Dignosis can be done by history, detail examination and judicious use of investigation.  H/o past PID, tubal surgery,current contraceptive measures should be asked  Wide spectrum of clinical presentation from asymtomatic pt to others with acute abdomen and in shock.
ACUTE ECTOPIC PREGNANCY  Classical triad is present in 50% of pt with rupture ectopic. - PAIN:- most constant feature in 95% pt - variable in severity and nature - AMENORRHOEA:- 60-80% of pt - there may be delayed period or slight spotting at the time of expected menses. - VAGINAL BLEEDING: - scanty dark brown  Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to reflex vasomotor disturbance.  Abdominal pain most comm. Feature. Shoulder tip pain.
 O/E:- patient is restless in agony, looks blanched, pale, sweating with cold clammy skin. Features of shock, tachycardia, hypotension.  P/A:- abdomen tense, tender mostly in lower abdomen,shifting dullness, rigidity may be present.  P/S:- minimal bleeding may be present  P/V:- uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain on movement of cervix. POD may be full, uterus floats as if in water.
CHRONIC ECTOPIC PREGNANCY Symptoms  It can be diagnosed by high clinical suspicion  Patient had previous attack of acute pain from which she has recovered.  She may have amenorrhoea,  vaginal bleeding with  dull pain in abdomen and  with bladder and bowel complaints like dysuria, frequency or retention of urine,  rectal tenesmus.
 O/E:- patient look ill, varying degree of pallor, slightly raised temperature. Features of shock are absent.  P/A:- Tenderness and muscle guard on the lower abdomen. A mass may be felt, irregular and tender.  P/V:- Vaginal mucosa pale, uterus may be normal in size or bulky, ill defined boggy tender mass may be felt in one of the fornix.
UNRUPTURED ECTOPIC  High degree of suspicion & ectopic conscious clinician can diagnose.  Diagnosed accidentally in Laparoscopy or Laparotomy C/F – delayed period, spotting with discomfort in lower abdomen. P/A – tenderness in lower abdomen P/V  should be done gently  uterus is normal size, firm  small tender mass may be felt in the fornix Investigations- TVS, radioimmunoassay of β-HCG and Laparoscopy
DIAGNOSIS “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
DIAGNOSIS  In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.  This is due to the 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%.
DIAGNOSIS  Patient with acute ectopic can be diagnosed clinically.  Blood should be drawn for Hb%, CBC, blood grouping and cross matching,.Serology and Coagulation profile.  Should be catheterized to know urine output. Bed side test:- 1. Urine pregnancy test:- positive in 95% cases. ELISA is sensitive to 10-50 mlU/ml of β hCG and can be detected on 24th day after LMP. 2. Culdocentesis:- (70-90%)  Can be done with 16-18 G lumbar puncture needle through posterior fornix into POD.  Positive tap is 0.5ml of non clotting blood.
DIAGNOSIS Imaging:- 1. Ultra Sonography- a) Transvaginal Sonography (TVS):  Is more sensitive  It detect intrauterine gestational sac at 4-5wks and at S-β hCG level as low as 1500 IU/L .
ENDOMETRIAL CAVITY -A trilaminar endometial pattern seen -pseudogestational sac -decidual cyst may be seen PSEUDOSAC – All pregnancies induce an endometrial decidual reaction, and sloughing of the decidua can create an intracavitary fluid collection called a pseudosac Early Gestational Sac Pseudosac Location Eccentrically located Midline within E.cavity Shape Round-shape Irregular Border Double Ring sign Vascularity High Avascular Pattern Peripheral -
DECIDUAL CYST It is identified as an anechoic area lying with in the endometrium but remote from the canal and often at the endometrial-myometrial border.  Adenxa - 15-30% an extrauterine yolk sac or embryo seen in fallopian tubes confirms tubal pregnancy. - A halo or tubal ring surrounded by a thin hypoechoic area caused by subserosal edema can be seen.  Rectouterine cul-de-sac Free peritonial fluid with an adnexal mass suggestive of ectopic pregnancy
b) Color Doppler Sonography(TV-CDS): - Improve the accuracy. - Identify the placental shape (ring-of-fire pattern) and blood flow outside the uterine cavity. c) Transabdominal Sonography: - can identify gestational sac at 5-6 wks - S-β hCG level at which intrauterine gestational sac is seen by TAS is 1800 IU/L.
USG PICTURE 1.‘Bagel’ sign – Hyperechoic ring around gestational sac in adnexal region 2. ‘Blob’ sign – Seen as small inconglomerate mass next to ovary with no evidence of sac or embryo. 3. Adnexal sac with fetal pole and cardiac activity is most specific. 4. Corpus luteum is useful guide when looking for EP as present in 85% cases in Ipsilateral ovary.
Hyperechoic ring around gestational sac in adnexal region
Ring sign — a hyperechoic ring around an extrauterine gestational sac.
2. β-HCG Assay- a) Single β-HCG: little value b) Serial β-HCG: is required when result of initial USG is confusing. - When hCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy. -Rise of β-HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy . Biochemical pregnancy is applied to those women who have two β-HCG values >10 IU/L
3. Serum Progesterone –  level >25 ngm/ml is suggestive of normal intrauterine pregnancy.  level <15 ngm/ml is suggestive of ectopic pregnancy.  level <5 ngm/ml indicates nonviable pregnancy, irrespective of its location. 4. Diagnostic Laparoscopy (Gold standard)– Can be done only when patient is haemodynamically stable. -It confirms the diagnosis and removal of ectopic mass can be done at the same time.
