This document provides an overview of ectopic pregnancy. It begins with an introduction defining ectopic pregnancy and reviewing anatomy and physiology related to implantation. It then covers epidemiology, risk factors, clinical presentation, diagnostic tools like beta-hCG and ultrasound, and management options including expectant, medical, and surgical approaches. The focus is on tubal ectopic pregnancy as the most common type. Key points include the discriminatory hCG level for diagnosing ectopic versus intrauterine pregnancy and criteria for medical management with methotrexate versus surgical intervention.
Successful implantation of the embryos in the uterus after IVF cycle is about 20%. It represents the bottleneck in the procedure of in vitro fertilization and embryo transfer. In this presentation we look at factors affecting implantation and how to improve it.
An update INDUCTION OF LABOR : WHO, WHEN, HOW ,WHERE & OUTCOME? DGFPublicAwareness
IOL..first mentioned HIPPOCRATES
The …NIPPLE STIMULATION OR MECHANICAL METHODS
NOW…
MOST USED
MOST EFFECTIVE INTERVENTIONS IN MODERN OBSTETRICS.
“EXACT KNOWLEDGE ON WHOM,WHEN,WHERE HOW HAS BEEN LACKING”
NO CONSENSUS BASED ON LARGE RCTs
Preterm labor is the labor that starts before the 37th completed week. In this presentation, we will discover causes, pathogenesis, diagnosis, clinical features, and management principles for preterm labor along with the most recent evidence.
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Successful implantation of the embryos in the uterus after IVF cycle is about 20%. It represents the bottleneck in the procedure of in vitro fertilization and embryo transfer. In this presentation we look at factors affecting implantation and how to improve it.
An update INDUCTION OF LABOR : WHO, WHEN, HOW ,WHERE & OUTCOME? DGFPublicAwareness
IOL..first mentioned HIPPOCRATES
The …NIPPLE STIMULATION OR MECHANICAL METHODS
NOW…
MOST USED
MOST EFFECTIVE INTERVENTIONS IN MODERN OBSTETRICS.
“EXACT KNOWLEDGE ON WHOM,WHEN,WHERE HOW HAS BEEN LACKING”
NO CONSENSUS BASED ON LARGE RCTs
Preterm labor is the labor that starts before the 37th completed week. In this presentation, we will discover causes, pathogenesis, diagnosis, clinical features, and management principles for preterm labor along with the most recent evidence.
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
This describes the ultrasound findings in various types of ectopic pregnancies. This also goes on to integrate Beta hCG into the diagnostic algorithm of ectopic pregnancy. The lecture also briefly introduces the use of progesterone levels in the diagnostic work-up of ectopic pregnancy.
A miscarriage, or spontaneous abortion, is an event that results in the loss of a fetus before 20 weeks of pregnancy. It typically happens during the first trimester, or first three months, of the pregnancy. Miscarriages can happen for a variety of medical reasons, many of which aren't within a person's control.
In ectopic pregnancy, implantation occupies at a site other than the endometrium. Ectopic pregnancies are responsible for approximately 10 percent of all maternal mortality. The prognosis for future reproduction is poor. Only one half of women having an ectopic pregnancy are eventually delivered of a liveborn infant. Various factors contribute to ectopic pregnancies, the most common being infection. Unlike intrauterine spontaneous abortions, genetic factors are not paramount in the etiology of ectopic pregnancy.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
3. Introduction
• Ectopic pregnancy is a pregnancy in which the blastocyst
implants anywhere other than the endometrial lining of the
uterine cavity.
• Ectopic- Greek= ektopos “out of place”
• Occasionally, a multifetal pregnancy contains one
conceptus with normal uterine implantation and the other
implanted ectopically is termed a heterotopic pregnancy
4. Review Of Physiology
Fertilization of the ovum normally takes place in the
ampullary portion of the fallopian tube.
The fertilized ovum is carried down the tube by ciliary and
peristaltic action.
The fertilized ovum reaches the uterine cavity 5-6 days
after ovulation.
