Management of non tubal ectopic pregnancy

Management of Non tubal Ectopic
pregnancy
Berhanu Mohammed
Ovarian

Contents
1. Introduction
2. Interstitial Pregnancy
3. Abdominal Pregnancy
4. Ovarian EP
5. Cervical EP
6. Heterotopic pregnancy
7. cesarean scar ectopic pregnancy (CSP)
8. PUL
9. References

Introduction
• Derived from the Greek word ektopos, meaning out of
place
• Ectopic pregnancies were initially described in the
10th century (Albucasis in 936-1013 A.D.)
• In 1693 Boucier noted the presence of ectopic
pregnancy at postmortem examination of an executed
prisoner
• A more complete report was made in 1731
• for a long time were universally fatal events for the
mother

….cnt’d
• Nontubal ectopic pregnancies accounts for only 5 % of
all EPS, yet they account for 20 % of the fatalities
• Traditionally diagnosed late and have been associated
with significant morbidity and mortality
• Over recent years increase in the early diagnosis of
non-tubal ectopic pregnancies
• Management has now progressed from open surgical
management to the use of minimal access techniques
and the exploration of medical and conservative
treatments either alone or as adjuvant therapies

Sites of implantation of 1800 ectopic pregnancies from a 10-year population-
based study. (Data from Callen, 2000; Bouyer and colleagues, 2003.)

Aetiology
• Unclear
• Many theories

Presentation
• Acute
• Silent
• Subacute

Diagnosis
• Short period of Ammenorrhea , pain and vaginal
bleeding(slight, brownish, continouse , clots rarely)
• Pain in epigastrium and shoulder(acute bleeding)
• History of PID, Use of IUD
• History of sterility
• Palpable mass , tenderness in the pelvis, enlarged
ux
• Cervical motion tenderness

…cnt’d
Signs
• Adler’s sign-fixed abdominal
tenderness
• Bath room sign-pain on
defaecation or perineal discomfort
manifest as inability to sit square
on hard seat
• Cullen’s sign-periumblical
ecchymosis from intraperitoneal
bleeding
• Davis’s sign- subdiaphragmatic
space – shoulder tip pain
• Murphy’s sign- blood along the
urachus to umbilicus bruise

…cnt’d
Lab findings
• Hgb /Hct is falling
• HCG test -75% positive
• Leucocytes <20,000, mostly only slight
increased but ESR rises
Currettage
X-ray

…cnt’d
ULTRASONOGRAPHY
• At defined hCG titers, ultrasonography is excellent
for identifying an IUP.
• Transabdominal ultrasound : detects GS by 5 – 6 wks
Detects fetal heart activity at 7 wks of gestation.
Detects IUP at β-hCG of 6000 to 6500 mIU/ml
• Transvaginal ultrasound : detects IUP 1 wk earlier
than transabdominal U/S. It diagnosis IUP in the
range of 1500 to 2000 mIU/ml hCG.

…cnt’d
Culdocentesis
• Positive tap - aspiration of
at least 0.5ml non clotting
blood that has a Hct of
15%
– obtained in 70-90% of
patients with EP.
• Negative tap - aspiration
of at least 0.5ml of serous
fluid.
• Nondiagnostic - Failure to
aspirate any fluid -the
needle is not in the cul-de-
sac

…cnt’d
Laparascopy
• Is the gold standard for diagnosis
• Used when diagnosis is uncertain
• Direct visualization of pelvic organs offer a
reliable diagnosis.
• Compared with laparotomy, laparoscopy is
more cost - effective

Interstitial Pregnancy
• The proximal portion that lies within the muscular wall
of the uterus. It is 0.7 mm wide and approximately 1–2
cm long
• Rare condition,
• Accounts for no more than 2% to 4% of all tubal
pregnancies, a mortality rate in the range of 2.0–2.5%.
• Occurs once every 2,500 to 5,000 live births
• Gestational sac is better protected in the interstitial
than in other portions of the tube
• symptoms of interstitial ectopic pregnancies may
manifest later (>12 gestational weeks)----myometrial
distensibility