DIAGNOSIS 5. Dilatation & Curettage –  Is recommended in suspected case of incomplete abortion vs ectopic pregnancy.  Identification of decidua without chorionic villi is suggestive of extra uterine pregnancy.  “Arias-Stella” endometrial reaction is suggestive but not diagnostic of ectopic pregnancy. 6. Other Novel Tests –  Placenta protein (PP14) decrease in EP  PAPPA (Pregnancy Associated Plasma Protein A), PAPPC (schwangerchaft protein 1) has low value in EP  CA-125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic pregnancy.  VEGF, Fetal Fibronectin, Mass spectrometry
SUSPECTED ECTOPIC PREGNANCY Urine Pregnancy test positive Transvaginal USG IU sac No IU sac Quantitative S-hCG + S progesterone < 66% rise in 48 hr or S progesterone < 5-10 ng/ml D & C Villi present Villi absent Incomplete abortion Laparoscopy >66% rise in 48 hr or S progesterone > 5-10 ng/ml Repeat S-hCG in 48 hrs till USG discrimination zone No sac IU sac Continue to monitor
DIFFERENTIAL DIAGNOSIS D/D of Acute Ectopic 1. Rupture corpus luteum of pregnancy 2. Rupture of chocolate cyst 3. Twisted ovarian cyst 4. Torsion / degeneration of pedunculated fibroid 5. Incomplete abortion 6. Acute Appendicitis 7. Perforated peptic ulcer 8. Renal colic 9. Splenic rupture
D/D OF CHRONIC (SUB ACUTE) ECTOPIC 1. Pelvic abscess 2. Pyosalpinx 3. Subserous uterine fibroid 4. Salpingintis 5. Retroverted gravid uterus 6. Appendicular lump
MANAGEMENT Expectant management Medical management Surgical management Local Systemic (USG or Laparoscopic) salpingocentesis - Methotrexate - Potassium chloride - Prostagladin(PGF2α) - Hypersmolar glucose - Actinomycin D - Mifepristone Methotrexate Radical Salpingectomy Conservative -Salpingostomy -Salpingotomy - Segmental resection -Milking or fimbrial expression
MANAGEMENT OF ECTOPIC- PRINCIPLE: Resuscitation and Laparotomy/Laparoscopy ANTI SHOCK TREATEMENT: - IV line made patent, crystalloid is started - Blood sample for Hb, blood grouping & cross matching, BT, CT - Folley’s catheterization done - Colloids for volume replacement LAPAROTOMY: Principle is ‘Quick in and Quick out’ - Rapid exploration of abdominal cavity is done - Salpingectomy is the definitive surgery (sent for HP study) - Blood transfusion to be given - Autotransfusion only when donated blood not available.
MANAGEMENT OF ECTOPIC PREGNANCY- Laparoscopy  Preferred method if haemodynamically stable  Tubal Patency no significant difference  Followed by similar number of uterine pregnancy  Shorter operative time Salpingostomy  Less than 2cm size  10-15mm incision
MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY OPTIONS: -  SURGICAL-  SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT  MEDICAL TREATMENT  EXPECTANT MANAGEMENT
EXPECTANT MANAGEMENT IDENTIFICATION CRITERIA - : 1. Tubal ectopic pregnancies only 2. Haemodynamically stable 3. No rupture or bleeding 4. Adnexal mass of < 3.5 cm without heart beat. 5. Initial β HCG <1000 IU/L and falling in titre (single best) SUCCESS RATE - Upto 60% PROTOCOL: - Hospitalization with strict monitoring of clinical symptom - Daily Hb estimation - Serum β HCG monitoring 3-4 days until it is <10 IU/L - TVS to be done twice a week.
EXPECTANT MANAGEMENT  Spontaneous resolution occurs in 72%,while 28% will need laparoscopic salpingostomy  In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant level.  The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2.  Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low.
MEDICAL MANAGEMENT Surgery is the mainstay of T/t worldwide Medical M/m may be tried in selected cases CANDIDATES FOR METHOTREXATE (MTX)  Unruptured sac < 3.5cm without cardiac activity  S-hCG < 10,000 IU/L  Persistant Ectopic after conservative surgery PHYSICIAN CHECK LIST  CBC, LFT, RFT, S-hCG  Transvaginal USG within 48 hrs  Obtain informed consent  Anti-D Ig if pt is Rh negative
MEDICAL MANAGEMENT METHOTREXATE:  It can be used as oral,intramuscular ,intravenous usually along with folinic acid.  Resolution 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 also be used for tubal pregnancy.  Mechanism of action-Methotrexate is a folic acid antagonist that inactivates the enzyme dihydrofolate reductase.Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the trophoblast.
MEDICAL MANAGEMENT Single dose Mtx 50mg/m² IM βHCG levels at days 4 & 7 •If difference ≥15% repeat weekly till ≤5IU/ml •If difference ˂15% between day 4 & 7 repeat dose & begin D₁ •If fetal Cardiac +ve at D₇ repeat D₁ Mtx •Surgical management if βHCG not ↓ or fetal cardiac +ve after 3 doses Two dose on Day 0, 4 Follow-up same as One dose regimen Variable doses 1. Mtx 1gm/kg IM D₁₃₅₇ 2. Leucovorin 0.1mg/kg IM D₂₄₆₈ Measure βHCG levels at D₁₃₅₇ . Continue alternate day regimen until βHCG levels decrease ≥15% in 48hrs, or 4 doses of Mtx given. Then, weekly βHCG levels until <5iu/ml
CONTD……  Advantages –  Minimal Hospitalisation.Usually outdoor treatment  Quick recovery  90% success if cases are properly selected  Disadvantages-  Side effects like GI & Skin  Monitoring is essential-  Total blood count,  LFT &  Serum HCG once weekly till it becomes negative
SURGICALLY ADMINISTERED MEDICAL TT (SAM)  Aim- trophoblastic destruction without systemic side effects  Technique- Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by-  Laparoscopy or  Ultrasonographically guided  Transabdominal (Porreco, 1992)  Transvaginal (Feichtingar, 1987)  With Falloposcopic control (Kiss, 1993)
Trophotoxic substances used- Methtrexate (Pansky, 1989) Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486) PGF2 (Limblom, 1987) Hyper osmolar glucose solution Actinomycin D Advantage of local MTX : - Increase tissue concentration at local site - Decrease systemic side effects - Decrease hospitalization - Greater preservation of fertility Follow up: - Serum β HCG twice weekly till < 5 IU/L - TVS weekly for 4-6 weeks - HCG after 6 months for tubal patency SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
INSTRUCTION TO THE PATIENTS  If T/t on outpatient basis rapid transportation should be available  Refrain from alcohol, sunlight, multivitamins with folic acid, and sexual intercourse until S-hCG is negative.  Report immediately when vaginal bleeding, abdominal pain, dizziness, syncope (mild pain is common called separation pain or resolution pain)  Failure of medical therapy require retreatment  Chance of tubal rupture in 5-10 % require emergency Laparotomy.