Implantation-usually at the fundus
6. Epidemiology
• EP accounts for approximately 2% of all reported pregnancies(ACOG)
• Accounts for 3% of all pregnancy-related death (Creanga,2017)
• The prevalence of EP among women presenting to an emergency
department with first-trimester vaginal bleeding, or abdominal pain, or
both, has been reported to be as high as 18% (ACOG)
• Prevalence 2-5% in patients who utilized ART (panelli , 2015)
• In Uganda EP prevalence is 1.9% (Teziita 2013)
9. Rare sites
• Ovarian ectopic pregnancy (3.2%)
• Abdominal ectopic pregnancy (1.3%) on omentum,
liver and retroperitoneum
• Cesarean scar pregnancy (CSP)
• Cervical ectopic pregnancy (rare)
• Cornual in mullerian agenesis vs interstitial
(Cornual)
• Intraligamentous
10. Risk factors
• High risk factors
• Tubal corrective surgery
• Tubal sterilization
• Previous ectopic- 15%, 30%
• ART
• PID-9%
• Documented tubal pathology
• Other risk factors
• Endometriosis
• Fibroids
• Diethylstilbestrol (DES) exposure
• Congenital anomalies of the uterus
• Maternal age 35-44
• One third no risk factor found
Moderate risk factors
• Infertility & ovulation induction
• Contraception failure- IUDs, POPs, BTL
• Previous genital infections
• Multiple sexual partners
Slight risk factors
• Previous pelvic or abdominal surgery
• Smoking
• Douching
• Intercourse before 18 years
11. Tubal pregnancy
• Risks : Abnormal fallopian tube anatomy underlies most cases
• Prior tubal pregnancy (highest risk),
• Tubal Surgery ,
• prior tubal infection
• peritubal adhesions from salpingitis,appendicitis and endometrisosis
• Infertility and ART,
• Contraceptive failure (IUD, COCs,POP )
• smoking
12. pathogenesis
• With tubal pregnancy, because the fallopian tube lacks a submucosal
layer, the fertilized ovum promptly burrows through the epithelium.
• The zygote comes to lie near or within the muscularis, which is
invaded by rapidly proliferating trophoblast.
• Potential outcomes from this include tubal rupture, tubal abortion, or
pregnancy failure with resolution.
13. Pathophysiology
• Acute and chronic intraluminal inflammation that leads tubal damage
with subsequent fibrin deposition, and tubal scarring
• Also delayed hypersensitivity reaction from persistent chlamydial
antigen leads to slower, continued tubal damage
• Intraluminal inflammation results in arrest of embryo transport and
provide a premature preimplantation signal
• Interference of normal function of oviduct interstitial cells of Cajal
(specialized pacemaker cells) responsible for oviduct motility and egg
transport also implicated
14. Pathophysiology
• Cannabinoid receptor (CB1) also involved with oviductal transport of
embryos, mediated by endocannabinoid signaling mechanism
• Chronic exposure to nicotine can affect endocannabinoid levels and
lead to fallopian tube dysfunction
• E-cadherin, an adhesion molecule, has also been implicated
• The E-cadherin strongly localized to the tubal embryo implantation
site only in women who underwent ART
• Destruction of normal tubal anatomy & hence transport, resulting in
delayed or prevention in passage of blastocyst uterine cavity
15. Pathophysiology
• Fallopian tube lacks a submucosal layer beneath its epithelium and this
results in faster root for the blastocyst to invade & implants in the
mascularis layer hence erosion, bleeding
• Thereafter it causes acute or chronic ectopic presentation
• Aris stella reaction : hormone related atypical endometrial change
with hypertrophy and vacuolization of glandular epithelial cells. Arias
Stella Reaction is not specific for ectopic pregnancy but for
blightening of conceptus either intra uterine or extrauterine.
16. Outcomes of tubal ectopic pregnancy
• Tubal rupture(35%)- isthmic pregnancy. Intercourse or bimanual
examination can lead to rupture
• Tubal abortion (65%)- especially in cases of Fimbrial pregnancy
(distal implantation) resulting in complete absorption, complete or
incomplete detachment or tubal mole
• Secondary abdominal pregnancy if extruded pregnancy continue to
grow while still maintain trophoblastic connection to tubal epithelium
• Pregnancy failure with resolution
17. Risk factors for tubal rupture
• Ovulation induction
• Serum β-human chorionic gonadotropin (β-hCG) level > 10,000 IU/L,
• Never having used contraception
• “Ring of fire” placental blood flow within the periphery of the
complex adnexal mass
18. Clinical Presentation
• Consider ectopic as a diagnosis in any patient of reproductive age
with vaginal bleeding and or abdominal pain with x-tics
• Pregnancy not yet confirmed, conceived by IVF, unknown pregnancy
status, in rare cases hemodynamic instability and an acute abdomen
that’s is not explained by another diagnosis
• Before rupture, symptoms and signs are often subtle or absent
• Isthmic rupture usually occurs at 6–8 weeks, the ampullary one at 8–
12 weeks and the interstitial one at about 16 weeks.