…cnt’d
• Pelvic pain and vaginal spotting are common
early symptoms
• Most of the same risk factors for interstitial
pregnancy are similar to those for ectopic
pregnancy in general
• PID, previous pelvic surgery and the use of
ART
• Ipsilateral salpingectomy is unique risk factor,
occurring in 37.5% of patients

Diagnosis
• critical evaluation of all the criteria used for
other types of tubal pregnancy
• includes acute abdominal pain, intraperitoneal
bleeding, a low hematocrit, and a positive
serum or urine pregnancy test
• sensitive Î²-hCG immunoassay and vaginal
ultrasonography
• Asymmetry of the uterus

Timor-Tritsch and colleagues established
TVU criteria
• An empty uterine cavity,
• A chorionic sac seen separately and >1 cm from the
most lateral edge of the uterine cavity, and
• A thick myometrial layer surrounding the chorionic
sac.
• "Interstitial line sign“ echogenic line extending from
endometrial cavity into the cornual region & abutting
the gestational sac
Specificity (88% to 93%), sensitivity (only about 40%)
for the diagnosis of interstitial pregnancy

Treatment
• Traditionally, the treatment of cornual
pregnancy has been hysterectomy or cornual
resection at laparotomy
• Depends on the extent of trauma that has
occurred in the uterine wall and on the
interest of the patient in preserving her
fertility

…cnt’d
Surgical
Laparotomy
• Hysterectomy
• Cornual resection
• Uterine artery ligation and repair of ruptured uterine
cornu
Laparoscopic procedures
• Cornual resection
• Salpingostomy-
• Cornual resection and salpingectomy

…cnt’d
Hysteroscopic procedures
• Hysteroscopic endometrial resection under
laparoscopic control
• Hysteroscopic cornual evacuation aided by polyp
forceps under ultrasound (USS) or laparoscopic
guidance
Medical
• Systemic methotrexate
• USS guided methotrexate
• Laparoscopic guided methotrexate/potassium chloride
• Systemic methotrexate followed by selective uterine
artery embolisation

Key points for medical treatment
• Haemodynamic stability is an essential
prerequisite for medical management.
• There should be no signs of rupture.
• The woman should be well motivated to
attend for regular (perhaps prolonged) follow-
up.
• There should be no medical contraindications
to methotrexate.

Future pregnancy
• Uterine rupture
• C/S
• Rate of recurrence
• In conservatively treated cases

Abdominal pregnancies
• Very Rare,0.9- 1% all EP
• Ranging from 1 in 3,371 deliveries to greater than
1 in 10,200 deliveries
• Maternal mortality risk 7.7 times tubal EP, 90x
greater than IUP
– 5.1 per 1000 cases
• Classified as primary or secondary
• Most are secondary, the result of early tubal
abortion, rupture or ovarian abortion with
secondary implantation of the pregnancy into the
peritoneal cavity

Primary Abdominal pregnancy
• rare event, first true primary peritoneal pregnancy
described by Gallabin, 1903
Must meet the three criteria defined by Studdiford in 1942:
1. Both tubes and ovaries must be in normal condition with
no evidence of recent or remote injury.
2. No evidence of uteroperitoneal fistula should be found.
3. The pregnancy must be related exclusively to the
peritoneal surface and
4. early enough to eliminate the possibility that it is a
secondary implantation following a primary implantation
in the tube.
• ???? Helpful diagnosis or management.

Dx
Made usually intraoperatively (hx, P/E and Ix)
• Recurrent abdominal discomfort,
• Fetal movement beneath the abdominal wall, and
• Presence of fetal movements high in the upper
abdomen
• Cessation of fetal movement,
• Vomiting late in pregnancy,
• Fetal malposition,
• Closed and uneffaced cervix, or the
• Failure of oxytocin to stimulate the gestational mass

