ectopic pregnancy

GARBHASHAYANANTAR
GARBHADHAN
Directed by-
Dr. A. Neelima Reddy
Dr. Rashmi sharma
Presented by-
Jay Prakash Gupta
Batch 2012

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Normal pregnancy implantation
 Pregnancy is the period during which a woman carries a developing
fetus normally in the uterus, starting from conception (fertilization
of ova) until the baby born.
 After ovulation the ovum is picked up by the fimbria of fallopian
tubes and then swept by ciliary action towards the ampulla where
fertilization occurs.
 As soon as the zygote develops it begin dividing very rapidly, it
remains in the fallopian tube for 3 -4 days untill reaches morula stage
(8-32 cell stage)

• The embryo proceeds through the isthmus to the uterine cavity for up
to 72 hours, by the sixth day it enters the uterus and begins to
penetrate the decidua (endometrium) this is called implantation
which takes place within the uterine cavity in normal positioned
pregnancy .
• Then hCG is produced by trophoblast, which can be detected in the
serum of the mother in the first week after implantation, its level
doubles every 36-48 hours in normal healthy pregnancy starting from
5 to 50 ,100, till reaching 1000 IU/L

• Delay or obstruction of the passage of fertilized egg down the
fallopian tube to the uterus may result in implantation in the
fallopian tube or ovary or peritoneal cavity, this known as ectopic
pregnancy which eventually most fails to develop , and the hCG
fails to raise dramatically as happens in the normal intra uterine
pregnancy.

Etymological derivation
 The term “ectopic” comes from the Greek “ektopis” meaning
“ displacement (“ek” ,out of + “topos” , place = out of place).
 The word “pregnant” comes from the Latin premeaning before
+(g)natus Meaning birth =before (giving) birth.
 The first person to use “ectopic” in a medical context was the
english obstetrician ROBERT BARNES (1817-1907) who
applied it to an extrauterine pregnancy ; An ectopic pregnancy.

Definition
 An ectopic pregnancy is one in which the fertilised ovum
becomes implanted in a site other than the normal uterine cavity.
 Although extrauterine pregnancy is often used as a synonymous
term,
 Ectopic pregnancy is the consequence of an abnormal
implantation of the blastocyst.

Frequency
 Ectopic pregnancy is seen in about 2 per cent of all pregnancies in
USA, 3-4 per cent worldwide incidence.
 In some studies the incidence reported is as high as 16 ectopic
pregnancy for 1000.
 The incidence of ectopic pregnancy has risen in the past 20 years
due to various reasons like predisposing factors and also better
diagnostic techniques
 Ectopic pregnancy is the leading cause of maternal mortality in
USA (10-15%).

Sites of Ectopic Pregnancy
The possible sites can be classified according to above downwards
and according to frequency.
Above downwards
 1. Abdominal cavity
 2. Ovary
 3. Fallopian tubes
 4. Broad ligament
 5. Rudimentary horn of uterus
 6. Cervix
Ectopic pregnancy is commoner on the right side
Frequency
1. Fallopian tubes 95-98 per
cent
2. Uterine cornu 2-2.5 per
cent
3. Ovary, cervix and
abdominal cavity <1 per cent
.

Why?
The reason for the increase in ectopic pregnancy during this time
period is not entirely clear, but it was thought that the increase
of risk factors were responsible for a significant portion of the
increased number of cases of ectopic pregnancy.

1. Pelvic inflammatory diseases (6 fold increased risk).
2. Use of IUCD’s (3-5% increased risks)
3. Smoking (2.5% increased risks)
4. ART pregnancies (3-5% increased risk)
5. Tubal damage (Surgical occlusions or cilial damage).
6. Tubal Surgery (5.8% increased risk)
7. Salpingitis isthimica nodosa (3.5% increased risk)
8. Prior ectopic pregnancy (10 fold increased risk)
9. Age risk of ectopic is 3 fold greater in women of 35-44 years as
compared to 18-24 years
10. Non-white race (1.5 fold increased risk)
11. Endometriosis (1.5 fold increased risk)
12. Developmental errors
13. Overdevelopment of ovum and external migration.
Risk Factors

Pelvic inflammatory disease: Infection of the tubes is seen
as the commonest cause preceding ectopic pregnancy
and histopathological evidence of salpingitis is identified
in almost 50 per cent of tubes harbouring ectopic
Pregnancy.
Salingitis causes:-
peritubal adhesion
partial tubal lumen occlusion
intra tubal adhesion
diverticula and disturbed tubal functions
Salpingitis (PID) may be due to Chlamydia, gonococcal
infection

Smoking
Cigarette smokers who smoke more than 20 cigarettes
per day may have a relative risk of 2.5 times compared
to non-smokers
Assisted Reproduction Techniques
• There is a higher incidence of ectopic pregnancy after in
vitro fertilisation (IVF).
• These maybe the result of direct injection of embyros into the
fallopian tube, retrograde propulsion by uterine contraction, and pre-
existing tubal damage.
• The position of the catheter in the uterine cavity
and the volume of transfer medium may also be risk
factors.