SURGICAL MANAGEMENT OF ECTOPIC Conservative Surgery Can be done Laparoscopically or by microsurgical laparotomy INDICATION: - Patient desires future fertility - Contralateral tube is damaged or surgically removed previously CHOICE OF TECHNIQUE: depends on - Location and size of gestational sac - Condition of tubes - Accessibility
VARIOUS CONSERVATIVE SURGERIES 1.Linear Salpingostomy: - Indicated in unruptured ectopic <2cm in ampullary region. - Linear incision given on antimesentric border over the site and product removed by fingers, scalpel handle or gentle suction and irrigation. - Incision line kept open (heals by secondary intention) 2. Linear Salpingotomy : - Incision line is closed in two layers with 7-0 interrupted vicryl sutures. 3. Segmental Resection & Anastomosis: - Indicated in unruptured isthmic pregnancy - End to end anastomosis is done immediately or at later date
4. Milking or fimbrial Expression: - This is ideal in distal ampullary or infundibular pregnancy. - It has got increased risk of persistent ectopic pregnancy. ADVANTAGES OF LAPAROSCOPY - It helps in diagnosis, evaluation, and treatment . - Diagnose other causes of infertility. - Decreased hospitalization, operative time, recovery period, analgesic requirement. Follow up after conservative surgery - With weekly Serum β HCG titre till it is negative. - If titre increases methotrexate can be given.
DEBATABLE ISSUES ? Salpingectomy Vs Salpingostomy ? Laparotomy Vs Laparoscopy ? Reproductive outcome ? Risk of Recurrent Ectopic
SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY  All tubal pregnancies can be treated by partial or total Salpingectomy  Salpingostomy / Salpingotomy is only indicated when: 1. The patient desires to conserve her fertility 2. Patient is haemodinamically stable 3. Tubal pregnancy is accessible 4. Unruptured and < 5Cm. In size 5. Contralateral tube is absent or damaged
CONTD……  The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment.  Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.
Fertility reducing factor Score • Antecedent one Ectopic pregnancy 2 • Antecedent each further Ectopic pregnancy 1 • Antecedent Adhesiolysis 1 • Antecedent Tubal micro surgery 2 • Antecedent Salpingitis 1 • Solitary tube 2 • Homolateral Adhesions 1 • Contralateral Adhesions 1  The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy.  Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more.
Laparotomy Vs Laparoscopy - Laparoscopy is reserved for pt who are hemodynamically stable. - Ruptured Ectopic does not necessarily require Laparotomy, but if large clots are present Laparotomy should be considered. Reproductive outcome Is similar in pt treated with either Laparoscopy or Laparotomy. Identical rates of 40% of IUP, around 12% risk of recurrent pregnancy with either radical or conservative pregnancy.
LAPAROSCOPIC SALPINGECTOMY It is carried out by laparoscopic scissors & 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 stitch. The excised tissue is removed by piece meal or in tissue removal bag LAPAROSCOPIC SALPINGOTOMY  To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal saline is injected into the mesosalpinx.  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)  The tubal pregnancy is then evacuated by suction irrigation.
PERSISTENT ECTOPIC PREGNANACY  This is a complication of salpingotomy / salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy.  Diagnosis is made because of a raised postoperative β HCG  If untreated, can cause life threatening hemorrhage Risk Factor: (seifer 1997) 1. Early ectopic pregnancy (< 6 wks amenorrhoea) 2. Smaller size < 2 cm (Incomplete removal) 3. Preoperative high serum β HCG (> 3,000 IU/L) and postoperative Day1 titre is < 50% of preoperative level, is predictor of persistent EP. 4. Implantation medial to the salpingostomy site. Treatment surgery Total or partial salpingectomy Medical (selected Asymptomatic pt) MTX + Leukovorin
OVARIAN ECTOPIC PREGNANCY Incidence: 1:40,000 Risk factor: - IUCD - Endometriosis on surface of ovary Course: C/F are same as tubal pregnancy ruptures within 2-3 wks Diagnosis: On Laparotomy Spiegelberg’s Criteria 1. Ipsilateral tube is intact and separate from sac 2. Sac occupies the position of the ovary 3. Connected to uterus by ovarian ligament 4. Ovarian tissue found on its wall on HP study M/MRuptured Laparotomy Oophorectomy Unruptured Ovarian wedge resection Ovarian Cystectomy
ABDOMINAL PREGNANCY Incidence: Rarest MMR : 7-8 times > tubal ectopic 90 times > Intrauterine pregnancy H/O : - Irregular bleeding, spotting - Nausea, vomiting, flatulence, constipation, diarrhoea, abdominal pain. - Fetal movement may be painful and high in the abdomen O/E : - Abnormal fetal position, easy in palpating fetal parts. - uterus palpated separate from sac - no uterine contraction after oxytocin infusion
Diagnosis: Confirmed by USG, CT scan, MRI, Radiography TYPE Primary Secondary Studiford’s criteria 1. Both tubes and ovaries normal 2. Absence of Uteroperitonal fistula 3. Pregnancy related to Peritoneal surface & young enough to rule out possibility of secondary implantation Conceptus escapes out through a rent from primary site Intraperitoneal Extraperitoneal Broad ligament
FATE OF SECONDARY ABDOMINAL PREGNANCY : 1. Death of ovum – complete absorption 2. Placental separation – massive intraperitoneal haemorrhage 3. Infection – fistulous communication with intestine, bladder, vagina, or umbilicus 4. Fetus dies (majority) – mummification, adipocere formation, or calcified to lithopaedion 5. Rarely – continue to term (malformation) M/M: - Urgent Laparatomy irrespective of period of gestation - Ideal to remove entire sac fetus, placenta, membrane - Placenta may be left if attached to vital organs, get absorbed by aseptic autolysis
CERVICAL PREGNANCY Implantation occurs in cervical canal at or below internal Os. Incidence: 1 in 18,000 RISK FACTORS : - Previous induced abortion - Previous caesarean delivery - Asherman’s syndrome - IVF - DES exposure - Leiomyoma
