The document discusses ectopic pregnancy, which occurs when a fertilized egg implants and grows outside the uterus, usually in the fallopian tubes. It notes that ectopic pregnancies have increased in incidence due to factors like PID, IUD use, and ART. The document covers the signs, symptoms, risk factors, diagnosis, and management of ectopic pregnancies. It emphasizes the importance of early diagnosis and treatment to prevent life-threatening tubal rupture.

1. Prof. M.C.BansalProf. M.C.Bansal
MBBS,MS,MICOG,FICOGMBBS,MS,MICOG,FICOG
Professor OBGYProfessor OBGY
Ex-Principal & ControllerEx-Principal & Controller
Jhalawar Medical College & HospitalJhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.Mahatma Gandhi Medical College, Jaipur.

2. DEFINITIONDEFINITION
““Any pregnancy where the fertilised ovumAny pregnancy where the fertilised ovum
gets implanted & develops in a site othergets implanted & develops in a site other
than normal uterine cavity”.than normal uterine cavity”.
It represents a serious hazard to a woman’sIt represents a serious hazard to a woman’s
health and reproductive potential, requiringhealth and reproductive potential, requiring
prompt recognition and early aggressiveprompt recognition and early aggressive
interventionintervention..

3. Is one in which fertilized ovum is implanted &
develops outside normal uterine cavity

4. IMPLANTATIONS SITESIMPLANTATIONS SITES
EXTRAUTERINE UTERINE
TUBAL 95-96%
-Ampulla 70%
-Isthmus 12%
-Infundibulum 11%
-Interstitial &
cornual 2%
OVARIAN
(1:40,000)
ABDOMINAL
(1:10,000)
-CERVICAL
(1:18,000)
-ANGULAR
-CORNUAL
-CAESAREAN
SCAR (<1)
PRIMARY SECONDARY
Intraperitoneal Extraperitoneal
Broad Ligament
(rare)

6. INCIDENCEINCIDENCE
• Increased due to PID, use of IUCD, TubalIncreased due to PID, use of IUCD, Tubal
surgeries, and Assisted reproductivesurgeries, and Assisted reproductive
techniques (ART).techniques (ART).
• Ranges from 1:25 to 1:250Ranges from 1:25 to 1:250
• Average range is 1 in 100 normalAverage range is 1 in 100 normal
pregnancies.pregnancies.
• Late marriages and late child bearing ->Late marriages and late child bearing ->
2%2%
• ART -> 5%ART -> 5%
• Recurrence rate - 15% after 1Recurrence rate - 15% after 1stst
, 25% after, 25% after
2 ectopics2 ectopics

7. ETIOLOGYETIOLOGY::
 Any factor that causes delayed transportAny factor that causes delayed transport
of the fertilised ovum through the tube.of the fertilised ovum through the tube.
 Fallopian tube favours implantation in theFallopian tube favours implantation in the
tubal mucosa itself thus giving rise to atubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.tubal ectopic pregnancy.
 These factors may beThese factors may be CongenitalCongenital oror
AcquiredAcquired..

8. ETIOLOGYETIOLOGY
 CONGENITALCONGENITAL
• Tubal HypoplasiaTubal Hypoplasia
• TortuosityTortuosity
• Congenital diverticuliCongenital diverticuli
• Accessory ostiaAccessory ostia
• Partial stenosisPartial stenosis
• ElongationElongation
• Intamural polypIntamural polyp
• Entrap the ovum on its way.Entrap the ovum on its way.

9.  ACQUIREDACQUIRED --
Pelvic Inflammatory disease (6-10 times)Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most commonChlamydia trachomatis is most common
Contraceptive FaliureContraceptive Faliure
CuT - 4%CuT - 4%
Progestasart -17%Progestasart -17%
Minipills -4-10%Minipills -4-10%
Norplant -30%Norplant -30%

10. Tubal sterilization faliure -40%Tubal sterilization faliure -40%
Depends on sterilization technique and age ofDepends on sterilization technique and age of
the patientthe patient
Bipolar Cauterisation -65%Bipolar Cauterisation -65%
Unipolar Cautery -17%Unipolar Cautery -17%
Silicon rubber band -29%Silicon rubber band -29%
Interval Salpingectomy -43%Interval Salpingectomy -43%
Postpartum Salpingectomy -20%Postpartum Salpingectomy -20%
Reversal of sterilisationReversal of sterilisation
-- Depends on method of sterilization, Site ofDepends on method of sterilization, Site of
tubal occlusion, residual tubal length.tubal occlusion, residual tubal length.
- Reanastomosis of cauterised tube -15%- Reanastomosis of cauterised tube -15%
- Reversal of Pomeroy’s - < 3%- Reversal of Pomeroy’s - < 3%

11. Tubal reconstructive surgeryTubal reconstructive surgery (4-5 times)(4-5 times)
Assisted Reproductive techniqueAssisted Reproductive technique
-- Ovulation induction, IVF-ET and GIFT (4-7%)Ovulation induction, IVF-ET and GIFT (4-7%)
- Risk of heterotopic pregnancy(1%)- Risk of heterotopic pregnancy(1%)
Previous Ectopic PregnancyPrevious Ectopic Pregnancy
-- 7-15% chances of repeat ectopic pregnancy7-15% chances of repeat ectopic pregnancy

12. Other Risk factorsOther Risk factors
 Age 35-45 yrsAge 35-45 yrs
 Previous induced abortionPrevious induced abortion
 Previous pelvic surgeriesPrevious pelvic surgeries
 Cigarette smokingCigarette smoking
 DES Exposure in UteroDES Exposure in Utero
 InfertilityInfertility
 Salpingitis Isthmica NodosaSalpingitis Isthmica Nodosa
 Genital TuberculosisGenital Tuberculosis
 Fundal Fibroid & Adenomyosis of tubeFundal Fibroid & Adenomyosis of tube
 Transperitoneal migration of ovumTransperitoneal migration of ovum

13. Iffy hypothesisIffy hypothesis ––
““Theory of reflux” menstural fluid throw theTheory of reflux” menstural fluid throw the
fertilised ovum into the tubefertilised ovum into the tube
Factors facilitating nidation of ovum in tubeFactors facilitating nidation of ovum in tube::
- Premature degeneration of zona pellucida- Premature degeneration of zona pellucida
- Increased decidual reaction- Increased decidual reaction
- Tubal endometriosis- Tubal endometriosis