19. Clinical presentations
• The classic triad is amenorrhea (80%) that is followed by pain (90%)
and vaginal bleeding(70%).
• Symptoms of early pregnancy: breast tenderness, nausea….less
• Referred pain to shoulder/neck may suggests sizable hemoperitoneum
• Symptoms of Anaemia: malaise, weakness, dizziness, sense of passing
out on standing/syncope, fainting
20. Tubal ectopic presentation
• Acute ectopic: more common
• characterized by a high serum β-hCG level at presentation, rapid
growth, higher risk of rupture & rapid diagnosis
• Chronic ectopic:
• characterized by earlier death of trophoblast with resultant negative,
low or static serum β-hCG level, complex pelvic mass, late rupture if
ever at all and requires surgical diagnosis
21. Examination findings
• General examination:
• Pallor, dehydration , early signs of pregnancy, evidence of hemodynamic
instability- hypotension, tachycardia, tachypnea, hypothermia
• Abdominal examination:
• abdominal tenderness (80%), worse on affected side
• Signs of peritoneal irritation: guarding, rigidity, rebound tenderness
• Pelvic examination:
• vaginal bleeding (70%), Bulky enlarged & soft uterus
• cervical motion tenderness, Adnexal mass (50-90%)- tender or non-
tender, Bulging posterior fornix
22. Shock index
• Shock index is the heart rate divided by systolic blood pressure
• can be used assess the severity of ruptured ectopic pregnancy, trauma
patients or hypovolemic or septic shock.
• The normal range lies between 0.5 and 0.7 for nonpregnant patients.
• A shock index > 0.85 and a systolic blood pressure < 110 mm Hg are
highly suggestive of a potentially life-threatening gynecologic
emergency, such as a ruptured ectopic pregnancy
23. Investigations
• an initial urine β-hCG assay, urinalysis, and Hb or hematocrit are
routine. ABO & Rh type and cross-matching
• CBC to assess WBC count if serious infection is a possible diagnosis.
• A positive urine pregnancy test result should prompt a serum β-hCG
assay for those with pain or bleeding
• For women with a positive pregnancy test result plus bleeding or pain,
an initial TVS is typically performed to locate the gestation
24. Beta Human Chorionic Gonadotropin
• Lower limits of detection are 20 to 25 mIU/mL for urine and ≤5
mIU/mL for serum (Greene, 2015).
• The initial β-hCG level sets expectations for anticipated TVS Finding.
• With values above a discriminatory threshold, a normal IUP is
expected to be seen within the uterus
• TVS discriminatory threshold at ≥1500 mIU/ mL, whereas others use
≥2000 mIU/mL. Connolly and associates (2013) suggested an even
higher threshold >3510 mIU/mL.
25. Discriminatory level
β-hCG level above which IUP is reliably visualized in nearly 100%
cases.
Suspect ectopic if:
Transabdominal sonography shows no IUP & hCG >6500mIU/mL or
IU/L and Transvaginal sonography with >1500mIU/mL
Follow up serial serum β-hCG : rising, falling or plateauing
26. Discriminatory zone
• Lack of IUP when β-hCG is above discriminatory zone may suggest
1. Ectopic pregnancy
2. Multiple gestation
3. Failing IUP
4. Recent completed abortion
• After serial β-hCG endometrial sampling is informative looking for
chorionic villi or sac
27. Progesterone
• Aids in ectopic pregnancy diagnosis when serum β-hCG levels and TVS
fndings are inconclusive (Stovall, 1992).
• A single value is sufcient. From studies, a serum progesterone level <6
ng/mL (<20 nmol/L) has a pooled specifcity of 98 % to predict a nonviable
pregnancy in women with a PUL (Verhaegen, 2012)
• A value >25 ng/mL suggests a live IUP and excludes ectopic pregnancy
with 97-percent sensitivity (Carson, 1993).