Dx …cnt’d
• Fetal small parts in the lateral position overlying the
maternal spine was first noted by Weinberg and
Sherwin in 1956
• A plain abdominal X-ray may reveal the fetus to be
separate from the uterus and the finding of bowel
shadows amid the fetus is said to be pathonomonic
• Ultrasound can usually identify an abdominal gestation
as separate from the nonpregnant uterus
• MRI, if U/S is unequivocal
• serum a-fetoprotein

characteristics of abdominal
pregnancy on ultrasound
• Presence of a fetus outside the uterus
• Absence of the uterine wall between the bladder and the
fetus
• Extrauterine location of the placenta
• poor visualization of the placenta
• pseudo-placenta previa appearance
• Oligohydramnios
• Fetal parts adjacent to the mother’s abdominal contents
• Abnormal fetal presentation, and
• The absence of amniotic fluid between the fetus and
placenta

…cnt’d
• MRI is becoming the investigation of choice in
suspected abdominal pregnancy
• Hysterosalpingography is reserved for cases
where fetal death has been confirmed

Complications
• Massive bleeding, Anemia
• Pelvic abscess
• Peritonitis
• Sepsis
• DIC
• Pulmonary embolism
• Massive rectal bleeding or
rectal passage of fetal bones
• MM 4% to 29%
• Fetal mortality is notoriously
high, ranging from 75% to 95%
of all cases

When to operate
• Immediate laparotomy before viability
• Between the 28th and 34th weeks controversial
with alive fetuse
• For dead fetus waiting for 8weeks if there is no
evidence of infection
• In cases with a live foetus near to obstetric
viability, to delay the operation in the hope of
obtaining a live baby
• The patient must be hospitalized as soon as the
diagnosis is suspected

Prerequisites for conservative
approach
• absence of fetal malformation;
• absence of maternal or fetal decompensation;
• continued surveillance of fetal well-being;
• placental implantation low in the abdomen, far
away from the liver or spleen;
• adequate amniotic fluid;
• continuous hospitalization in an appropriate
facility; and
• informed consent from the patient

Management
• Preoperative preparation include
• an adequate supply of compatible blood and blood
products
• appropriate intravenous infusion lines that can
deliver large amounts of fluid quickly
• surgical team should be standing by (bowel, vascular,
or genitourinary)
• Anti-shock trousers and autotransfusion apparatus
should also be available
• bowel preparation and prophylactic antibiotic
administration in preparation for surgery

Placenta management
• Still controversial
• Most clinicians believe the best treatment is
• to clamp the cord
• to leave the placenta in situ, and
• to close the abdomen, but to allow retroperitoneal drainage if
possible
• Can be removed after complete cessation of function is
demonstrated by quantitative Î²-hCG titers
• Removed during laparotomy only if it is accessible and if
its removal can be accomplished without excessive blood
loss
• MTX

Factors that favour primary removal
• Early gestation and therefore a smaller and less
vascular placenta;
• placental invasion that is confined to removable
organs such as tube, ovary and uterus;
• foetal death with probable thrombosis of most of the
placental vessels;
• attachment of the placenta to the broad ligament;
and
• severity of any haemorrhage present and the
effectiveness of haemostatic measures already
applied

Ovarian Ectopic Pregnancy
• 1 in 10 000 pregnancies; they account for 0·5–
3 per cent of all ectopic pregnancies
• may be primary or secondary and diagnosis is
seldom made prior to surgery
• associated with neither PID nor infertility
• DDX (1) haemorrhagic ovarian cyst, and (2)
ruptured corpus luteum cyst

…cnt’d
The etiology and pathogenesis of OP two seem to
be the most responsible causes:
• primary OP with intra-follicle fertilization
• retrograde flow in the fallopian tube of the
fertilized ovum released on to the ovary
Clinical picture
• same as that of a tubal ectopic, but
• degree of haemorrhage and haemoperitoneum
more sever

Diagnosis
Based on Spiegelberg’s criteria formulated in 1878.
The criterion states that:
(1) The tube on the affected side must be intact.
(2) The fetal sac must occupy the position of the
ovary.
(3) The ovary must be connected to the uterus by
the ovarian ligament.
(4) Definite ovarian tissue must be found in the sac
wall.