14. EvolutionEvolution
 Tubal pregnancies rapidly invade theTubal pregnancies rapidly invade the
mucosa, feeding from the tubal vessels,mucosa, feeding from the tubal vessels,
which become enlarged and engorged. Thewhich become enlarged and engorged. The
segment of the affected tube is distendedsegment of the affected tube is distended
as the pregnancy grows. Possibleas the pregnancy grows. Possible
outcomes of such abnormal gestations areoutcomes of such abnormal gestations are
as follows:as follows:

15.  The pregnancy is unable to survive owingThe pregnancy is unable to survive owing
to its poor blood supply, thus resulting in ato its poor blood supply, thus resulting in a
tubaltubal abortionabortion andand resorptionresorption, or it is, or it is
expelled from the fimbriated end into theexpelled from the fimbriated end into the
abdominal cavity.abdominal cavity.
 The pregnancy continues to grow until theThe pregnancy continues to grow until the
overdistended tubeoverdistended tube rupturesruptures, with, with
resulting profuse intraperitoneal bleeding.resulting profuse intraperitoneal bleeding.
 Isthmic – 6-8 wks, Ampullary – 8-12wks,Isthmic – 6-8 wks, Ampullary – 8-12wks,
Interstitial -4 monthsInterstitial -4 months
 AbortionAbortion is common inis common in ampullaryampullary
pregnancies,pregnancies,whereaswhereas rupturerupture is inis in isthmic.isthmic.

16.  In rare instances, a tubal pregnancy willIn rare instances, a tubal pregnancy will
be expelled from the tube and seed ontobe expelled from the tube and seed onto
sites in the abdominal cavity (e.g. thesites in the abdominal cavity (e.g. the
omentum, the small or large bowel, or theomentum, the small or large bowel, or the
parietal peritoneum), and gives rise to aparietal peritoneum), and gives rise to a
viableviable abdominal pregnancyabdominal pregnancy..

18. Pictures showing
TUBAL ABORTION

19. CLINICAL APPROACHCLINICAL APPROACH
 Dignosis can be done by history, detail examinationDignosis can be done by history, detail examination
and judicious use of investigation.and judicious use of investigation.
 H/o past PID, tubal surgery,current contraceptiveH/o past PID, tubal surgery,current contraceptive
measures should be askedmeasures should be asked
 Wide spectrum of clinical presentation fromWide spectrum of clinical presentation from
asymtomatic pt to others with acute abdomen and inasymtomatic pt to others with acute abdomen and in
shock.shock.

20. ACUTE ECTOPIC PREGNANCYACUTE ECTOPIC PREGNANCY
 Classical triadClassical triad is present in 50% of pt withis present in 50% of pt with
rupture ectopic.rupture ectopic.
-- PAIN:-PAIN:- most constant feature in 95% ptmost constant feature in 95% pt
- variable in severity and nature- variable in severity and nature
-- AMENORRHOEA:-AMENORRHOEA:- 60-80% of pt60-80% of pt
- there may be delayed period or slight- there may be delayed period or slight
spotting at the time of expected menses.spotting at the time of expected menses.
-- VAGINAL BLEEDING: -VAGINAL BLEEDING: - scanty dark brownscanty dark brown
 Feeling of nausea,vomiting,fainting attack, syncopeFeeling of nausea,vomiting,fainting attack, syncope
attack(10%) due to reflex vasomotor disturbance.attack(10%) due to reflex vasomotor disturbance.

21.  O/EO/E:-:- patient is restless in agony, looks blanched,patient is restless in agony, looks blanched,
pale, sweating with cold clammy skin.pale, sweating with cold clammy skin.
Features of shock, tachycardia, hypotension.Features of shock, tachycardia, hypotension.
 P/A:P/A:-- abdomen tense, tender mostly in lowerabdomen tense, tender mostly in lower
abdomen,shifting dullness, rigidity may beabdomen,shifting dullness, rigidity may be
present.present.
 P/S:-P/S:- minimal bleeding may be presentminimal bleeding may be present
 P/V:-P/V:- uterus may be bulky, deviated to oppositeuterus may be bulky, deviated to opposite
side, fornix is tender, excitation pain onside, fornix is tender, excitation pain on
movement of cervix.movement of cervix.
POD may be full, uterus floats as if in water.POD may be full, uterus floats as if in water.

22. CHRONIC ECTOPIC PREGNANCYCHRONIC ECTOPIC PREGNANCY
 It can be diagnosed by high clinical suspicion.It can be diagnosed by high clinical suspicion.
 Patient had previous attack of acute pain fromPatient had previous attack of acute pain from
which she has recovered.which she has recovered.
 She may have amenorrhoea, vaginal bleedingShe may have amenorrhoea, vaginal bleeding
with dull pain in abdomen,and with bladder andwith dull pain in abdomen,and with bladder and
bowel complaints like dysuria,frequency orbowel complaints like dysuria,frequency or
retention of urine, rectal tenesmus.retention of urine, rectal tenesmus.

23.  O/E:-O/E:- patient look ill, varying degree of pallor,patient look ill, varying degree of pallor,
slightly raised temperature. Features of shockslightly raised temperature. Features of shock
are absent.are absent.
 P/A:-P/A:- Tenderness and muscle guard on the lowerTenderness and muscle guard on the lower
abdomen.abdomen.
A mass may be felt, irregular and tender.A mass may be felt, irregular and tender.
 P/V:-P/V:- Vaginal mucosa pale, uterus may be normalVaginal mucosa pale, uterus may be normal
in size or bulky, ill defined boggy tenderin size or bulky, ill defined boggy tender
mass may be felt in one of the fornix.mass may be felt in one of the fornix.