• With most ectopic pregnancies, progesterone levels range between 10 and
25 ng/mL and thus have limited diagnostic utility (ACOG 2019c).
28. Imaging
• TVS: accurate and initial investigation of choice
• Definitive IUP, definitive ectopic, probable IUP, Probable ectopic, PULs
• Features IUP: eccentrically placed ovoid fluid filled sac (gestational sac)
with sonolucent center >5mm in Diameter, surrounded by thick concentric
bright echogenic ring within the endometrium. It contains fetal pole, yolk
sac or both. Positive decidual sign
• Decidual sign: echogenic rim around gestational sac
• Features probably Abnormal pregnancy: irregular, crenated gestational Sac
>10mm with out fetal pole or with fetal pole but no cardiac activity
29. Placental blood flow within the periphery of
the complex adnexal mass—the ring of fire
30. Features of definitive ectopic
1. A definitive gestational sac outside the uterus (with intact well defined tubal
ring= Doughnut or Bagel sign),
2. empty uterus or centrally placed pseudogestational sac; negative Decidual sign
3. cystic or solid adnexal or tubal mass,
4. hematosalpinx,
5. free fluid or clotted blood in cul-de-sac or intraperitoneal gutters (Morrison’s
pouch),
6. Trillaminar endometrial pattern
7. Endometrial stripe thickness <8mm
8. Decidual cyst
• TVS ectopic diagnostic criteria- Rottem et al (1991)
31. Other diagnostic modalities
• Laparoscopy- “Gold standard”
• Culdocentesis-
• presence of non-clotted blood in POD, Free fuid in this pouch
typically is not seen until accumulated volumes reach 400 to 600 mL
• If sonography is unavailable, culdocentesis is a simple technique and
was used commonly in the past
• Endometrial sampling
33. Treatment
• Treatment option include: Expectant, Medical & Surgical management
• Option taken will depend on
1. Patient age
2. Future reproductive capacity
3. Nature of lesion: rupture status, location of the ectopic, & its size
4. Patients hemodynamic status
34.
35. Expectant management :
• Only observation is done in hope of spontaneous resolution.
• no treatment is given, patient is admitted & vitals are monitored. b-
hCG levels are measured every 48 hours till they become ‘N’
• Indication:
• Decreasing serial β-HCG titres
• Tubal pregnancies only
• No evidence of intraabdominal bleeding or rupture assessed by vaginal
sonography
• Diameter of the ectopic mass< 3.5 cm (Preferably < 3 cm)
• Baseline hCG < 1000 IU/L and falling , best results are obtained if b-
hCG < 200 MIU/ml.
36. When to abandoned expectant management
• Significant increase in symptoms e.g. abdominal pain
• Serum hCG start to raise or fails to decrease
• Signs of tubal rupture
• Nb; A commitment to surveillance visits and relative proximity to
emergency care are safeguards
37. Medical management
• Fails in 5-10%
• Consider if surgical risk is unacceptably high & patient meets medical
criteria
• Single outpatient therapy versus multiple inpatient therapy
• Drug of choice: methotrexate
• Other experimental agents: potassium chloride, hyperosmolar glucose,
antiprogestin mifepristone (RU 480), prostaglandins
• Tubal rupture in 5-10% requiring emergency surgery
38.