DIAGNOSIS: CLINICAL CRITERIA: Paulman & McEllin 1. Uterine bleeding, no cramping, following amenorrhoea 2. Cervix distended,thin walled,soft consistency 3. Enlarged uterine fundus may be palpated. 4. Internal Os is closed 5. External Os is partially opened USG CRITERIA: American Journal of O&G 1. Echo-free uterine cavity/ pseudo-gestational sac 2. Decidual reaction 3. Hourglass uterus with ballooned cervical canal 4. Gestational sac in endocervix 5. Closed internal Os 6. Placental tissue in Cx canal
DIAGNOSIS HISTOPATHOLOGIC CRITERIA Rubin’s: 1. Cervical glands present opposite to placenta 2. Placental attachment to the cervix must be below the entrance of uterine vessels . 3. Fetal element absent from corpus uteri. D/d :  Carcinoma Cx  Cervical submucous fibroid  Trophoblastic tumour  Placenta previa
MANAGEMENT Surgical Mainstay therapy in past Radical surgery Hysterectomy Conservative D & C (risk of torrential bleeding) - Cerclage Bernstein ≈ Mc Donald’s Wharton ≈ Shirodkar’s -Transvaginal ligation of Cx branch of uterine artery - Angiographic uterine A embolisation - Intracervical vasopressin inj - Foley’s catheter as tamponade Medical Recently proposed Single or Combination OR Adjunct to surgery - Methotrexate - Actinomycin - KCl - Etoposide
CORNUAL PREGNANCY SITE: Implantation occurs in rudimentary horn of Bicornuate uterus COURSE :Rupture of horn occurs by 12-20 wks D/D : 1. Interstitial tubal pregnancy 2. Painful leiomyoma along with pregnancy 3. Ovarian tumor with pregnancy 4. Asymmetrical enlargement of uterus. Implantation into cornu of normal uterus is sometime called Angular pregnancy . TREATEMENT: - Affected cornu with pregnancy is removed - Hysterectomy - Hysteroscopically guided suction curettage if communication with Cx is patent
HETEROTYPIC PREGNANCY Co-existing intrauterine and extra uterine pregnancies Incidence: 1 : 30,000 - With ART – 1:7000 - With ovulation induction – 1:900 More likely: a) Ass. reproductive technique b) Rising HCG titre after D & C c) More than 1 corpus luteum at laparotomy M/M : Depends on the site. Ectopic site may be removed with continuation of IU pregnancy (Rh Immunoglobulin: dose of 50 μ gm is sufficient to prevent sensitization.)
INTERSTITAL PREGNANCY (2%) It ruptures late at 3-4 months gestation. Fatal rupture – severe bleeding as both uterine & ovarian artery supply. Early & Unruptured – Local or IM MTX with followup Cornual resection by Laparotomy may be done. There is high risk of uterine rupture in subsequent pregnancy. Rupture – Hysterectomy is indicated
CAESAREAN SCAR ECTOPIC PREGNANCY  Recently reported  USG slows on empty uterine cavity and gestational sac attached low to the lower segment caesarean scar. C/F : similar to threatened or inevitable abortion Diagnosis : Doppler imaging confirms Management:  Methotrexate injection  Hysterectomy in a multiparous women. In young pt resection & suturing of scar may be done (high risk of rupture).
OTHER RARE TYPES 1. Multiple Ectopic pregnancy 2. Pregnancy after hysterectomy 3. Primary splenic pregnancy 4. Primary hepatic pregnancy 5. Rectroperitoneal pregnancy 6. Diaphragmatic pregnancy MORTALITY : In general population is 10-15% mainly due to haemorrhage.
SUMMARY - KEY POINTS  Incidence of ectopic pregnancy is rising while maternal mortality from it is falling.  Ectopic pregnancy can be diagnosed early (before it ruptures) with recent advances in Immunoassay to detect β-hCG , high resolution USG, and diagnostic Laparoscopy.  There has been shift in the M/m from ablative surgery to conservative fertility preserving therapy  Laparotomy should be done when in doubt  The choice today is Laparoscopic treatment of un-ruptured ectopic pregnancy.  Careful monitoring and proper counselling of patients is mandatory.
I was intra- uterine….

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Ectopic pregnancy

  • 1.
  • 2.
    DEFINITION “Any pregnancy wherethe fertilised ovum gets implanted & develops in a site other than normal uterine cavity”. It represents a serious hazard to a woman’s health and reproductive potential, requiring prompt recognition and early aggressive intervention.
  • 3.
    Is one inwhich fertilized ovum is implanted & develops outside normal uterine cavity
  • 4.
    IMPLANTATIONS SITES EXTRAUTERINE UTERINE OVARIANABDOMINAL PRIMARY SECONDARY Intraperitoneal Extraperitoneal Broad Ligament (rare) 1. Cervical <1 2. Angular 3. Caesarean 4. CornualTUBAL 95-96% •Ampulla 70% •Isthmus 25% •Interstistial 18% •Infundibulum2%
  • 6.
    INCIDENCE & MORTALITY •Increased • PID • IUCD • Tubal surgeries, and • Assisted reproductive techniques (ART). • Rate in India – 5.6/10000 deliveries • Late marriages and late child bearing -> 2% • ART -> 5% • Recurrence rate - 15% after 1st, 25% after 2 ectopics Innovative Journal of Medical and Health Science 4 : 1 Jan - Feb(2014) 305-309.
  • 7.
    ETIOLOGY:  Any factorthat causes delayed transport of the fertilised ovum through the tube.  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.
    ETIOLOGY  CONGENITAL  TubalHypoplasia  Tortuosity  Congenital diverticuli  Accessory ostia  Partial stenosis  Elongation  Intamural polyp  Entrap the ovum on its way.
  • 9.
    ETIOLOGY ACQUIRED - Pelvic Inflammatorydisease (6-10 times) Chlamydia trachomatis is most common Contraceptive Faliure  CuT - 4%  Progestasart -17%  Minipills -4-10%  Norplant -30%
  • 10.
    •Tubal sterilization faliure-40% Depends on sterilization technique and age of the patient •Bipolar Cauterisation -65% •Unipolar Cautery -17% •Silicon rubber band -29% •Interval Salpingectomy -43% •Postpartum Salpingectomy -20% •Reversal of sterilisation •Depends on • method of sterilization, • Site of tubal occlusion, • residual tubal length. •Reanastomosis of cauterised tube -15% •Reversal of Pomeroy’s - < 3%
  • 11.
    ETIOLOGY Tubal reconstructive surgery(4-5 times) Assisted Reproductive technique - Ovulation induction, IVF-ET and GIFT (4-7%) - Risk of heterotopic pregnancy(1%) Previous Ectopic Pregnancy - 7-15% chances of repeat ectopic pregnancy
  • 12.