24. UNRUPTURED ECTOPICUNRUPTURED ECTOPIC
 High degree of suspicion & ectopic consciousHigh degree of suspicion & ectopic conscious
clinician can diagnose.clinician can diagnose.
 Diagnosed accidentally in Laparoscopy orDiagnosed accidentally in Laparoscopy or
LaparotomyLaparotomy
C/FC/F – delayed period, spotting with discomfort in– delayed period, spotting with discomfort in
lower abdomen.lower abdomen.
P/AP/A – tenderness in lower abdomen– tenderness in lower abdomen
P/VP/V – should be done gently– should be done gently
uterus is normal size, firmuterus is normal size, firm
small tender mass may be felt in the fornixsmall tender mass may be felt in the fornix

27. DIAGNOSISDIAGNOSIS
““Pregnancy in the fallopian tube is a blackPregnancy in the fallopian tube is a black
cat on a dark night. It may make itscat on a dark night. It may make its
presence felt in subtle ways and leap at youpresence felt in subtle ways and leap at you
or it may slip past unobserved. Although it isor it may slip past unobserved. Although it is
difficult to distinguish from cats of otherdifficult to distinguish from cats of other
colours in darkness, illumination clearlycolours in darkness, illumination clearly
identifies it.”identifies it.”
--Mc. Fadyen - 1981--Mc. Fadyen - 1981

28. DIAGNOSISDIAGNOSIS
 In recent years, inspite of an increase in theIn recent years, inspite of an increase in the
incidence of ectopic pregnancy there has been aincidence of ectopic pregnancy there has been a
fall in the case fatality rate.fall in the case fatality rate.
 This is due to the widespread introduction ofThis is due to the widespread introduction of
diagnostic tests and an increased awareness ofdiagnostic tests and an increased awareness of
the serious nature of this disease.the serious nature of this disease.
 This has resulted in early diagnosis and effectiveThis has resulted in early diagnosis and effective
treatment.treatment.
 Now the rate of tubal rupture is as low as 20%.Now the rate of tubal rupture is as low as 20%.

29. DIAGNOSISDIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb gm%, blood groupingBlood should be drawn for Hb gm%, blood grouping
and cross matching, DC and TWBC, BT, CT.and cross matching, DC and TWBC, BT, CT.
 Should be catheterized to know urine output.Should be catheterized to know urine output.
Bed side testBed side test:-:-
1.1. Urine pregnancy testUrine pregnancy test:- positive in 95% cases.:- positive in 95% cases.
ELISA is sensitive to 10-50 mlU/ml ofELISA is sensitive to 10-50 mlU/ml of ββ hCG andhCG and
can be detected on 24can be detected on 24thth
day after LMP.day after LMP.

30. 2.2. CuldocentesisCuldocentesis:- (70-90%):- (70-90%)
- Can be done with 16-18 G lumbar- Can be done with 16-18 G lumbar
puncture needle through posterior fornixpuncture needle through posterior fornix
into POD.into POD.
- Positive tap is 0.5ml of non clotting blood.- Positive tap is 0.5ml of non clotting blood.
 Other Investigations:-Other Investigations:-
1. Ultra Sonography-1. Ultra Sonography-
a)a) Transvaginal SonographyTransvaginal Sonography (TVS)(TVS)::
- Is more sensitive- Is more sensitive
- It detect intrauterine gestational sac at- It detect intrauterine gestational sac at
4-5wks and at S-4-5wks and at S-ββ hCG level as low as 1500hCG level as low as 1500

31.  Endometrial cavityEndometrial cavity
-A trilaminar endometial pattern seen-A trilaminar endometial pattern seen
-pseudogestational sac-pseudogestational sac
-decidual cyst may be seen-decidual cyst may be seen
PSEUDOSAC –PSEUDOSAC – All pregnancies induce an endometrialAll pregnancies induce an endometrial
decidual reaction, and sloughing of the decidua candecidual reaction, and sloughing of the decidua can
create an intracavitary fluid collection called acreate an intracavitary fluid collection called a
pseudosacpseudosac
Early gestational sacEarly gestational sac PseudosacPseudosac
locationlocation below the midline echo along thebelow the midline echo along the
burried into endometium cavity line b/wburried into endometium cavity line b/w
endometrialendometrial
layerslayers
shapeshape usually round mayusually round may
change,oviodchange,oviod
bordersborders double ring single layerdouble ring single layer

32. DECIDUAL CYSTDECIDUAL CYST
It is identified as an anechoic area lying with in theIt is identified as an anechoic area lying with in the
endometrium but remote from the canal and often atendometrium but remote from the canal and often at
the endometrial-myometrial border.the endometrial-myometrial border.
 AdenxaAdenxa
- 15-30% an extrauterine yolk sac or embryo seen- 15-30% an extrauterine yolk sac or embryo seen
in fallopian tubes confirms tubal pregnancy.in fallopian tubes confirms tubal pregnancy.
- A halo or tubal ring surrounded by a thin- A halo or tubal ring surrounded by a thin
hypoechoic area caused by subserosal edema can behypoechoic area caused by subserosal edema can be
seen.seen.
 Rectouterine cul-de-sacRectouterine cul-de-sac
Free peritonial fluid with an adnexal massFree peritonial fluid with an adnexal mass
suggestive of ectopic pregnancysuggestive of ectopic pregnancy

33. b)b) Color Doppler Sonography(TV-CDS):Color Doppler Sonography(TV-CDS):
- Improve the accuracy.- Improve the accuracy.
-Identify the placental shape-Identify the placental shape (ring-(ring-
of-fire pattern)of-fire pattern) and blood flowand blood flow
outside the uterine cavity.outside the uterine cavity.
c)c) Transabdominal Sonography:Transabdominal Sonography:
- can identify gestational sac at 5-6 wks- can identify gestational sac at 5-6 wks
- S-- S-ββ hCG level at which intrauterine gestationalhCG level at which intrauterine gestational
sac is seen by TAS is 1800 IU/L.sac is seen by TAS is 1800 IU/L.

34. USG PICTUREUSG PICTURE
1.‘Bagel’ sign – Hyperechoic ring around gestational1.‘Bagel’ sign – Hyperechoic ring around gestational
sac in adnexal regionsac in adnexal region
2. ‘Blob’ sign – Seen as small inconglomerate mass2. ‘Blob’ sign – Seen as small inconglomerate mass
next to ovary with no evidence of sac ornext to ovary with no evidence of sac or
embryo.embryo.
3. Adnexal sac with fetal pole and cardiac activity is3. Adnexal sac with fetal pole and cardiac activity is
most specific.most specific.
4. Corpus luteum is useful guide when looking for4. Corpus luteum is useful guide when looking for
EP as present in 85% cases in Ipsilateral ovary.EP as present in 85% cases in Ipsilateral ovary.