39. prerequisite for medical management
Ectopic <4cm with no cardiac activity
or <3.5cm with cardiac activity Plus
absence of free fluid in POD
Desire for future fertility
No evidence of tubal rupture
Serum hCG <3000- 15000 IU/L
Not breast feeding
Does not have coexisting intrauterine
pregnancy
Does not have known contraindication
to methotrexate
Hemodynamically stable & Has no
pelvic pain
Patient reliable & compliant: will
return for follow up
Availability of facility for follow up
care
No underlying severe medical
condition
Patient agrees to use reliable
contraception for 3-4 month post
treatment
No abnormalities of LFTs, RFTs &
CBC, showing normal liver, kidney &
bone marrow
Currently not taking NSAIDS,
diuretics, penicillin & tetracycline
group of drugs
40. Contraindications to medical management
Absolute
Active Intraabdominal bleeding
Breast feeding
Alcoholism
Immunodeficiency
Liver & renal disease
Blood dyscrasias
Acute pulmonary disease
Peptic ulcers
Folic acid supplements
Relative
Sexual intercourse
Alcohol intake
41. Methotrexate
• Folic acid antagonist which inhibit DNA synthesis in actively dividing
cells. Binds to DHFR blocking active folate formation (THF)
• Success rate 94% in 3-7 weeks
• Side effects: bone marrow suppression, elevated liver enzymes,
alopecia, rash, stomatitis, nausea & vomiting
• Best predictor of success: hCG <5000IU/L
• Multiple dose superior to single dose
• Single dose: less expensive, lower side effects (29% vs 48%), require
less extensive monitoring, does not require rescue folinic acid
42. Contraindications to methotrexate
Absolute Relative
Pregnancy & lactation
Hepatic (>2 normal transaminase) , renal
(creatinine >1.5mg/dl) & hematological
dysfunction
Over or laboratory evidence of
immunosuppression with WBC <1.5 *109
Peptic ulcer disease
Alcoholism, alcoholic liver disease or other
chronic liver disease
Active pulmonary disease
Preexisting blood dyscrasias such as bone
marrow hypoplasia, leukopenia,
thrombocytopenia & significant Anaemia
Known sensitivity to methotrexate
Gestational sac > 3.5cm
Presence of cardiac activity
strenuous exercise
43. Methotrexate protocol
Single dose Multiple/variable dose
Pretreatment investigation: CBC, LFTs, KFTs, serum hCG, ABO typing & Rh
antibody, TVS
Pretreatment prerequisites: signed informed consent by partner & patient,
weight & height measurement and calculate BSA
Mosteller formula: BSA (M2)= square root of {height (cm)* weight (kg)
divided by 3600}
Dose= IM methotrexate 50mg/m2 on day 1 (day of treatment) plus RhoGAM
300mcg with the following instructions: avoid folic acid supplements, refrain
from strenuous exercise, alcohol and intercourse. Discontinue folinic acid
Day 4 hCG measurement: baseline for subsequent measurements if >15% ok
If<15% repeat dose then begin new day 1
Day 7 hCG measurement: drop of >15% is ok. If day 7 hCG decline is < 15%
may give a second dose or if cardiac activity still present
Weekly hCG till negative results or < 15 IU/L. if weekly hCG increase or
plateau second dose may be given
Day 14 hCG measurement: if no drop in hCG surgical intervention indicated
If symptoms worsen repeat TVS for possible rupture, AST levels, CBC,
Any time perform Laparoscopy if severe abdominal pain, acute abdomen or
rupture develops
Indications: cervical ectopic &
Cornual ectopic
Dosage: every alternate day of
1mg/kg of I.M Methotrexate
alternating with 0.1mg/kg of
I.M Leucovorin calcium for a
total of 4 doses (30 hours after
MTX dose)
{MTX days 1, 3, 5 & 7 and
Leucovorin on days 2,4,6 & 8}
Follow up with CBC, LFTs,
RFTs, serum hCG at baseline,
day 1, day 3, day 5 and day 7
till hCG drops
Weekly serum hCG till
undetectable or <5IU/L
44. Other measures in ectopic management
• Blood transfusion in anemia
• Analgesics
• Antibiotics if history of infection- doxycycline recommended
• Antiglobulin D 300mg if mother Rhesus negative With incompatibility
• Slow fluid infusion
• Until resolved avoid coitus, alcohol, folic acid supplements, NSAIDS ,
Sunlight(ACOG 2019)