Surgical Obstruction (Tubal damage)
• The fertilised ovum sometimes implants on the stump of a tube
after partial salpingectomy.
• Tubal pregnancy is also recorded after tubal ligation, and after
hysterectomy with conservation of the tube, when the operation
is performed within 48 hours of coitus.
Tubal Surgery
Ectopic pregnancy is seen following surgery for blocked tubes and
reversal of sterilisation. The risk depends on the method and site of
ligation, residual tube length and adhesions, and is also higher
following cauterisation procedures.

Salpingitis Isthimica Nodosa
This is a condition seen in chronic infections like tuberculosis and in
this the tubal epithelium extends into the myometrium and forms a
true diverticulum where the blastocyst is likely to implant.

Prior Ectopic Pregnancy
• Women who have had one ectopic pregnancy are likely to have a 10
fold increased risk of having an ectopic pregnancy again, even after a
surgical removal of tube has been done in the first instance.
• This risk is due to the fact that PID and salpingitis is a bilateral
disease and the risk factor will be same for other side even after
ectopic on one side.
Age: It has been observed that older age group women (35-44 years) are at
a 3 fold increased risk of an ectopic pregnancy as compared to younger
women (18-24 years).
Non-white race: Asians, blacks and other non-white race have a slightly
higher risk of having an ectopic pregnancy.

Endometriosis:
Endometriosis of fallopian tubes leads to
a patchy differentiation of endosalpinx into endometrium and this may
provide as a site for implantation.

Use of IUCD’s
Tubal pregnancy is more likely in women using IUCD (some studies
are contrary to this). IUCD prevent intrauterine pregnancy hence the
ratio of ectopic to intrauterine pregnancies is much higher.
Ectopic pregnancy is more likely with progesterone IUCD
rather than copper IUCD’s

Developmental Errors of the Tube :
Rarely the fallopian tube may show developmental errors such as
hypoplasia undue tortuosity, undue length, diverticula accessory lumen.
These may trap the travelling embryo and impede its progress leading to
a faulty implantation.
Overdevelopment of the Ovum-External Migration of the
Ovum :
An ovum discharged from one ovary can be fertilised in the peritoneal
cavity and cross the pelvis by a process of external migration to enter the
tube on the opposite Side.

ECTOPIC PREGNANCY IN FALLOPIAN
TUBES
Sites :
Excluding tubal ‘stump pregnancy’ the ovum implants in one of four
main positions.
• Fimbriated opening: A primary implantation at this site is unusual
(17%).
• Ampulla: This is the commonest and least dangerous site (55%).
• Isthmus: This is less common but is more dangerous because of the
likelihood of tubal rupture (25%).
• Interstitial: This is probably rare although some cases may be missed
because the pregnancy can be discharged through the uterus: it is said
to be the site in 3 per cent of all tubal pregnancies.
• Diverticulum of fallopian tube.

Reactions of the Tube
The ovum burrows into the tube as it does into the uterus and, in so
doing, induces a decidual reaction in the cells of the endosalpinx.
Reactions of the Uterus
The uterus itself is under the influence of the hormones of the corpus
luteum and of the trophoblast, so it
responds by generalised enlargement, increased vascularity, hypertrophy
of all tissues, and decidual reaction in the endometrium.
General Reactions
The woman responds to pregnancy in the usual way and may experience
nausea, vomiting, changes in appetite, and pain and tenderness in the
breasts.

Pregnancy Outcome
The tube is capable for only limited distention and is unable to provide
secure placentation also due to the unsatisfactory environment, 80 per
cent of these embryos are malformed and more than 99 per cent of these
pregnancies do not progress beyond 6 weeks. The course of pregnancy is
illustrated in the flow chart. Usually this condition will lead to a disaster
in one of the following ways:
1. Tubal abortion
2. Complete absorption
3. Complete abortion
4. Incomplete abortion
5. Missed abortion (Tubal Mole)
6. Tubal rupture
7. Chronic ectopic adnexal mass
8. Foetal survival to term.

