The document is a tutorial presentation on ectopic pregnancy, including its definition, epidemiology, etiology, clinical approaches, diagnosis, differential diagnoses, and management strategies. Ectopic pregnancy is described as a significant public health issue in sub-Saharan Africa, posing serious risks to women's health and reproductive potential. The presentation emphasizes the importance of early recognition and intervention to reduce morbidity and mortality associated with ectopic pregnancies.

1. USLTH PCMH, OBGYN RESIDENTS’ WEEKLY
TUTORIALS
TOPIC: ECTOPIC PREGNANCY
PRESENTER: DR. SAM ISSA BANGURA
SUPERVISOR: DR.ROSSETTA COLE
CONSULTANT: DR. MICHAEL EZEANOCHIE
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31 JULY 2024 JULY 31 2024

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PRESENTATION OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• ETIOLOGY
• CLINICAL APPROACH
• DIADNOSIS
• DIFFERENTIAL DIAGNOSIS
• MANAGEMENT
• SUMMARY
• REFERENCES
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Introduction
Ectopic pregnancy is any pregnancy where the
fertilised ovum gets implanted & develops in a site
other than normal uterine cavity.
Ectopic pregnancy is a more appropriate term than
extrauterine pregnancy because pregnancy may be
located in the uterus and yet be ectopic.
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 Ectopic pregnancy is a common gynaecological
emergency in Sub- Saharan Africa and has become a
public health problem of epidemic proportion.
 It still continue to exert it toll on human reproduction
contributing to increasing morbidity and mortality
 It represents a serious hazard to a woman’s health and
reproductive potential, requiring prompt recognition and
early aggressive intervention.
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one in which fertilized ovum is implanted &
velops outside normal uterine cavity
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IMPLANTATIONS SITES
EXTRAUTERINE UTERINE
OVARIAN ABDOMINAL
PRIMARY SECONDARY
Intraperitoneal Extraperitoneal
Broad Ligament
(rare)
1. Cervical <1
2. Angular
3. Caesarean scar
4. Cornual
TUBAL 95-96%
• Ampulla 70%
• Isthmus 25%
• Interstistial 18%
• Infundibulum2%
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Epidemiology
• The occurrence of ectopic pregnancy is reported to
be at a rate of 1 – 2% of pregnancies and can occur
in any sexually active fertile woman.
• The incidence in developing countries is high
compared to developed countries.
• It is 1 in 24 – 44 deliveries in Ghana, 1 in 37 – 43
deliveries in Nigeria, 1 in 241 deliveries is USA
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• The increased in incidence in the past few decades is thought to be due
to:
(i) Rise in the incidence of STIs and salpingitis.
(ii) Rise in the incidence of pregnancy following ART procedures.
(iii) IUCD use
(iv) Increased tubal surgery (either sterilization or tuboplasty procedure).
(v) Early detection of cases that were otherwise destined to undergo
spontaneous absorption.
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• While there has been about fourfold increase in
incidence over the couple of decades, but the mortality
has been slashed down by 80%:
 Recognition of high-risk cases
 Early diagnosis (even before rupture) with the use of
TVS, serum b-hCG and laparoscopy have significantly
improved the management of ectopic pregnancy.
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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.
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ETIOLOGY
CONGENITAL
– Tubal Hypoplasia
– Tortuosity
– Congenital diverticuli
– Accessory ostia
– Partial stenosis
– Elongation
– Intramural polyp Entrap the ovum on its way.
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ETIOLOGY
ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
Possible mechanisms:
(a) Loss of cilia of the lining epithelium and impairment of muscular peristalsis.
(b) Narrowing of the tubal lumen.
(c) Formation of pockets due to adhesions between mucosal folds.
(d) Peritubal adhesions resulting in kinking and angulation of the tube
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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
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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
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MORBID ANATOMY
Changes
– Implantation- intercolumnar or between two mucosal folds
– Decidual change at the site of implantation is minimal.
– Muscle hyperplasia & Hypertrophy minimal.
– Intramuscular implantation
– Pseudo capsule formation
– Trophoblast invasion-erosion of blood vessel
– The stretching of the peritoneum over the site of implantation results in episodic pain.