45. Surgical treatment
• Surgical approach: open surgery (laparotomy) or minimally invasive
(laparoscopy)
• Surgical options: Salpingostomy, salpingectomy, salpingotomy
• Indications for surgical therapy
• Candidates not suitable for medical therapy
• Failed medical therapy
• Heterotopic pregnancy with viable intrauterine pregnancy
• Hemodynamically unstable patient & requires immediate treatment
• Preoperative preparation
46. Factors influencing surgical approach
• Choice of Laparotomy vs laparoscopy influenced by:
Prior multiple surgeries
Pelvic adhesions
Skills of the surgeon & surgical staff
Availability of the equipment's
Condition of the patient
Size & location of the ectopic
47. Pre-operative preparation
• Written informed consent
• Typed & crossed matched blood (ABO &Rh)- at least 4 units
• CBC
• RhoGAM be administered if Rh negative
• If hemodynamically unstable immediate resuscitation
• Inform theatre staffs, anesthetist
• Catheterization
48. Surgical approach
Laparoscopy Laparotomy
Advantages:
fewer postoperative morbidity
less postoperative pain hence less analgesic
use
short Hospital stay
reduced complication rates such as wound
infection & adhesion formation and
faster recovery & return to normal activity
Possible laparoscopic complication
Missed diagnosis
Bleeding
Incomplete removal of ectopic pregnancy
Visceral injury
Leakage of purulent exudates
Intraabdominal abscess
Indications & advantages:
Hemodynamically unstable patient
Cervical, interstitial or abdominal ectopic
Presence of >1500mls of hemoperitoneum or
large hematoma
Underlying cardiac disease & COPD
Prior abdominal surgery
49. Surgical options
Salpingectomy- removal of affected tube Salpingotomy-
indications:
Severely damaged tube
Uncontrolled bleeding
Recurrence of ectopic on the same tube
Tubal pregnancy wit Size >5cm
Ruptured ectopic
Completed family ( future pregnancy not
desired)
Ectopic follows sterilization procedure or
tubal reconstructive surgery
Patient requests sterilization
Bleeding continues after salpingotomy
Chronic tubal pregnancy
no longer done but has same outcome
comparable to salpingostomy
Here incision sutured
Abandoned due to increased operation time
Salpingostomy
Opening of the tube
Incision over the ectopic, extract the ectopic & allow
healing without closure
10-15% risk of persistent ectopic
Segmental resection & anastomosis (partial
salpingectomy)
Used in unruptured isthmic tubal pregnancy because
salpingostomy may cause scarring & subsequent
narrowing of small isthmic lumen
50.
51.
52. Ovarian ectopic pregnancy
• Spielberg’s (1878) criteria for diagnosis of primary ovarian pregnancy
1. The tube on the affected side must be intact & distinct from ovary
2. Fetal sac must occupy the position of the ovary
3. The ovary must be connected to the uterus by the ovarian ligament
4. Ovarian tissue must be located in the sac wall
• Highest risk factors ART & IUD failure (24%)
• Clinical presentation: one third rupture may occur earlier
• Diagnosis: mostly surgical
• Treatment: mostly ovarian wedge resection or cystectomy for small lesion
and oophorectomy for larger lesions
53. Cervical ectopic pregnancy
• Cervical gland found histologically opposite placental attachment site
& part or all placenta found below the entrance of uterine vessels or
below peritoneal reflection on anterior uterus
• Incidence 1 in 8600- 1 in 12400, on rise due to ART
• Risk factor: D & C (70%), ART
• Presentation: painless PV bleeding (90%), massive hemorrhage,
• Medical treatment: offer medical if hemodynamically stable. Direct
injection of MTX or IM 50-75mg/m2 BSA into the sac +/- uterine
artery embolization +/- kill fetus in utero using 2ml of KCl
54. Cervical ectopic pregnancy
• Ultrasound criteria for cervical pregnancy (Paalman’s)
1. Echo-free uterine cavity or the presence of a false gestational sac
only
2. Hourglass uterine shape
3. Ballooned cervical canal
4. Gestational sac in the endocervix
5. Placental tissue in the cervical canal
6. Closed internal os
55.