Symptoms and Signs
1. Normal symptoms and signs of pregnancy
(amenorrhoea and uterine softening)
2. Acute Abdominal pain (dull, crampy or colicky pain)
3. Evidence of haemodynamic unstability (hypotension,
collapse, sign and symptoms of shock)
4. Adnexal mass (with or without tenderness)
5. Vaginal bleeding
6. Signs of peritoneal irritation
7. Absence of gestational sac on ultrasound with a
β−HCG of ≥2500 mIU/ml
8. Abdominal pregnancy.

Chronic Ectopic Pregnancy
This is seen when intraperitoneal bleeding from the tube is small in
amount but recurrent, as in tubal abortion and tubal mole.
Amenorrhoea :
 The patient has a short period of amenorrhoea and sometimes notices
other symptoms of early pregnancy such as nausea and breast pain.
 When a menstrual period is overdue by a few days (that is, when the
pregnancy is only 2-3 weeks old), distension or contractions of the
tube may cause aching in one or other iliac fossa.
Pain :
 sharp stabbing pain caused by choriodecidual haemorrhages or by
the escape of blood into the peritoneal cavity.
 The severity of pain depends on the amount of blood lost and there
is nearly always an associated syncope.

Vaginal Discharge :
 Slight vaginal bleeding follows lower abdominal pain and this is
easily mistaken for the late onset of a menstrual period.
 It is uterine in origin and indicates separation of the decidua.
 Once this bleeding has begun it tends to continue (if only as a brown
discharge) without intermission.
Per abdominal :Tenderness and muscle guarding over the lower
abdomen, especially on the affected side, is a striking feature.
Per vaginal :arterial pulsation in the fornix on the affected side; an
irregular and tender enlargement of the adnexum on the affected side;
and an ill-defined tender semi-solid swelling in the pouch of Douglas.
 The patient looks pale and the pulse rate is likely to be raised,
especially after an attack of pain.

Acute Clinical Picture
This is seen when there is a sudden massive intraperitoneal haemorrhage and
is typical of tubal rupture rather than tubal abortion. It may supervene on
a previously chronic picture.
 After a short period of amenorrhoea, and sometimes none, the patient is
seized with a severe lancinating pain in one iliac fossa or in the
hypogastrium.
 This is immediately followed by profound collapse marked by pallor,
low blood pressure, subnormal temperature and
a weak rapid pulse.
 Death may ensue in a very short time.

 Examination reveals obvious signs of shock and anaemia.
 The lower abdomen (and sometimes the upper as well) is usually
acutely tender.
 The presence of free blood in the peritoneal cavity may be indicated
by dullness in the flanks and intestinal distension in front.

Classical Triad
A patient with
 Amenorrohea
 pain and
 vaginal bleeding
should always be suspected to have an ectopic pregnancy. The dictum
to early diagnosis and successful management is to “THINK
ECTOPIC” but also not to
“OVER THINK ECTOPIC”.

Amenorrhea
Ectopic
Pregnancy
Abdominal pain Abnormal vaginal
bleeding

UNRUPTURED ECTOPIC PREGNANCY
 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, form
 small tender mass may be felt in the fornix

Differential Diagnosis
The picture of ectopic pregnancy is extremely variable and can mimic
any intra-abdominal disease. It should be kept in mind here that:
1. 85-90 per cent patients have abdominal pain
2. 80-85 per cent have amenorrhoea
3. 80-85 per cent have vaginal bleeding
In ectopic pregnancy the clinical diagnosis is more on symptoms
rather than signs
 The following conditions are most likely to be confused with
ectopic pregnancy
 Obstertic Disease

 Abortion of an early intrauterine pregnancy
 Abortion followed by salpingitis
 Early pregnancy with pelvic Tumours
 Retroverted gravid uterus (Threatened abortion)
 Septic abortion
B. Gynaecological diseases
 Degenerating fibroid
 Dysfunctional uterine bleeding
 Endometriosis
 Ovulation (Mittleschmerz)
 Ruptured corpus luteum
 Torsion of adnexal mass
 Acute or subacute salpingitis (including tuberculosis)
 Dysmenorrhoea

C. Non-gynaecological conditions
 Appendicitis
 Gastroenteritis
 Mesentric thrombosis
 Perforated peptic ulcear
 Renal colic
 Intraperitoneal haemorrhage from any source

Diagnosis
Mostly the diagnosis is based on the classical clinical triad Of
A. pelvic pain,
B. vaginal spotting and
C. amenorrhoea (5-9weeks).
Other classical symptoms are dizziness, pregnancy symptoms and
vaginal passage of clot/tissue. The most common classical finding is
adnexal tenderness and adnexal mass.