35. Hyperechoic ring aroundHyperechoic ring around
gestational sac in adnexal regiongestational sac in adnexal region

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

37. 2.2. ββ-HCG Assay--HCG Assay-
a) Singlea) Single ββ-HCG: little value-HCG: little value
b) Serialb) Serial ββ-HCG: is required when result of-HCG: is required when result of
initial USG is confusing.initial USG is confusing.
- When hCG level < 2000 IU/L doubling time- When hCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.help to predict viable Vs nonviable pregnancy.
-Rise of-Rise of ββ-HCG <66% in 48 hrs indicate-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterineectopic pregnancy or nonviable intrauterine
pregnancy .pregnancy .
Biochemical pregnancy is applied to thoseBiochemical pregnancy is applied to those
women who have twowomen who have two ββ-HCG values >10 IU/L-HCG values >10 IU/L

38. 3.3. Serum ProgesteroneSerum Progesterone ––
- level >25 ngm/ml is suggestive of normal- level >25 ngm/ml is suggestive of normal
intrauterine pregnancy.intrauterine pregnancy.
- level <15 ngm/ml is suggestive of ectopic- level <15 ngm/ml is suggestive of ectopic
pregnancy.pregnancy.
- level <5 ngm/ml indicates nonviable- level <5 ngm/ml indicates nonviable
pregnancy, irrespective of its location.pregnancy, irrespective of its location.
4.4. Diagnostic Laparoscopy (Gold standard)–Diagnostic Laparoscopy (Gold standard)–
-- Can be done only when patient isCan be done only when patient is
haemodynamically stable.haemodynamically stable.
-It confirms the diagnosis and removal of-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.ectopic mass can be done at the same time.

39. 5. Dilatation & Curettage –5. Dilatation & Curettage –
- Is recommended in suspected case of- Is recommended in suspected case of
incomplete abortion vs ectopic pregnancy.incomplete abortion vs ectopic pregnancy.
- Identification of decidua without chorionic- Identification of decidua without chorionic
villi is suggestive of extra uterine pregnancy.villi is suggestive of extra uterine pregnancy.
- “Arias-Stella” endometrial reaction is- “Arias-Stella” endometrial reaction is
suggestive but not diagnostic of ectopicsuggestive but not diagnostic of ectopic
pregnancy.pregnancy.
6. Other hormonal Tests –6. Other hormonal Tests –
- Placenta protein (PP14) decrease in EP- Placenta protein (PP14) decrease in EP
- PAPPA (Pregnancy Associated Plasma Protein A),- PAPPA (Pregnancy Associated Plasma Protein A),
PAPPC (schwangerchaft protein 1) has low valuePAPPC (schwangerchaft protein 1) has low value
in EPin EP
- CA-125, Maternal serum creatine kinase,- CA-125, Maternal serum creatine kinase,
Maternal serum AFP elevated in ectopicMaternal serum AFP elevated in ectopic
pregnancy.pregnancy.

40. SUSPECTED ECTOPIC PREGNANCYSUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positiveUrine 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

41. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
D/D of Acute EctopicD/D of Acute Ectopic
1. Rupture corpus luteum of pregnancy1. Rupture corpus luteum of pregnancy
2. Rupture of chocolate cyst2. Rupture of chocolate cyst
3. Twisted ovarian cyst3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion5. Incomplete abortion
6. Acute Appendicitis6. Acute Appendicitis
7. Perforated peptic ulcer7. Perforated peptic ulcer
8. Renal colic8. Renal colic
9. Splenic rupture9. Splenic rupture

42. D/D OF CHRONIC (SUB ACUTE) ECTOPICD/D OF CHRONIC (SUB ACUTE) ECTOPIC
1. Pelvic abscess1. Pelvic abscess
2. Pyosalpinx2. Pyosalpinx
3. Subserous uterine fibroid3. Subserous uterine fibroid
4. Salpingintis4. Salpingintis
5. Retroverted gravid uterus5. Retroverted gravid uterus
6. Appendicular lump6. Appendicular lump

43. MANAGEMENTMANAGEMENT
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

44. MANAGEMENT OF RUPTURED ECTOPICMANAGEMENT OF RUPTURED ECTOPIC
PRINCIPLE:PRINCIPLE: Resuscitation and LaparotomyResuscitation and Laparotomy
ANTI SHOCK TREATEMENT:ANTI SHOCK TREATEMENT:
- IV line made patent, crystalloid is started- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching,- Blood sample for Hb, blood grouping & cross matching,
BT, CTBT, CT
- Folley’s catheterization done- Folley’s catheterization done
- Colloids for volume replacement- Colloids for volume replacement
LAPAROTOMY:LAPAROTOMY:
Principle is ‘Quick in and Quick out’Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given- Blood transfusion to be given
- Autotransfusion only when donated blood not available.- Autotransfusion only when donated blood not available.

46. MANAGEMENT OF UNRUPTUREDMANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OPTIONS: -OPTIONS: -
 SURGICAL-SURGICAL-
 SURGICALLY ADMINISTEREDSURGICALLY ADMINISTERED
MEDICAL (SAM) TREATMENTMEDICAL (SAM) TREATMENT
 MEDICAL TREATMENTMEDICAL TREATMENT
 EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

47. EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
IDENTIFICATION CRITERIAIDENTIFICATION CRITERIA (Ylostalo et al , 1993)-(Ylostalo et al , 1993)- ::
1. Tubal ectopic pregnancies only1. Tubal ectopic pregnancies only
2. Haemodynamically stable2. Haemodynamically stable
3. Haemoperitoneum < 50ml3. Haemoperitoneum < 50ml
4. Adnexal mass of < 3.5 cm without heart beat.4. Adnexal mass of < 3.5 cm without heart beat.
5. Initial5. Initial ββ HCG <1000 IU/L and falling in titreHCG <1000 IU/L and falling in titre
SUCCESS RATESUCCESS RATE - Upto 60%- Upto 60%
PROTOCOL:PROTOCOL:
- Hospitalization with strict monitoring of clinical symptom- Hospitalization with strict monitoring of clinical symptom
- Daily Hb estimation- Daily Hb estimation
- Serum- Serum ββ HCG monitoring 3-4 days until it is <10 IU/LHCG monitoring 3-4 days until it is <10 IU/L

48. EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
 Spontaneous resolution occurs in 72%,while 28%Spontaneous resolution occurs in 72%,while 28%
will need laparoscopic salpingostomywill need laparoscopic salpingostomy
 In spontaneous resolution, it may take 4-67 daysIn spontaneous resolution, it may take 4-67 days
(mean 20 days) for the serum HCG to return to(mean 20 days) for the serum HCG to return to
non pregnant level.non pregnant level.
 The percentage fall in serum HCG by day 7 is aThe percentage fall in serum HCG by day 7 is a
better indicator than the percentage fall by day 2.better indicator than the percentage fall by day 2.
 Warning: - Tubal pregnancies have been knownWarning: - Tubal pregnancies have been known
to rupture even when Serum HCG levels are low.to rupture even when Serum HCG levels are low.