56. Management of cervical ectopic
• Surgical option: suction curettage or hysterectomy for advanced pregnancy
& unstable
• Failure rate higher for gestational age> 9 weeks, β-hCG levels > 10,000
IU/L, crown-rump length> 10 mm, and fetal cardiac activity
• Minimizing bleeding in cervical ectopic
1. uterine artery embolization
2. Local methotrexate injection into the amnionic sac before D & C,
3. ligation of the descending branches o the uterine arteries, or
4. Cerclage placement at the internal os to compress feeding vessels
5. Placement of 26F Foley catheter post D & C
57. Abdominal ectopic pregnancy
• May be primary or secondary implantation
• Studdiford’s criteria for diagnosis of primary abdominal pregnancy
1. Presence of normal tubes & ovaries with no evidence of recent or
past pregnancy
2. No evidence of uteroperitoneal fistula
3. Presence of a pregnancy related exclusively to the peritoneal surface
and early enough to eliminate the possibility of secondary
implantation after primary tubal nidation
58. Management of abdominal ectopic
• Diagnosis is difficult due to absent or vague symptoms, uninformative
laboratory, abnormal fetal positions & uninformative sonography
• Oligohydramnios common
• MRI best
• Conservative management carries risk for massive hemorrhage, fetal
malformation & deformation (20%) hence terminate if <24 weeks
• If reached viability deliver the baby & choose your option carefully in
managing the placenta
59. Cesarean scar pregnancy
• Incidence 1 in 2000 pregnancies, increased with increases cs rates
• Pathogenesis follows similar to placenta accrete
• Diagnosis: sonographic criteria for diagnosis
1. An empty uterine cavity
2. An empty cervical canal
3. A gestational sac in the anterior part of the uterine isthmus
4. Absence of healthy myometrium between the bladder and
gestational sac
60. Management of CSP
• Treatment standards lacking
• Expectant management: 57% live birth report but risk of hemorrhage,
placenta accreta syndrome & uterine rupture
• Hysterectomy better initial option if done with family or fertility-
preserving medical & surgical options
• Uterine artery embolization to minimize bleeding, balloon tamponade
• Long term complications: uterine arteriovenous malformations
61. Interstitial pregnancy
• Implantation within the proximal part of the tube
• Occasionally carried to viability due to greater distensibility of the
myometrium covering interstitium but can cause severe bleeding due
to proximity to uterine ad ovarian vessels
• Mortality as high as 2.5%
• Also referred incorrectly to as cornual pregnancy
• Risk factors: prior ipsilateral salpingectomy
• Presentation: rupture may occur at 8-16 weeks,
62. Management interstitial ectopic
• Diagnosis difficult but the following criteria is helpful
• Empty uterus
• Gestational sac seen separate from the endometrium& > 1cm away
from the most lateral edge of the uterine cavity
• Thin, <5mm myometrial mantle surrounding the sac
• “Interstitial line sign” echogenic line extending from the sac to the
endometrial cavity
• Laparoscopic evidence of enlarged protuberance outside the round
ligament
63. Management
• Cornual wedge resection or cornuostomy with intraoperative
intramyometrial vasopressin injection to limit bleeding
• Also a role for medical management but protocol lacking
• Needs longer follow up with β-hCG due to higher initial β-hCG
• Consider caesarian for subsequent pregnancy
• Angular pregnancy sometimes carried to term displaces the round
ligament upward & outward but interstitial does not
64. Heterotropic pregnancy
• A uterine pregnancy in conjunction with an extrauterine pregnancy
• Earlier incidence 1 per 30,000 pregnancies, now 1 per 7000 following
ART & 1 per 900 with ovulation induction
• Suspect if
1. Persistent or rising hCG following D& C
2. More then one corpus luteum
3. Absence of vaginal bleeding with signs & symptoms of ectopic
pregnancy
• Mgt – surgical resection/aspiration, intralesional KCL or Glucose
(hyperosmolar) MTX avoided
65. Complication
• Usually results from late diagnosis
• Tubal rupture
• Hemorrhagic shock, DIC, death
• Surgery &Recurrent ectopic pregnancy
• Persistent trophoblast (5-15%)
• anaesthesia: infection, visceral injury
• Infertility
66. Prognosis
• Haemorrhage is the main cause of death
• >60% will become pregnant again
• Presence of contralateral tubal damage reduces chances of successful
conception
• Risk of subsequent pregnancy becoming ectopic is 10-20% compared
to 1% in general population
67. Reference
• William obstetrics 26th edition
• William gynecology 3rd edition
• Llewellyn- Jones Fundamentals of obstetrics and Gynaecology 10th
edition by Jeremy Oats and Suzanne Abraham
• ACOG :Tubal Ectopic Pregnancy 2018
• UP TO DATE
Editor's Notes
Angular pregnancy is defined as a pregnancy implanted in one of the lateral angles of the uterine cavity.
Unlike an interstitial pregnancy, which implants in the intranmural part of fallopian tube, an angular pregnancy can progress to term
If a yolk sac, embryo, or fetus is found within the uterus or within
the adnexa, a diagnosis is made. However, if no evidence of an
IUP is seen with TVS, the diagnosis is a pregnancy of unknown
location (PUL). Most PULs reflect: (1) a failing IUP, (2) recent
completed abortion, (3) early IUP, or (4) ectopic pregnancy.