    Other Risk factors Age 35-45 yrs  Previous induced abortion  Previous pelvic surgeries  Cigarette smoking  DES Exposure in Utero  Infertility  Salpingitis Isthmica Nodosa  Genital Tuberculosis  Fundal Fibroid & Adenomyosis of tube  Transperitoneal migration of ovum
  • 13.
    Iffy hypothesis – “Theoryof reflux” menstural fluid throw the fertilised ovum into the tube Factors facilitating nidation of ovum in tube: - Premature degeneration of zona pellucida - Increased decidual reaction - Tubal endometriosis
  • 14.
    EVOLUTION  Tubal pregnanciesrapidly invade the mucosa, feeding from the tubal vessels, which become enlarged and engorged. The segment of the affected tube is distended as the pregnancy grows. Possible outcomes of such abnormal gestations are as follows:
  • 15.
    MORBID ANATOMY Changes  Implantation-intercolumnar or between mucosal flods  Decidual change minimal  Muscle hyperplasia & Hypertrophy min.  Intramuscular implatation  Pseudocapsule formation  Trophoblast invasion-erosion of blood vessel  The pregnancy is unable to survive owing to its poor blood supply, thus resulting in a  tubal abortion and  resorption, (rare)  Tubal Rupture  Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months  Abortion is common in ampullary pregnancies,whereas rupture is in isthmic.
  • 16.
    ARIAS – STELLAREACTION Arias – Stella reaction is charecterised by a benign, focal and unusual decidual changes in the presence of chorionic tissue,  Loss of polarity  Pleomorphism  Hyperchromatic nuclei  Vacuolated cytoplasm  Intraluminal budding Though seen in Ectopic Pregnancy but is not specific for it and can also be seen in uterine pregnancy
  • 17.
    Pictures showing TUBALABORTION Ruptured ectopic
  • 18.
    CLINICAL APPROACH  Dignosiscan be done by history, detail examination and judicious use of investigation.  H/o past PID, tubal surgery,current contraceptive measures should be asked  Wide spectrum of clinical presentation from asymtomatic pt to others with acute abdomen and in shock.
  • 19.
    ACUTE ECTOPIC PREGNANCY Classical triad is present in 50% of pt with rupture ectopic. - PAIN:- most constant feature in 95% pt - variable in severity and nature - AMENORRHOEA:- 60-80% of pt - there may be delayed period or slight spotting at the time of expected menses. - VAGINAL BLEEDING: - scanty dark brown  Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to reflex vasomotor disturbance.  Abdominal pain most comm. Feature. Shoulder tip pain.
  • 20.
     O/E:- patientis restless in agony, looks blanched, pale, sweating with cold clammy skin. Features of shock, tachycardia, hypotension.  P/A:- abdomen tense, tender mostly in lower abdomen,shifting dullness, rigidity may be present.  P/S:- minimal bleeding may be present  P/V:- uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain on movement of cervix. POD may be full, uterus floats as if in water.
  • 21.
    CHRONIC ECTOPIC PREGNANCY Symptoms It can be diagnosed by high clinical suspicion  Patient had previous attack of acute pain from which she has recovered.  She may have amenorrhoea,  vaginal bleeding with  dull pain in abdomen and  with bladder and bowel complaints like dysuria, frequency or retention of urine,  rectal tenesmus.
  • 22.
     O/E:- patientlook ill, varying degree of pallor, slightly raised temperature. Features of shock are absent.  P/A:- Tenderness and muscle guard on the lower abdomen. A mass may be felt, irregular and tender.  P/V:- Vaginal mucosa pale, uterus may be normal in size or bulky, ill defined boggy tender mass may be felt in one of the fornix.
  • 23.
    UNRUPTURED ECTOPIC  Highdegree of suspicion & ectopic conscious clinician can diagnose.  Diagnosed accidentally in Laparoscopy or Laparotomy C/F – delayed period, spotting with discomfort in lower abdomen. P/A – tenderness in lower abdomen P/V  should be done gently  uterus is normal size, firm  small tender mass may be felt in the fornix Investigations- TVS, radioimmunoassay of β-HCG and Laparoscopy
  • 25.
    DIAGNOSIS “Pregnancy in thefallopian 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
  • 26.
    DIAGNOSIS  In recentyears, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.  This is due to the 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%.
  • 27.
    DIAGNOSIS  Patient withacute ectopic can be diagnosed clinically.  Blood should be drawn for Hb%, CBC, blood grouping and cross matching,.Serology and Coagulation profile.  Should be catheterized to know urine output. Bed side test:- 1. Urine pregnancy test:- positive in 95% cases. ELISA is sensitive to 10-50 mlU/ml of β hCG and can be detected on 24th day after LMP. 2. Culdocentesis:- (70-90%)  Can be done with 16-18 G lumbar puncture needle through posterior fornix into POD.  Positive tap is 0.5ml of non clotting blood.
  • 28.
    DIAGNOSIS Imaging:- 1. Ultra Sonography- a)Transvaginal Sonography (TVS):  Is more sensitive  It detect intrauterine gestational sac at 4-5wks and at S-β hCG level as low as 1500 IU/L .
  • 29.
    ENDOMETRIAL CAVITY -A trilaminarendometial pattern seen -pseudogestational sac -decidual cyst may be seen PSEUDOSAC – All pregnancies induce an endometrial decidual reaction, and sloughing of the decidua can create an intracavitary fluid collection called a pseudosac Early Gestational Sac Pseudosac Location Eccentrically located Midline within E.cavity Shape Round-shape Irregular Border Double Ring sign Vascularity High Avascular Pattern Peripheral -
  • 30.
    DECIDUAL CYST It isidentified as an anechoic area lying with in the endometrium but remote from the canal and often at the endometrial-myometrial border.  Adenxa - 15-30% an extrauterine yolk sac or embryo seen in fallopian tubes confirms tubal pregnancy. - A halo or tubal ring surrounded by a thin hypoechoic area caused by subserosal edema can be seen.  Rectouterine cul-de-sac Free peritonial fluid with an adnexal mass suggestive of ectopic pregnancy
  • 31.
    b) Color DopplerSonography(TV-CDS): - Improve the accuracy. - Identify the placental shape (ring-of-fire pattern) and blood flow outside the uterine cavity. c) Transabdominal Sonography: - can identify gestational sac at 5-6 wks - S-β hCG level at which intrauterine gestational sac is seen by TAS is 1800 IU/L.
  • 32.