– The trophoblasts of ectopic pregnancy do not usually grow as that of a normal
pregnancy. As a result, hCG production is inadequate compared to a normal
pregnancy.
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Mode of termination of ectopic.
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.
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Arias – Stella Reaction
This is characterized by a typical adenomatous change of the endometrial glands.
Intraluminal budding together with typical cell changes:
– Loss of polarity
– Pleomorphism
– Hyperchromatic nuclei
– Vacuolated cytoplasm
– Intraluminal budding
This is strikingly due to progesterone influence. It is present in about 10– 15% cases of
ectopic pregnancy
Though seen in Ectopic Pregnancy but is not specific for it and can also be seen in
uterine pregnancy
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Pictures showing TUBAL ABORTION
Ruptured ectopic
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CLINICAL APPROACH
• Diagnosis 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 asymptomatic
patient to others with acute abdomen and in shock.
• Clinically three distinct types are described:
Acute, unruptured, and subacute (chronic or old)
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ACUTE ECTOPIC PREGNANCY
It is associated with cases of tubal rupture or tubal abortion with massive
intraperitoneal hemorrhage.
• 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 common feature. Shoulder tip pain.
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• 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.
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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 amenorrhea, vaginal bleeding with dull pain
in abdomen and with bladder and bowel complaints like
dysuria, frequency or retention of urine, rectal tenesmus.
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• 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.
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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
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DIAGNOSIS
• In recent years, in spite 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%.
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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.
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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 .
The diagnostic features are:
(1) Absence of intrauterine pregnancy with a positive pregnancy test.
(2) Fluid (echogenic) in the pouch of Douglas.
(3) Adnexal mass clearly separated from the ovary.
(4) Rarely cardiac motion may be seen in an unruptured tubal ectopic pregnancy.
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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
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DECIDUAL CYST
It is identified as an anechoic area lying within 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 peritoneal fluid with an adnexal mass suggestive of ectopic
pregnancy
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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 6000 IU/L.
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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.
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Hyperechoic ring around
gestational sac in adnexal region
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Ring sign — a hyperechoic ring around an
extrauterine gestational sac.
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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
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Discriminatory zone
 The lowest level of serum b-hCG at which a gestational sac is
consistently visible using TVS (discriminatory zone) is 1,500
IU/L.
 The corresponding value of serum b-hCG for TAS is 6,000
IU/L.
a. When the b-hCG value is greater than 1,500 IU/L and there is
an empty uterine cavity, ectopic pregnancy is more likely.
b. Failure to double the value of b-hCG by 48 hours along with
an empty uterus is very much suggestive.
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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.
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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
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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
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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
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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
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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.
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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
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MANAGEMENT OF UNRUPTURED ECTOPIC
PREGNANCY
OPTIONS: -
• SURGICAL-
• SURGICALLY ADMINISTERED
MEDICAL (SAM) TREATMENT
• MEDICAL TREATMENT
• EXPECTANT MANAGEMENT
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EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA:
1. Tubal ectopic pregnancies only
2. Hemodynamically 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%
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EXPECTANT MANAGEMENT
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.
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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.
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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
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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.
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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
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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
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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)
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Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
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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
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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
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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
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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
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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.
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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/M
Ruptured
Laparotomy
Oophorectomy
Unruptured
Ovarian wedge resection
Ovarian Cystectomy
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ABDOMINAL PREGNANCY
Incidence: Rarest
MMR : 7-8 times > tubal ectopic
90 times > Intrauterine pregnancy
H/O : - Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation, diarrhea,
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
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Diagnosis: Confirmed by USG,
CT scan, MRI, Radiography
TYPE
Primary Secondary
Studiford’s criteria
. Both tubes and ovaries normal
. Absence of Uteroperitonal fistula
. 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
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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
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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
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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
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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
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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
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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
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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
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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.)
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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
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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).
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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.
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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.
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THANK YOU FOR
LISTENING
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REFERENCES
• TEXTBOOK OF DC DUTTA’S OBSTETRIC
• COMPREHENSIVE GYNAECOLOGY IN THE
TROPICS
• UP TO DATE
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