…cnt’d
• Most difficult
• does not always present by the triad of period of
amenorrhoea, per vaginal bleeding and pelvic
pain/tenderness/ cervical excitation
• persistent pelvic pain alone, a symptom not
always easily related to its cause, is the most
frequent clinical manifestation of an ovarian
gestation
• Haemothorax (4 case reports RT side
haemothorax )
• ovarian pregnancy does not recur

Management
Conservative Mx: Important because these patients are
usually young, healthy, fertile & desire future
childbearing.
Medical Management
Systemic methotrexate
• unruptured ovarian pregnancy
• no significant hemoperitoneum
• hemodynamically stable patient
Localized surgical resection
• ovarian wedge resection or
• cystectomy

…cnt’d
Laparoscopy : used to resect or perform laser
ablation of ovarian pregnancies
Definitive Mx : Oopherectomy
indications :
1. Technical difficulties due to increased
vascularity & fragility
2. Rarely profuse/uncontrolled hemorrhage

Cervical Ectopic Pregnancy
• Rare, less than 1% of all ectopic gestations
• Have an estimated incidence of one in 2500 to
one in 18,000 pregnancies.
• Passage of a blastocyst through the uterine
cavity and its subsequent implantation and
growth within the mucosa that lines the
endocervical canal
• Dx frequently delayed and is often made
intraoperatively in the presence of extensive
hemorrhage, necessitating an emergency
hysterectomy in about 50% of cases

The Aetiology is unknown,
• likely to result from a combination of factors
including local cervical pathology.
• Predisposing factors include
• previous instrumentation
• anatomic anomalies (myomas, synechiae),
• Intrauterine device (IUD) use,
• in vitro fertilisation (IVF 3.7%), and
• diethylstilbestrol exposure, although these are
not strong associations.

Presentation
• Presenting symptoms generally include
• Vaginal bleeding which is usually painless but
may be coupled with
• Abdominal pain and urinary problems,
particularly in more advanced pregnancies
• Examination findings at admission vary,
• Enlarged, Globular or
• Distended cervix, which is often associated with
dilatation of the external os.

Rubin's criteria Dx cv preg
• close attachment of the placenta to the cervix,
cervical glands present opposite the
implantation site,
• placental location below uterine vessel
insertion or below anterior and posterior
reflections of the visceral peritoneum of the
uterus, and
• No fetal elements in the uterine corpus

Clinical criteria
• Uterine bleeding without cramping pain following
a period of amenorrhea
• A soft, enlarged cervix equal to or larger than the
fundus
• The presence of a closed internal os,
• No chorionic tissue found on curettage of the
endometrial cavity, and
• Dilation of the external os

DDX
• A cervical ectopic pregnancy and
• Intrauterine pregnancies with a low
implantation site (isthmico-cervical
pregnancy) or in the process of spontaneous
expulsion
• Incomplete Abortion

…DDX
• cardiac activity is often seen in a cervical
pregnancy with a visible embryo, but not in an
incomplete abortion
• the gestational sac of a cervical pregnancy has
regular contours, while an incomplete abortion
sac often has irregular contours that may change
shape during the scan
• the cervical os is typically closed in a cervical
pregnancy, but is open in an incomplete abortion

MX
• In the past hysterectomy often performed
• A range of conservative (uterus preserving)
treatment options have been suggested and may
be broadly categorised as:
• Cerclage
• Curettage and tamponade,
• Reduction of blood supply, Arterial Embolization
• Excision of trophoblastic tissue,
• intra amniotic fetocide and systemic chemotherapy
(Medical Management)

…cnt’d
• Dilatation and curettage, with uterine artery
ligation or embolisation, or cervical balloon
tamponade to prevent blood loss
– had a high failure rate (hysterectomy required in
22% of patients)
– their role is now limited mainly to patients with
life-threatening bleeding

…cnt’d
• Local injection of the ectopic pregnancy with
potassium chloride or methotrexate became
the favoured technique in the late 1990s.
• The success rates were high (close to 100%)
• Systemic side-effects and complication rates
low