    USG PICTURE 1.‘Bagel’ sign– Hyperechoic ring around gestational sac in adnexal region 2. ‘Blob’ sign – Seen as small inconglomerate mass next to ovary with no evidence of sac or embryo. 3. Adnexal sac with fetal pole and cardiac activity is most specific. 4. Corpus luteum is useful guide when looking for EP as present in 85% cases in Ipsilateral ovary.
  • 33.
  • 34.
    Ring sign —a hyperechoic ring around an extrauterine gestational sac.
  • 35.
    2. β-HCG Assay- a)Single β-HCG: little value b) Serial β-HCG: is required when result of initial USG is confusing. - When hCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy. -Rise of β-HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy . Biochemical pregnancy is applied to those women who have two β-HCG values >10 IU/L
  • 36.
    3. Serum Progesterone–  level >25 ngm/ml is suggestive of normal intrauterine pregnancy.  level <15 ngm/ml is suggestive of ectopic pregnancy.  level <5 ngm/ml indicates nonviable pregnancy, irrespective of its location. 4. Diagnostic Laparoscopy (Gold standard)– Can be done only when patient is haemodynamically stable. -It confirms the diagnosis and removal of ectopic mass can be done at the same time.
  • 37.
    DIAGNOSIS 5. Dilatation &Curettage –  Is recommended in suspected case of incomplete abortion vs ectopic pregnancy.  Identification of decidua without chorionic villi is suggestive of extra uterine pregnancy.  “Arias-Stella” endometrial reaction is suggestive but not diagnostic of ectopic pregnancy. 6. Other Novel Tests –  Placenta protein (PP14) decrease in EP  PAPPA (Pregnancy Associated Plasma Protein A), PAPPC (schwangerchaft protein 1) has low value in EP  CA-125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic pregnancy.  VEGF, Fetal Fibronectin, Mass spectrometry
  • 38.
    SUSPECTED ECTOPIC PREGNANCY UrinePregnancy test positive Transvaginal USG IU sac No IU sac Quantitative S-hCG + S progesterone < 66% rise in 48 hr or S progesterone < 5-10 ng/ml D & C Villi present Villi absent Incomplete abortion Laparoscopy >66% rise in 48 hr or S progesterone > 5-10 ng/ml Repeat S-hCG in 48 hrs till USG discrimination zone No sac IU sac Continue to monitor
  • 39.
    DIFFERENTIAL DIAGNOSIS D/D ofAcute Ectopic 1. Rupture corpus luteum of pregnancy 2. Rupture of chocolate cyst 3. Twisted ovarian cyst 4. Torsion / degeneration of pedunculated fibroid 5. Incomplete abortion 6. Acute Appendicitis 7. Perforated peptic ulcer 8. Renal colic 9. Splenic rupture
  • 40.
    D/D OF CHRONIC(SUB ACUTE) ECTOPIC 1. Pelvic abscess 2. Pyosalpinx 3. Subserous uterine fibroid 4. Salpingintis 5. Retroverted gravid uterus 6. Appendicular lump
  • 41.
    MANAGEMENT Expectant management Medical management Surgical management Local Systemic (USG orLaparoscopic) salpingocentesis - Methotrexate - Potassium chloride - Prostagladin(PGF2α) - Hypersmolar glucose - Actinomycin D - Mifepristone Methotrexate Radical Salpingectomy Conservative -Salpingostomy -Salpingotomy - Segmental resection -Milking or fimbrial expression
  • 42.
    MANAGEMENT OF ECTOPIC- PRINCIPLE:Resuscitation and Laparotomy/Laparoscopy ANTI SHOCK TREATEMENT: - IV line made patent, crystalloid is started - Blood sample for Hb, blood grouping & cross matching, BT, CT - Folley’s catheterization done - Colloids for volume replacement LAPAROTOMY: Principle is ‘Quick in and Quick out’ - Rapid exploration of abdominal cavity is done - Salpingectomy is the definitive surgery (sent for HP study) - Blood transfusion to be given - Autotransfusion only when donated blood not available.
  • 43.
    MANAGEMENT OF ECTOPICPREGNANCY- Laparoscopy  Preferred method if haemodynamically stable  Tubal Patency no significant difference  Followed by similar number of uterine pregnancy  Shorter operative time Salpingostomy  Less than 2cm size  10-15mm incision
  • 45.
    MANAGEMENT OF UNRUPTURED ECTOPICPREGNANCY OPTIONS: -  SURGICAL-  SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT  MEDICAL TREATMENT  EXPECTANT MANAGEMENT
  • 46.
    EXPECTANT MANAGEMENT IDENTIFICATION CRITERIA- : 1. Tubal ectopic pregnancies only 2. Haemodynamically stable 3. No rupture or bleeding 4. Adnexal mass of < 3.5 cm without heart beat. 5. Initial β HCG <1000 IU/L and falling in titre (single best) SUCCESS RATE - Upto 60% PROTOCOL: - Hospitalization with strict monitoring of clinical symptom - Daily Hb estimation - Serum β HCG monitoring 3-4 days until it is <10 IU/L - TVS to be done twice a week.
  • 47.
    EXPECTANT MANAGEMENT  Spontaneousresolution occurs in 72%,while 28% will need laparoscopic salpingostomy  In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant level.  The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2.  Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low.
  • 48.
    MEDICAL MANAGEMENT Surgery isthe mainstay of T/t worldwide Medical M/m may be tried in selected cases CANDIDATES FOR METHOTREXATE (MTX)  Unruptured sac < 3.5cm without cardiac activity  S-hCG < 10,000 IU/L  Persistant Ectopic after conservative surgery PHYSICIAN CHECK LIST  CBC, LFT, RFT, S-hCG  Transvaginal USG within 48 hrs  Obtain informed consent  Anti-D Ig if pt is Rh negative
  • 49.
    MEDICAL MANAGEMENT METHOTREXATE:  Itcan be used as oral,intramuscular ,intravenous usually along with folinic acid.  Resolution 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 also be used for tubal pregnancy.  Mechanism of action-Methotrexate is a folic acid antagonist that inactivates the enzyme dihydrofolate reductase.Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the trophoblast.
  • 50.