Tests and Aids to Diagnosis
1. Urine pregnancy test: Is positive in about 50 per cent of case.
2. β-hCG levels: In ectopic pregnancy the production of β-hCG is less
as compared to normal pregnancy.
3. Serum progesterone: Also may be helpful as an adjunct to β-hCG
in evaluating ectopic pregnancy.
4. Transvaginal ultrasound :is a valuable diagnostic tool. The
presence of an intrauterine pregnancy generally excludes ecotopic
pregnancy.

 Is more sensitive
 It detect intrauterine gestational sac at
4-5wks and at S-β hCG level as low as 1500 IU/L .
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.

Adnexal findings (Extra uterine findings)

Ring sign — a hyperechoic ring around an extrauterine gestational sac.

Hyperechoic ring around
gestational sac in adnexal region

 Human placental Lactogen (HPL)
 Pregnancy associated plasma proteins (PAPP-A).
 Pregnancy specific β (1) - glycoprotein (sp1)
 Serum IL-8, IL-6 and TNFα concentrations also increased in women
with ectopic.
 Cancer Antigen 125 (CA 125) is not specific but may indicate
pregnancy failure.
6. Pelvic Examination Under GA and Culdocentesis
(Culdotomy/Posterior Colpotomy)
Examination under GA to determine presence of an adnexal mass has
no place in modern management of ectopic pregnancy. It is potentially
dangerous and may result in rupture and haemorrhage
5. Other Placental Markers:
 Serum creatine kinase levels (CK)

8. Curettage: A diagnostic curettage will identify chorionic tissue in
the curetted material (floatation test, look under microscope for villi and
histo pathological examination).
9. Other laboratory tests: A complete blood test (haemogram and
CBS and blood grouping and typing) All other routine blood tests should
be done. A high ESR may suggest tubercular salpingitis in cases of
unruptured ectopic pregnancies.
7. Laparoscopy: A laparoscopic confirmation of
diagnosis is useful.

MANAGEMENT
Expectant
management
Medical
management
Surgical
management
Local
(USG or Laparoscopic)
-Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Actinomycin D
Systemic
-Methotrexate
Radical
Salpingectomy
Conservative
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbrial
expression

EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA
1. Tubal ectopic pregnancies only
2. Haemodynamically stable
3. Haemoperitoneum < 50ml
4. Adnexal mass of < 3.5 cm without heart beat.
5. Initial β HCG <1000 IU/L and falling in titre
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.

 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
 Follow up on day1, 4 and 7.

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.

Local injection of methotrexate

 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

SURGICALMANAGEMENT OF
ECTOPIC PREGNANCY
 ACUTE ECTOPIC PREGNANCY
 CHRONIC ECTOPIC PREGNANCY
 UNRUPTERED ECTOPIC PREGNANCY

ACUTE ECTOPIC PREGNANCY
Principle:
The principle in the management of acute ectopic is resuscitation
and laparotomy and not resuscitation followed by laparotomy.

Antishock treatment:
Antishock measures are to be taken energetically with simultaneous
preparation for urgent laparotomy.
 Ringer’s solution (crystalloid) is started, if necessary with
venesection.
 Arrangement is made for blood transfusion. Even if blood is not
available, laparotomy is to be done desperately. When the blood
is available, it is better to be transfused after the clamps are placed to
occlude the bleeding vessels on laparotomy, as it is of little help to
transfuse when the vessels are open.
 After drawing the blood samples for grouping and cross matching,
volume replacement with colloids (hemaccel) is to be done.

Laparotomy:
Indications of laparotomy are—
 Patient hemodynamically unstable
 Laparoscopy contraindicated.
 Evidence of rupture.
The principle in laparotomy is “quick in quick out”

Steps:
 Abdomen is opened by infraumbilical longitudinal incision.
 To grasp the uterus and draw it up under vision.
 The tubes and ovaries of both the sides are quickly inspected to find
out the side of rupture.
 Salpingectomy is the definitive surgery. The excised tube should be
sent for histological examination.
 The ipsilateral ovary and its vascular supply is preserved.
Oophorectomy is done only if the ovary is damaged beyond
salvage or is pathological.
 Place of subtotal hysterectomy.
In interstitial pregnancy, the rupture rent is so big and the general
condition is so low that, most often, a quick subtotal hysterectomy
is done.

CHRONIC ECTOPIC:
 All cases of chronic or suspected ectopic are to be admitted as an
emergency.
 The patient is kept under observation, investigations are done and
the patient is put up for laparotomy at the earliest convenient time.
 Usually a pelvic hematocele is found. Blood clots are removed.
 The affected tube is identified and salpingectomy is commonly done.