49. MEDICAL MANAGEMENTMEDICAL MANAGEMENT
Surgery is the mainstay of T/t worldwideSurgery is the mainstay of T/t worldwide
Medical M/m may be tried in selected casesMedical M/m may be tried in selected cases
CANDIDATES FOR METHOTREXATE (MTX)CANDIDATES FOR METHOTREXATE (MTX)
 Unruptured sac < 3.5cm without cardiac activityUnruptured sac < 3.5cm without cardiac activity
 S-hCG < 10,000 IU/LS-hCG < 10,000 IU/L
 Persistant Ectopic after conservative surgeryPersistant Ectopic after conservative surgery
PHYSICIAN CHECK LISTPHYSICIAN CHECK LIST
 CBC, LFT, RFT, S-hCGCBC, LFT, RFT, S-hCG
 Transvaginal USG within 48 hrsTransvaginal USG within 48 hrs
 Obtain informed consentObtain informed consent
 Anti-D Ig if pt is Rh negativeAnti-D Ig if pt is Rh negative
 Follow up on day1, 4 and 7.Follow up on day1, 4 and 7.

50. MEDICAL MANAGEMENTMEDICAL MANAGEMENT
METHOTREXATE:METHOTREXATE:
 It can be used as oral,intramuscular ,intravenous usuallyIt can be used as oral,intramuscular ,intravenous usually
along with folinic acid.along with folinic acid.
 Resolution of tubal pregnancy by systemic administration ofResolution of tubal pregnancy by systemic administration of
Methotrexate was first described by Tanaka et al (1982)Methotrexate was first described by Tanaka et al (1982)
 Mostly used for early resolution of placental tissue inMostly used for early resolution of placental tissue in
abdominal pregnancy.Can also be used for tubalabdominal pregnancy.Can also be used for tubal
pregnancy.pregnancy.
 Mechanism of action-Mechanism of action-Methotrexate is a folic acidMethotrexate is a folic acid
antagonist that inactivates the enzyme dihydrofolateantagonist that inactivates the enzyme dihydrofolate
reductase.reductase.Interferes with the DNA synthesis by inhibitingInterferes with the DNA synthesis by inhibiting
the synthesis of pyrimidines leading to trophoblastic cellthe synthesis of pyrimidines leading to trophoblastic cell
death. Auto enzymes and maternal tissues then absorb thedeath. Auto enzymes and maternal tissues then absorb the

52. Contd……Contd……
 Advantages –Advantages –
• Minimal Hospitalisation.Usually outdoorMinimal Hospitalisation.Usually outdoor
treatmenttreatment
• Quick recoveryQuick recovery
• 90% success if cases are properly selected90% success if cases are properly selected
 Disadvantages-Disadvantages-
• Side effects like GI & SkinSide effects like GI & Skin
• Monitoring is essential- Total blood count, LFTMonitoring is essential- Total blood count, LFT
& serum HCG once weekly till it becomes& serum HCG once weekly till it becomes
negativenegative

53. SURGICALLY ADMINISTERED MEDICAL TtSURGICALLY ADMINISTERED MEDICAL Tt
(SAM)(SAM)
 AimAim- trophoblastic destruction without systemic- trophoblastic destruction without systemic
side effectsside effects
 TechniqueTechnique- Injection of trophotoxic substance- Injection of trophotoxic substance
into the ectopic pregnancy sac or into theinto the ectopic pregnancy sac or into the
affected tube by-affected tube by-
• Laparoscopy orLaparoscopy or
• Ultrasonographically guidedUltrasonographically guided
 Transabdominal (Porreco, 1992)Transabdominal (Porreco, 1992)
 Transvaginal (Feichtingar, 1987)Transvaginal (Feichtingar, 1987)
• With Falloposcopic control (Kiss, 1993)With Falloposcopic control (Kiss, 1993)

54. Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2α (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
Advantage of local MTX :
- Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up: - Serum β HCG twice weekly till < 10 IU/L
- TVS weekly for 4-6 weeks
- HCG after 6 months for tubal patency
SURGICALLY ADMINISTERED MEDICAL Tt (SAM)

55. INSTRUCTION TO THE PATIENTSINSTRUCTION TO THE PATIENTS
 If T/t on outpatient basis rapid transportation shouldIf T/t on outpatient basis rapid transportation should
be availablebe available
 Refrain from alcohol, sunlight, multivitamins withRefrain from alcohol, sunlight, multivitamins with
folic acid, and sexual intercourse until S-hCG isfolic acid, and sexual intercourse until S-hCG is
negative.negative.
 Report immediately when vaginal bleeding,Report immediately when vaginal bleeding,
abdominal pain, dizziness, syncope (mild pain isabdominal pain, dizziness, syncope (mild pain is
common called separation pain or resolution pain)common called separation pain or resolution pain)
 Failure of medical therapy require retreatmentFailure of medical therapy require retreatment
 Chance of tubal rupture in 5-10 % requireChance of tubal rupture in 5-10 % require
emergency Laparotomy.emergency Laparotomy.

56. SURGICAL MANAGEMENT OF ECTOPICSURGICAL MANAGEMENT OF ECTOPIC
Conservative SurgeryConservative Surgery
Can be done Laparoscopically or by microsurgical laparotomyCan be done Laparoscopically or by microsurgical laparotomy
INDICATION:INDICATION:
- Patient desires future fertility- Patient desires future fertility
- Contralateral tube is damaged or surgically removed- Contralateral tube is damaged or surgically removed
previouslypreviously
CHOICE OF TECHNIQUE:CHOICE OF TECHNIQUE: depends ondepends on
- Location and size of gestational sac- Location and size of gestational sac
- Condition of tubes- Condition of tubes
- Accessibility- Accessibility

57. VARIOUS CONSERVATIVE SURGERIESVARIOUS CONSERVATIVE SURGERIES
1.Linear Salpingostomy1.Linear Salpingostomy::
- Indicated in unruptured ectopic <2cm in ampullary region.- Indicated in unruptured ectopic <2cm in ampullary region.
- Linear incision given on antimesentric border over the site- Linear incision given on antimesentric border over the site
and product removed by fingers, scalpel handle or gentleand product removed by fingers, scalpel handle or gentle
suction and irrigation.suction and irrigation.
- Incision line kept open (heals by secondary intention)- Incision line kept open (heals by secondary intention)
2.2. Linear Salpingotomy :Linear Salpingotomy :
-- Incision line is closed in two layers with 7-0 interruptedIncision line is closed in two layers with 7-0 interrupted
vicryl sutures.vicryl sutures.
3. Segmental Resection & Anastomosis:3. Segmental Resection & Anastomosis:
- Indicated in unruptured isthmic pregnancy- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at later- End to end anastomosis is done immediately or at later
datedate