    MEDICAL MANAGEMENT Single dose Mtx50mg/m² IM βHCG levels at days 4 & 7 •If difference ≥15% repeat weekly till ≤5IU/ml •If difference ˂15% between day 4 & 7 repeat dose & begin D₁ •If fetal Cardiac +ve at D₇ repeat D₁ Mtx •Surgical management if βHCG not ↓ or fetal cardiac +ve after 3 doses Two dose on Day 0, 4 Follow-up same as One dose regimen Variable doses 1. Mtx 1gm/kg IM D₁₃₅₇ 2. Leucovorin 0.1mg/kg IM D₂₄₆₈ Measure βHCG levels at D₁₃₅₇ . Continue alternate day regimen until βHCG levels decrease ≥15% in 48hrs, or 4 doses of Mtx given. Then, weekly βHCG levels until <5iu/ml
  • 51.
    CONTD……  Advantages – Minimal Hospitalisation.Usually outdoor treatment  Quick recovery  90% success if cases are properly selected  Disadvantages-  Side effects like GI & Skin  Monitoring is essential-  Total blood count,  LFT &  Serum HCG once weekly till it becomes negative
  • 52.
    SURGICALLY ADMINISTERED MEDICALTT (SAM)  Aim- trophoblastic destruction without systemic side effects  Technique- Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by-  Laparoscopy or  Ultrasonographically guided  Transabdominal (Porreco, 1992)  Transvaginal (Feichtingar, 1987)  With Falloposcopic control (Kiss, 1993)
  • 53.
    Trophotoxic substances used- Methtrexate(Pansky, 1989) Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486) PGF2 (Limblom, 1987) Hyper osmolar glucose solution Actinomycin D Advantage of local MTX : - Increase tissue concentration at local site - Decrease systemic side effects - Decrease hospitalization - Greater preservation of fertility Follow up: - Serum β HCG twice weekly till < 5 IU/L - TVS weekly for 4-6 weeks - HCG after 6 months for tubal patency SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
  • 54.
    INSTRUCTION TO THEPATIENTS  If T/t on outpatient basis rapid transportation should be available  Refrain from alcohol, sunlight, multivitamins with folic acid, and sexual intercourse until S-hCG is negative.  Report immediately when vaginal bleeding, abdominal pain, dizziness, syncope (mild pain is common called separation pain or resolution pain)  Failure of medical therapy require retreatment  Chance of tubal rupture in 5-10 % require emergency Laparotomy.
  • 55.
    SURGICAL MANAGEMENT OFECTOPIC Conservative Surgery Can be done Laparoscopically or by microsurgical laparotomy INDICATION: - Patient desires future fertility - Contralateral tube is damaged or surgically removed previously CHOICE OF TECHNIQUE: depends on - Location and size of gestational sac - Condition of tubes - Accessibility
  • 56.
    VARIOUS CONSERVATIVE SURGERIES 1.LinearSalpingostomy: - Indicated in unruptured ectopic <2cm in ampullary region. - Linear incision given on antimesentric border over the site and product removed by fingers, scalpel handle or gentle suction and irrigation. - Incision line kept open (heals by secondary intention) 2. Linear Salpingotomy : - Incision line is closed in two layers with 7-0 interrupted vicryl sutures. 3. Segmental Resection & Anastomosis: - Indicated in unruptured isthmic pregnancy - End to end anastomosis is done immediately or at later date
  • 57.
    4. Milking orfimbrial Expression: - This is ideal in distal ampullary or infundibular pregnancy. - It has got increased risk of persistent ectopic pregnancy. ADVANTAGES OF LAPAROSCOPY - It helps in diagnosis, evaluation, and treatment . - Diagnose other causes of infertility. - Decreased hospitalization, operative time, recovery period, analgesic requirement. Follow up after conservative surgery - With weekly Serum β HCG titre till it is negative. - If titre increases methotrexate can be given.
  • 58.
    DEBATABLE ISSUES ? SalpingectomyVs Salpingostomy ? Laparotomy Vs Laparoscopy ? Reproductive outcome ? Risk of Recurrent Ectopic
  • 59.
    SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY All tubal pregnancies can be treated by partial or total Salpingectomy  Salpingostomy / Salpingotomy is only indicated when: 1. The patient desires to conserve her fertility 2. Patient is haemodinamically stable 3. Tubal pregnancy is accessible 4. Unruptured and < 5Cm. In size 5. Contralateral tube is absent or damaged
  • 60.
    CONTD……  The choiceof surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment.  Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.
  • 61.
    Fertility reducing factorScore • Antecedent one Ectopic pregnancy 2 • Antecedent each further Ectopic pregnancy 1 • Antecedent Adhesiolysis 1 • Antecedent Tubal micro surgery 2 • Antecedent Salpingitis 1 • Solitary tube 2 • Homolateral Adhesions 1 • Contralateral Adhesions 1  The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy.  Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more.
  • 62.
    Laparotomy Vs Laparoscopy -Laparoscopy is reserved for pt who are hemodynamically stable. - Ruptured Ectopic does not necessarily require Laparotomy, but if large clots are present Laparotomy should be considered. Reproductive outcome Is similar in pt treated with either Laparoscopy or Laparotomy. Identical rates of 40% of IUP, around 12% risk of recurrent pregnancy with either radical or conservative pregnancy.
  • 63.
    LAPAROSCOPIC SALPINGECTOMY It iscarried out by laparoscopic scissors & 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 stitch. The excised tissue is removed by piece meal or in tissue removal bag LAPAROSCOPIC SALPINGOTOMY  To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal saline is injected into the mesosalpinx.  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)  The tubal pregnancy is then evacuated by suction irrigation.
  • 64.
    PERSISTENT ECTOPIC PREGNANACY This is a complication of salpingotomy / salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy.  Diagnosis is made because of a raised postoperative β HCG  If untreated, can cause life threatening hemorrhage Risk Factor: (seifer 1997) 1. Early ectopic pregnancy (< 6 wks amenorrhoea) 2. Smaller size < 2 cm (Incomplete removal) 3. Preoperative high serum β HCG (> 3,000 IU/L) and postoperative Day1 titre is < 50% of preoperative level, is predictor of persistent EP. 4. Implantation medial to the salpingostomy site. Treatment surgery Total or partial salpingectomy Medical (selected Asymptomatic pt) MTX + Leukovorin
  • 65.
    OVARIAN ECTOPIC PREGNANCY Incidence:1:40,000 Risk factor: - IUCD - Endometriosis on surface of ovary Course: C/F are same as tubal pregnancy ruptures within 2-3 wks Diagnosis: On Laparotomy Spiegelberg’s Criteria 1. Ipsilateral tube is intact and separate from sac 2. Sac occupies the position of the ovary 3. Connected to uterus by ovarian ligament 4. Ovarian tissue found on its wall on HP study M/MRuptured Laparotomy Oophorectomy Unruptured Ovarian wedge resection Ovarian Cystectomy
  • 66.