UNRUPTURED ECTOPIC PREGNANCY
Conservative management
may be either medical or surgical. Otherwise salpingectomy is done.
The advantages of conservative management are:
(1) Significant reduction in operative morbidity, hospital stay as well
as cost.
(2) Improved chance of subsequent intrauterine pregnancy
(3) Less risk of recurrence.

Conservative Surgery:
The procedure can be done either laparoscopically or by
microsurgical laparotomy.
Indications:
(a) Cases not fulfilling the criteria of medical therapy.
(b) Cases where b-hCG levels are not decreasing despite medical
therapy.
(c) persistent fetal cardiac activity.

1. Linear Salpingostomy:
 A longitudinal incision is made on the antimesenteric border directly
over the site of ectopic pregnancy.
 After removing the products (by fingers, scalpel handle or by
suction), the incision line is kept open to be healed later on by
secondary intention.
 Hemostasis is achieved by electrocautery or laser.
2. Linear Salpingotomy:
 The procedures are the same as those of salpingostomy.
 But the incision line is closed in two layers with 7-0 interrupted
vicryl sutures.
 This is not commonly done.

3. Segmental Resection:
This is of choice in isthmic pregnancy. End-to-end anastomosis can
be done immediately or at a later date after appropriate counseling of
the patient.
4. Fimbrial Expression:
This is ideal in cases of distal ampullary (fimbrial) pregnancy and is
done digitally.

Salpingectomy is done when
(i) whole of the affected tube is damaged,
(ii) contralateral tube is normal or
(iii) future fertility is not desired.
 Following conservative surgery or medical treatment, estimation
of β-hCG should be done weekly till the value becomes less than
5.0 mlU/mL. Additional monitoring by TVS is preferred.

Following laparoscopic salpingostomy, persistent ectopic pregnancy
ranges between 4% and 20%.
Persistent ectopic pregnancy is due to incomplete removal of
trophoblast.
It is high after fimbrial expression and in cases where initial serum β-
hCG level is greater than 3,000 IU/L. Prophylactic single dose MTX
(1 mg/kg) IM is effective to resolve the problem.

COMPLICATION of tubal ectopic pregnancy
 The most common complication is rupture with internal bleeding which
may lead to hypovolemic shock.
 Death from rupture is still the leading cause of death in the first
trimester of the pregnancy.

Rh-NEGATIVE WOMEN:
In Rh-negative women not yet sensitized to Rh antigen, anti-D
gamma globulin— 50 μg (if gestation < 12 weeks) or 300 μg (if >
12 weeks) intramuscularly is administered soon following operation
to prevent isoimmunization.

PROGNOSIS OF TUBAL PREGNANCY:
 Immediate prognosis so far as maternal mortality is concerned
has been markedly reduced (0.05%) due to early diagnosis, adequate
blood replacement and surgery even in desperately ill patient.
 An ectopic mother has got every chance of a viable birth in 1 in 3
and a chance of recurrence of ectopic in 1 in 10.
 Patient is asked to report after she misses her period to confirm
and to locate the new pregnancy.

PREVENTION OF RECURRENCE OF TUBAL
PREGNANCY:
 Incidence of subsequent intrauterine pregnancy (IUP) is 60–70%, in
women with unruptured tubal ectopic pregnancy treated by
conservative surgery.
 The incidence of subsequent ectopic pregnancy is about 10–20%
and successful conception is about 60%.
 Salpingostomy done for unruptured tubal ectopic pregnancy does
not increase the risk of ectopic pregnancy compared to
salpingectomy.
 Conservative surgery for unruptured tubal ectopic pregnancy is
beneficial.

Future advice:
Main concern is the risk of recurrence. Whenever there is
amenorrhea, pregnancy test is done and if positive, high resolution
TVS is done to know the site of pregnancy.

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 in diagnosis of ovarian
pregnancy are—
(1) Tube on the affected side must be intact.
(2) The gestation sac must be in the position of the ovary.
(3) The gestation sac is connected to the uterus by the
ovarian ligament.
(4) The ovarian tissue must be found on its wall on histological
examination.

MANAGMENT
RUPTURED UNRUPTURED
Laprotomy
oophorectomy
Ovarian wedge resection
Ovarian Cystectomy

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

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 of cervix
- Cervical submucous fibroid
- Trophoblastic tumour
- Placenta previa

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

MANAGEMENT
SURGICAL
RADICAL
SURGICAL
HYSTERECTOMY
CONSERVATIVE
D & C
Medical
-Methotrexate
- Actinomycin
- KCl

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)

MANAGEMENT
 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

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 Cervix 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.)

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
T/t : Methotrexate injection
Hysterectomy in a multiparous women.
In young pt resection & suturing of scar may be
done (high risk of rupture).

ectopic pregnancy

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