58. 4. Milking or fimbrial Expression:4. Milking or fimbrial Expression:
-- This is ideal in distal ampullary or infundibular pregnancy.This is ideal in distal ampullary or infundibular pregnancy.
- It has got increased risk of persistent ectopic pregnancy.- It has got increased risk of persistent ectopic pregnancy.
ADVANTAGES OF LAPAROSCOPYADVANTAGES OF LAPAROSCOPY
- It helps in diagnosis, evaluation, and treatment .- It helps in diagnosis, evaluation, and treatment .
- Diagnose other causes of infertility.- Diagnose other causes of infertility.
- Decreased hospitalization, operative time, recovery period,- Decreased hospitalization, operative time, recovery period,
analgesic requirement.analgesic requirement.
Follow up after conservative surgeryFollow up after conservative surgery
- With weekly Serum- With weekly Serum ββ HCG titre till it is negative.HCG titre till it is negative.
- If titre increases methotrexate can be given.- If titre increases methotrexate can be given.

59. DEBATABLE ISSUESDEBATABLE ISSUES
?? Salpingectomy Vs SalpingostomySalpingectomy Vs Salpingostomy
?? Laparotomy Vs LaparoscopyLaparotomy Vs Laparoscopy
?? Reproductive outcomeReproductive outcome
?? Risk of Recurrent EctopicRisk of Recurrent Ectopic

60. SALPINGECTOMYSALPINGECTOMY
VSVS
SALPINGOSTOMY / SALPINGOTOMYSALPINGOSTOMY / SALPINGOTOMY
 All tubal pregnancies can be treated by partial orAll tubal pregnancies can be treated by partial or
total Salpingectomytotal Salpingectomy
 Salpingostomy / Salpingotomy is only indicatedSalpingostomy / Salpingotomy is only indicated
when:when:
1.1. The patient desires to conserve her fertilityThe patient desires to conserve her fertility
2.2. Patient is haemodinamically stablePatient is haemodinamically stable
3.3. Tubal pregnancy is accessibleTubal pregnancy is accessible
4.4. Unruptured and < 5Cm. In sizeUnruptured and < 5Cm. In size
5.5. Contralateral tube is absent or damagedContralateral tube is absent or damaged

61. CONTD……CONTD……
 The choice of surgical treatment does not influence theThe choice of surgical treatment does not influence the
post treatment fertility, but prior history of infertility ispost treatment fertility, but prior history of infertility is
associated with a marked reduction in fertility afterassociated with a marked reduction in fertility after
treatment.treatment.
 Making the choice –Making the choice – Chapron et al (1993) haveChapron et al (1993) have
described a scoring system, based on the patient’sdescribed a scoring system, based on the patient’s
previous gynaecological history and the appearance ofprevious gynaecological history and the appearance of
the pelvic organs, to decide between salpingostomy /the pelvic organs, to decide between salpingostomy /
salpingotomy and salpingectomy.salpingotomy and salpingectomy.

62. Fertility reducing factorFertility reducing factor ScoreScore
• Antecedent one Ectopic pregnancyAntecedent one Ectopic pregnancy 22
• Antecedent each furtherAntecedent each further
Ectopic pregnancyEctopic pregnancy 11
• Antecedent AdhesiolysisAntecedent Adhesiolysis 11
• Antecedent Tubal micro surgeryAntecedent Tubal micro surgery 22
• Antecedent SalpingitisAntecedent Salpingitis 11
• Solitary tubeSolitary tube 22
• Homolateral AdhesionsHomolateral Adhesions 11
• Contralateral AdhesionsContralateral Adhesions 11
• The rationale behind the scoring system is to decide the risk ofThe rationale behind the scoring system is to decide the risk of
recurrent ectopic pregnancy.recurrent ectopic pregnancy.
• Conservative surgery is indicated with a score of 1-4 only,Conservative surgery is indicated with a score of 1-4 only,
while radical treatment is to be performed if the score is 5 orwhile radical treatment is to be performed if the score is 5 or
more.more.

63. Laparotomy Vs LaparoscopyLaparotomy Vs Laparoscopy
- Laparoscopy is reserved for pt who are- Laparoscopy is reserved for pt who are
hemodynamically stable.hemodynamically stable.
- Ruptured Ectopic does not necessarily require- Ruptured Ectopic does not necessarily require
Laparotomy, but if large clots are presentLaparotomy, but if large clots are present
Laparotomy should be considered.Laparotomy should be considered.
Reproductive outcomeReproductive outcome
Is similar in pt treated with either Laparoscopy orIs similar in pt treated with either Laparoscopy or
Laparotomy.Laparotomy.
Identical rates of 40% of IUP, around 12% risk ofIdentical rates of 40% of IUP, around 12% risk of
recurrent pregnancy with either radical orrecurrent pregnancy with either radical or
conservative pregnancy.conservative pregnancy.

64. LAPAROSCOPIC SALPINGECTOMYLAPAROSCOPIC SALPINGECTOMY
It is carried out by laparoscopic scissors & diathermy or Endo-loop.It is carried out by laparoscopic scissors & diathermy or Endo-loop.
After passing a loop of No.1 catgut over the ectopic pregnancy theAfter passing a loop of No.1 catgut over the ectopic pregnancy the
stitch is tightened and then the tubal pregnancy is cut distal tostitch is tightened and then the tubal pregnancy is cut distal to
the loop stitch.the loop stitch.
The excised tissue is removed by piece meal or in tissue removal bagThe excised tissue is removed by piece meal or in tissue removal bag
LAPAROSCOPIC SALPINGOTOMYLAPAROSCOPIC SALPINGOTOMY
 To reduce blood loss, first 10-40 IU of vasopressin diluted in10 mlTo reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml
of normal saline is injected into the mesosalpinx.of normal saline is injected into the mesosalpinx.
 Then the tube is opened through an antimesenteric longitudinalThen the tube is opened through an antimesenteric longitudinal
incision over the tubal pregnancy by aincision over the tubal pregnancy by a
– CoCo22 laser (Paulson, 1992)laser (Paulson, 1992)
– Argon laser (Keckstein et al; 1992)Argon laser (Keckstein et al; 1992)
– Laparoscopic scissors and ablating the bleeding points withLaparoscopic scissors and ablating the bleeding points with
bipolar diathermy.bipolar diathermy.
– Fine diathermy knife (Lundorff, 1992)Fine diathermy knife (Lundorff, 1992)
 The tubal pregnancy is then evacuated by suction irrigation.The tubal pregnancy is then evacuated by suction irrigation.

