Ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tubes. Risk factors include prior tubal surgery, genital infections, infertility treatments, smoking, and more. Diagnosis involves evaluating symptoms, risk factors, ultrasound imaging, and beta-HCG levels. Treatment depends on whether the ectopic pregnancy has ruptured or not. Unruptured ectopic pregnancies can sometimes be treated with methotrexate or laparoscopic surgery, while ruptured ectopic pregnancies usually require emergency surgery.

1. Ectopic Pregnancy
Dr.Richa Katiyar
MBBS, MD (AIIMS), Fellowship ART (Germany)
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

2. Definition
“ Implantation of fertilised ovum
anywhere apart from the endometrial
cavity
“ Incidence – 19.7/ 1000 reported
pregnancies
“CDC and P, 1993
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

3. Incidence by Location
“ Natural conception
“ Tubal- 98.3%
“ Abdominal- 1.4%
“ Cervical- 0.15 %
“ Ovarian- 0.15%
“ Conception after
ART
“ Tubal- 82.2%
“ Cervical- 1.5%
“ Abdominal/ Ovarian-
4.6%
“ Heterotopic- 11.7%
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

4. Risk Factors
“ Tubal surgery
“ Genital infections
“ Infertility & treatment
“ Contraceptive use
“ Smoking
“ Prior abdominal surgery
“ Abortion
“ SIN
“ Endometriosis & leiomyoma
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

5. Diagnosis
“ History- menstrual, obstetric, current
contraceptive status, risk factors, symptoms
“ Symptoms- abd pain, abnormal uterine
bleeding, amenorrhoea, syncope,
dizziness,nausea, urge to defecate.
“ Signs- abd tenderness, peritoneal signs, Cx
excitation, adnexal mass, uterine size,
vomiting, shock
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

6. Evaluation
“RIA- gold standard
“ Urine pregnancy test- uses monoclonal
antibody against βHCG
“ βHCG- if less than 66% rise in 48 hrs-abnormal
pregnancy
“Serum Progesterone- if < 25ng/ml
“ Others- CA-125, MSAFP, CRP, Inhibin
A, Estradiol- nonspecific
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

7. Ultrasonography
pregnancy seen earliest with USG
TVS (weeks) TAUSG(weeks)
Gestational sac 4.3 4.3
Double decidual
4.4 5
outline
Yolk sac 4.6 5
Fetal pole 4.6 6
Fetal heart activity 4.6 6.5
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

8. TVS signs in ectopic
pregnancy
“ Empty uterus sign
“ Pseudogestational sac
“ Tubal or adnexal rings
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

9. β HCG and USG
Discriminatory Zone- that value
of β HCG at which all viable
pregnancies are identified
TA-USG > 6,500mIU/mL
TVS- 1,000-2,000mIU/mL
Color Doppler
Non Gravid uterus- Low peak
systolic, high resistance flow
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

10. Culdocentesis
“ For emergency situations when USG cannot be
done. Non clotting blood- ruptured ectopic
Diagnostic Laparoscopy- Gold Standard
“ Allows for diagnosis & treatment
“ For hemodynamically stable patients
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

11. Natural History of Disease
“ Tubal abortion- i.e. expulsion from
fimbria
“ Tubal rupture- occurs around 8 weeks
“Secondary abdominal pregnancy
“Secondary broad ligament pregnancy
“ Spontaneous involution
“ Chronic ectopic pregnancy (Histology-
Arias Stella reaction)
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

12. Management
Unruptured
Medical- Methotrexate
SAM - surgically
administered medical
M/M)- Mtx, KCL,
PGF2α, Glucose, NaCl,
RU 486
Surgical
Expectant
Ruptured
Hemodynamically
stable-
Laparoscopic or
laparotomy
Hemodynamically
unstable-laparotomy
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

13. Methotrexate
Is a folinic acid antagonist, inhibits syn of
purines & pyramidines
I/C- USG - dia < 4 cm,
βHCG < 15,000mIU/ml
Contra I/C- USG- dia > 4 cm,
- FHA +
“ Rupture
“ Pain > 24 hrs
“ Hepatic, renal, blood, peptic dysfunction
“ Poor pt. compliance
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

14. Single dose Mtx Protocol
“Day 0- βHCG , Blood inv
“Day 1- 50mg/ sqm i.m.
“Day 4- βHCG
“Day 7- βHCG, blood inv
“ If < 15% decline in βHCG b/w D4 and
D7, give 2nd dose MTX
“ If > 15% decline- follow with weekly
titers
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

15. Variable dose Mtx
“Mtx 1 mg/kg – i.m. on days 1,3, 5, 7
“ Leucovorin 0.1 mg/kg i.m. days 2, 4, 6, 8
“ Continue alternate day inj until βHCG
decrease >15% in 48 hrs or 4 inj of Mtx
“ Pt instructions- abstinence, no NSAIDS,
alcohol, folic acid, sunlight, TVS, PV
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

16. Surgical Treatment
“ Salpingostomy- linear incision on
antimesenteric border, ectopic flushed out,
wound healing by secondary intention
“ Salpingotomy- incision closed with 7-0 vicryl
“ Salpingectomy – if FT is diseased/
destroyed, uncontrolled bleeding, large
ectopic, complete family
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

17. Surgical M/M (2)
“Segmental resection and anastomosis
“ Milking – for fimbrial pregnancy
“ Follow up after surgery – weekly β HCG
titers till it falls very low
“ Non sensitized Rh–ve patients–give Anti D
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

18. Expectant M/M
“ For very early pregnancy with falling beta
HCG titres
“ Persistent ectopic – defined as requiring a
2nd course of therapy, when β HCG titres
increase
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

19. Chronic Ectopic
“ When the ectopic does not completely resorb
“ Persistence of chorionic villi with bleeding into
the Tubal wall/ chronic bleeding from
fimbriated end of FT
“ Signs- amenorrhoea- 5-15 weeks, pain,
bleeding, pelvic mass, USG. β HCG levels-low
or absent
“ Tt- Surgical
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com