    ABDOMINAL PREGNANCY Incidence: Rarest MMR: 7-8 times > tubal ectopic 90 times > Intrauterine pregnancy H/O : - Irregular bleeding, spotting - Nausea, vomiting, flatulence, constipation, diarrhoea, abdominal pain. - Fetal movement may be painful and high in the abdomen O/E : - Abnormal fetal position, easy in palpating fetal parts. - uterus palpated separate from sac - no uterine contraction after oxytocin infusion
  • 67.
    Diagnosis: Confirmed byUSG, CT scan, MRI, Radiography TYPE Primary Secondary Studiford’s criteria 1. Both tubes and ovaries normal 2. Absence of Uteroperitonal fistula 3. Pregnancy related to Peritoneal surface & young enough to rule out possibility of secondary implantation Conceptus escapes out through a rent from primary site Intraperitoneal Extraperitoneal Broad ligament
  • 68.
    FATE OF SECONDARYABDOMINAL PREGNANCY : 1. Death of ovum – complete absorption 2. Placental separation – massive intraperitoneal haemorrhage 3. Infection – fistulous communication with intestine, bladder, vagina, or umbilicus 4. Fetus dies (majority) – mummification, adipocere formation, or calcified to lithopaedion 5. Rarely – continue to term (malformation) M/M: - Urgent Laparatomy irrespective of period of gestation - Ideal to remove entire sac fetus, placenta, membrane - Placenta may be left if attached to vital organs, get absorbed by aseptic autolysis
  • 69.
    CERVICAL PREGNANCY Implantation occursin cervical canal at or below internal Os. Incidence: 1 in 18,000 RISK FACTORS : - Previous induced abortion - Previous caesarean delivery - Asherman’s syndrome - IVF - DES exposure - Leiomyoma
  • 70.
    DIAGNOSIS: CLINICAL CRITERIA: Paulman& McEllin 1. Uterine bleeding, no cramping, following amenorrhoea 2. Cervix distended,thin walled,soft consistency 3. Enlarged uterine fundus may be palpated. 4. Internal Os is closed 5. External Os is partially opened USG CRITERIA: American Journal of O&G 1. Echo-free uterine cavity/ pseudo-gestational sac 2. Decidual reaction 3. Hourglass uterus with ballooned cervical canal 4. Gestational sac in endocervix 5. Closed internal Os 6. Placental tissue in Cx canal
  • 71.
    DIAGNOSIS HISTOPATHOLOGIC CRITERIA Rubin’s: 1. Cervicalglands present opposite to placenta 2. Placental attachment to the cervix must be below the entrance of uterine vessels . 3. Fetal element absent from corpus uteri. D/d :  Carcinoma Cx  Cervical submucous fibroid  Trophoblastic tumour  Placenta previa
  • 72.
    MANAGEMENT Surgical Mainstay therapy inpast Radical surgery Hysterectomy Conservative D & C (risk of torrential bleeding) - Cerclage Bernstein ≈ Mc Donald’s Wharton ≈ Shirodkar’s -Transvaginal ligation of Cx branch of uterine artery - Angiographic uterine A embolisation - Intracervical vasopressin inj - Foley’s catheter as tamponade Medical Recently proposed Single or Combination OR Adjunct to surgery - Methotrexate - Actinomycin - KCl - Etoposide
  • 73.
    CORNUAL PREGNANCY SITE: Implantationoccurs in rudimentary horn of Bicornuate uterus COURSE :Rupture of horn occurs by 12-20 wks D/D : 1. Interstitial tubal pregnancy 2. Painful leiomyoma along with pregnancy 3. Ovarian tumor with pregnancy 4. Asymmetrical enlargement of uterus. Implantation into cornu of normal uterus is sometime called Angular pregnancy . TREATEMENT: - Affected cornu with pregnancy is removed - Hysterectomy - Hysteroscopically guided suction curettage if communication with Cx is patent
  • 74.
    HETEROTYPIC PREGNANCY Co-existing intrauterineand extra uterine pregnancies Incidence: 1 : 30,000 - With ART – 1:7000 - With ovulation induction – 1:900 More likely: a) Ass. reproductive technique b) Rising HCG titre after D & C c) More than 1 corpus luteum at laparotomy M/M : Depends on the site. Ectopic site may be removed with continuation of IU pregnancy (Rh Immunoglobulin: dose of 50 μ gm is sufficient to prevent sensitization.)
  • 75.
    INTERSTITAL PREGNANCY (2%) Itruptures late at 3-4 months gestation. Fatal rupture – severe bleeding as both uterine & ovarian artery supply. Early & Unruptured – Local or IM MTX with followup Cornual resection by Laparotomy may be done. There is high risk of uterine rupture in subsequent pregnancy. Rupture – Hysterectomy is indicated
  • 76.
    CAESAREAN SCAR ECTOPICPREGNANCY  Recently reported  USG slows on empty uterine cavity and gestational sac attached low to the lower segment caesarean scar. C/F : similar to threatened or inevitable abortion Diagnosis : Doppler imaging confirms Management:  Methotrexate injection  Hysterectomy in a multiparous women. In young pt resection & suturing of scar may be done (high risk of rupture).
  • 77.
    OTHER RARE TYPES 1.Multiple Ectopic pregnancy 2. Pregnancy after hysterectomy 3. Primary splenic pregnancy 4. Primary hepatic pregnancy 5. Rectroperitoneal pregnancy 6. Diaphragmatic pregnancy MORTALITY : In general population is 10-15% mainly due to haemorrhage.
  • 78.
    SUMMARY - KEYPOINTS  Incidence of ectopic pregnancy is rising while maternal mortality from it is falling.  Ectopic pregnancy can be diagnosed early (before it ruptures) with recent advances in Immunoassay to detect β-hCG , high resolution USG, and diagnostic Laparoscopy.  There has been shift in the M/m from ablative surgery to conservative fertility preserving therapy  Laparotomy should be done when in doubt  The choice today is Laparoscopic treatment of un-ruptured ectopic pregnancy.  Careful monitoring and proper counselling of patients is mandatory.
  • 79.