65. PERSISTENT ECTOPIC PREGNANACYPERSISTENT ECTOPIC PREGNANACY
 This is a complication of salpingotomy / salpingostomyThis is a complication of salpingotomy / salpingostomy
when residual trophoblast continues to survive because ofwhen residual trophoblast continues to survive because of
incomplete evacuation of the ectopic pregnancy.incomplete evacuation of the ectopic pregnancy.
 Diagnosis is made because of a raised postoperativeDiagnosis is made because of a raised postoperative ββ HCGHCG
 If untreated, can cause life threatening hemorrhageIf untreated, can cause life threatening hemorrhage
Risk Factor: (seifer 1997)Risk Factor: (seifer 1997)
1. Early ectopic pregnancy (< 6 wks amenorrhoea)1. Early ectopic pregnancy (< 6 wks amenorrhoea)
2. Smaller size < 2 cm (Incomplete removal)2. Smaller size < 2 cm (Incomplete removal)
3. Preoperative high serum3. Preoperative high serum ββ HCG (> 3,000 IU/L) andHCG (> 3,000 IU/L) and
postoperative Day1 titre is < 50% of preoperative level, ispostoperative Day1 titre is < 50% of preoperative level, is
predictor of persistent EP.predictor of persistent EP.
4. Implantation medial to the salpingostomy site.4. Implantation medial to the salpingostomy site.
TreatmentTreatment
surgery
Total or partial
salpingectomy
Medical
(selected Asymptomatic pt)
MTX + Leukovorin

66. OVARIAN ECTOPIC PREGNANCYOVARIAN ECTOPIC PREGNANCY
Incidence:Incidence: 1:40,0001:40,000
Risk factor: -Risk factor: - IUCDIUCD
- Endometriosis on surface of ovary- Endometriosis on surface of ovary
Course:Course:
C/F are same as tubal pregnancyC/F are same as tubal pregnancy
ruptures within 2-3 wksruptures within 2-3 wks
Diagnosis:Diagnosis: On LaparotomyOn Laparotomy
Spiegelberg’s CriteriaSpiegelberg’s Criteria
1. Ipsilateral tube is intact and separate from sac1. Ipsilateral tube is intact and separate from sac
2. Sac occupies the position of the ovary2. Sac occupies the position of the ovary
3. Connected to uterus by ovarian ligament3. Connected to uterus by ovarian ligament
4. Ovarian tissue found on its wall on HP study4. Ovarian tissue found on its wall on HP study
M/MM/MRuptured
Laparotomy
Oophorectomy
Unruptured
Ovarian wedge resection
Ovarian Cystectomy

67. ABDOMINAL PREGNANCYABDOMINAL PREGNANCY
Incidence:Incidence: RarestRarest
MMR :MMR : 7-8 times > tubal ectopic7-8 times > tubal ectopic
90 times > Intrauterine pregnancy90 times > Intrauterine pregnancy
H/OH/O :: - Irregular bleeding, spotting- Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation,- Nausea, vomiting, flatulence, constipation,
diarrhoea, abdominal pain.diarrhoea, abdominal pain.
- Fetal movement may be painful and high in- Fetal movement may be painful and high in
the abdomenthe abdomen
O/E :O/E : - Abnormal fetal position, easy in palpating- Abnormal fetal position, easy in palpating
fetal parts.fetal parts.
- uterus palpated separate from sac- uterus palpated separate from sac
- no uterine contraction after oxytocin- no uterine contraction after oxytocin
infusioninfusion

68. Diagnosis:Diagnosis: Confirmed by USG,Confirmed by USG,
CT scan, MRI, RadiographyCT scan, MRI, Radiography
TYPETYPE
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

69. FATE OF SECONDARY ABDOMINAL PREGNANCY :FATE OF SECONDARY ABDOMINAL PREGNANCY :
1.1. Death of ovum – complete absorptionDeath of ovum – complete absorption
2. Placental separation – massive intraperitoneal2. Placental separation – massive intraperitoneal
haemorrhagehaemorrhage
3. Infection – fistulous communication with intestine,3. Infection – fistulous communication with intestine,
bladder, vagina, or umbilicusbladder, vagina, or umbilicus
4. Fetus dies (majority) – mummification, adipocere4. Fetus dies (majority) – mummification, adipocere
formation, or calcified to lithopaedionformation, or calcified to lithopaedion
5. Rarely – continue to term (malformation)5. Rarely – continue to term (malformation)
M/M:M/M:
-- Urgent Laparatomy irrespective of period of gestationUrgent Laparatomy irrespective of period of gestation
- Ideal to remove entire sac fetus, placenta, membrane- Ideal to remove entire sac fetus, placenta, membrane
- Placenta may be left if attached to vital organs, get- Placenta may be left if attached to vital organs, get
absorbed by aseptic autolysisabsorbed by aseptic autolysis

70. CERVICAL PREGNANCYCERVICAL PREGNANCY
Implantation occurs in cervical canal at or below internalImplantation occurs in cervical canal at or below internal
Os.Os.
Incidence:Incidence: 1 in 18,0001 in 18,000
RISK FACTORS :RISK FACTORS :
-- Previous induced abortionPrevious induced abortion
- Previous caesarean delivery- Previous caesarean delivery
- Asherman’s syndrome- Asherman’s syndrome
- IVF- IVF
- DES exposure- DES exposure
- Leiomyoma- Leiomyoma

71. Diagnosis:Diagnosis:
CLINICAL CRITERIACLINICAL CRITERIA:: Paulman & McEllinPaulman & McEllin
1. Uterine bleeding, no cramping, following1. Uterine bleeding, no cramping, following
amenorrhoeaamenorrhoea
2. Cervix distended,thin walled,soft consistency2. Cervix distended,thin walled,soft consistency
3. Enlarged uterine fundus may be palpated.3. Enlarged uterine fundus may be palpated.
4. Internal Os is closed4. Internal Os is closed
5. External Os is partially opened5. External Os is partially opened
USG CRITERIAUSG CRITERIA:: American Journal of O&GAmerican Journal of O&G
1. Echo-free uterine cavity/ pseudo-gestational1. Echo-free uterine cavity/ pseudo-gestational
sacsac
2. Decidual reaction2. Decidual reaction
3. Hourglass uterus with ballooned cervical canal3. Hourglass uterus with ballooned cervical canal
4. Gestational sac in endocervix4. Gestational sac in endocervix
5. Closed internal Os5. Closed internal Os
6. Placental tissue in Cx canal6. Placental tissue in Cx canal

72. HISTOPATHOLOGIC CRITERIA:HISTOPATHOLOGIC CRITERIA: Rubin’sRubin’s
1. Cervical glands present opposite to placenta1. Cervical glands present opposite to placenta
2. Placental attachment to the cervix must be2. Placental attachment to the cervix must be
below the entrance of uterine vessels .below the entrance of uterine vessels .
3. Fetal element absent from corpus uteri.3. Fetal element absent from corpus uteri.
D/d :D/d :
-- Carcinoma CxCarcinoma Cx
- Cervical submucous fibroid- Cervical submucous fibroid
- Trophoblastic tumour- Trophoblastic tumour
- Placenta previa- Placenta previa

73. MANAGEMENTMANAGEMENT
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

74. CORNUAL PREGNANCYCORNUAL PREGNANCY
SITE:SITE: Implantation occurs in rudimentary horn of BicornuateImplantation occurs in rudimentary horn of Bicornuate
uterusuterus
COURSE :COURSE :Rupture of horn occurs byRupture of horn occurs by
12-20 wks12-20 wks
D/D :D/D :
1.1. Interstitial tubal pregnancyInterstitial tubal pregnancy
2. Painful leiomyoma along with2. Painful leiomyoma along with
pregnancypregnancy
3. Ovarian tumor with pregnancy3. Ovarian tumor with pregnancy
4. Asymmetrical enlargement of uterus.4. Asymmetrical enlargement of uterus.
Implantation into cornu of normal uterus is sometimeImplantation into cornu of normal uterus is sometime
calledcalled Angular pregnancyAngular pregnancy ..
TREATEMENT:TREATEMENT:
-- Affected cornu with pregnancy is removedAffected cornu with pregnancy is removed
- Hysterectomy- Hysterectomy
- Hysteroscopically guided suction curettage if- Hysteroscopically guided suction curettage if

75. HETEROTYPIC PREGNANCYHETEROTYPIC PREGNANCY
Co-existing intrauterine and extra uterine pregnanciesCo-existing intrauterine and extra uterine pregnancies
Incidence:Incidence: 1 : 30,0001 : 30,000
With ART – 1:7000With ART – 1:7000
With ovulation induction – 1:900With ovulation induction – 1:900
More likely:More likely:
a) Ass. reproductive techniquea) Ass. reproductive technique
b) Rising HCG titre after D & Cb) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomyc) More than 1 corpus luteum at laparotomy
M/M :M/M :
Depends on the site. Ectopic site may be removedDepends on the site. Ectopic site may be removed
with continuation of IU pregnancywith continuation of IU pregnancy
(Rh Immunoglobulin:(Rh Immunoglobulin: dose of 50dose of 50 μμ gm is sufficient togm is sufficient to
prevent sensitization.)prevent sensitization.)

76. INTERSTITAL PREGNANCY (2%)INTERSTITAL PREGNANCY (2%)
It ruptures late at 3-4 months gestation.It ruptures late at 3-4 months gestation.
Fatal ruptureFatal rupture – severe bleeding as both uterine &– severe bleeding as both uterine &
ovarian artery supply.ovarian artery supply.
Early & UnrupturedEarly & Unruptured – Local or IM MTX with followup– Local or IM MTX with followup
Cornual resection by Laparotomy may be done.Cornual resection by Laparotomy may be done.
There is high risk of uterine rupture inThere is high risk of uterine rupture in
subsequent pregnancy.subsequent pregnancy.
RuptureRupture – Hysterectomy is indicated– Hysterectomy is indicated

77. CAESAREAN SCAR ECTOPIC PREGNANCYCAESAREAN SCAR ECTOPIC PREGNANCY
 Recently reportedRecently reported
 USG slows on empty uterine cavity and gestationalUSG slows on empty uterine cavity and gestational
sac attached low to the lower segment caesareansac attached low to the lower segment caesarean
scar.scar.
C/FC/F :: similar to threatened or inevitable abortionsimilar to threatened or inevitable abortion
DiagnosisDiagnosis :: Doppler imaging confirmsDoppler imaging confirms
T/t :T/t : Methotrexate injectionMethotrexate injection
Hysterectomy in a multiparous women.Hysterectomy in a multiparous women.
In young pt resection & suturing of scar may beIn young pt resection & suturing of scar may be
done (high risk of rupture).done (high risk of rupture).

78. OTHER RARE TYPESOTHER RARE TYPES
1. Multiple Ectopic pregnancy1. Multiple Ectopic pregnancy
2. Pregnancy after hysterectomy2. Pregnancy after hysterectomy
3. Primary splenic pregnancy3. Primary splenic pregnancy
4. Primary hepatic pregnancy4. Primary hepatic pregnancy
5. Rectroperitoneal pregnancy5. Rectroperitoneal pregnancy
6. Diaphragmatic pregnancy6. Diaphragmatic pregnancy
MORTALITY : In general population is 10-15% mainlyMORTALITY : In general population is 10-15% mainly
due to haemorrhage.due to haemorrhage.

79. SUMMARY - KEY POINTSSUMMARY - KEY POINTS
 Incidence of ectopic pregnancy is rising while maternalIncidence of ectopic pregnancy is rising while maternal
mortality from it is falling.mortality from it is falling.
 Ectopic pregnancy can be diagnosed early (before it ruptures)Ectopic pregnancy can be diagnosed early (before it ruptures)
with recent advances in Immunoassay to detect S-hCG , highwith recent advances in Immunoassay to detect S-hCG , high
resolution USG, and dignostic Laparoscopy.resolution USG, and dignostic Laparoscopy.
 There has been shift in the M/m from ablative surgery toThere has been shift in the M/m from ablative surgery to
conservative fertility preserving therapyconservative fertility preserving therapy
 Laparotomy should be done when in doubtLaparotomy should be done when in doubt
 The choice today is Laparoscopic treatment of unrupturedThe choice today is Laparoscopic treatment of unruptured
ectopic pregnancy.ectopic pregnancy.
 Careful monitoring and proper counselling of patients isCareful monitoring and proper counselling of patients is
mandatory.mandatory.