Heterotopic Pregnancy
• Coexistence of an IUP & ectopic pregnancy.
• The incidence is estimated to be 1: 30,000 of
spontaneous pregnancy.
• With the use of ovulation induction & ART, the incidence
is higher.
• Potentially a fatal condition, because
• diagnosis is often missed
• 50 % of cases present late with rupture
• associated with profuse hemorrhage

…cnt’d
Diagnosis : Criteria that aid diagnosis
• Uterine size compatible or more with date
• With persistent or rising β-hCG after D & C or
spontaneous abortion
• Presence of two corpus luteum
• Absence of vaginal bleeding with sign &
symptoms of an ectopic pregnancy
• After ART
• Ultrasonographic evidence of IUP & extra
uterine pregnancy

…cnt’d
Management.
• Systemic MTX is contraindicated in the presence of
IUP.
• LAPAROSCOPY: 60 % of patients with viable IUP at
the time of surgery had favorable outcome.
• LAPAROTOMY: Indicated in patients with
• hermodynamically unstable
• an interstitial- IUP is present
• Local injection of KCl into the extra uterine
gestation

cesarean scar ectopic pregnancy (CSP)
• Pregnancy implanted in a cesarean section
scar
• Rarest forms of ectopic pregnancy, 6 percent
of ectopic pregnancies among women with a
prior cesarean delivery
• Increased report
• Increase in c/s rate
• Better diagnostic accuracy of this condition

Strict imaging criteria to establish the
diagnosis:
• Empty uterus,
• Empty cervical canal,
• Development of the sac
in the anterior part of
isthmic portion, and
• A diminished
myometrial layer
between the bladder
and the sac

Management
• wedge resection of the ectopic pregnancy via
laparotomy or laparoscopy
• Hysteroscopic excision
• remove the pregnancy and repair the defect
• Local injection of 5 mEq KCl into the sac, and
• Local or systemic MTX administration
• risk of rupture and hemorrhage; hysterectomy may be
necessary
• Expectant management is not a good option
because of the risk of rupture and maternal death
• Recurrence, uterine rupture, placenta accreta,
severe hemorrhage in subsequent pregnancy

Pregnancies of unknown location(PUL)
• when a woman has a positive pregnancy test,
but no pregnancy can be visualised on
transvaginal ultrasound (TVS).
• low PUL rates of 7–10%, some report 30%
• modern units should try to maintain a PUL
rate of less than 15%

…cnt’d
Pregnancy outcomes
Four possible outcomes:
• Intra-uterine pregnancy
• Failing PUL -50–70%
• Ectopic pregnancy- 7–20% and
• Persisting PUL

MX
• Expectant management has been shown to be
safe for the majority of women.
• Serum progesterone levels have been used to
predict the outcome of PULs, but appear better
at predicting pregnancy viability than pregnancy
location.
• The change in serum hCG over 48 hours
expressed as the hCG ratio (hCG 48 hours/hCG 0
hours) is helpful in predicting the outcome of
PULs.
• Diagnostic laparoscopy or uterine curettage
should not be undertaken routinely

References
• JohnA.Rock, Howard W.jones, Ectopic Pregnancy TeLinde’s operative
Gynecology 10th edition
• Cunningham,Leveno, Bloom, Hauth, Rouse, Spong, Ectopic
Pregnancy , Williams Obstetrics 23rd Edition
• Prof. Lukman Yusuf , lecture note on Ectopic pregnancy
• MARTIN G. SHELTON, THE TREATMENT OF ABDOMINAL PREGNANCIES,
S.A. MEDICAL JOURNA L, 1 June 1963
• Dahab et al. Journal of Medical Case Reports 2011, Full-term extrauterine
abdominal pregnancy: a case report,
http://www.jmedicalcasereports.com/content/5/1/531
• Geneviève et al. , Imaging in the Management of Abdominal Pregnancy: A
Case Report and Review of the Literature, JANUARY JOGC JANVIER 2009
• Nuru Abseno, workineh Getaneh,Cases of Advanced Abdominal
pregnancies one of which was with viable fetus, Ethiop Med J, 42 2004

…cnt’d
• Thomas A Molinaro Kurt T Barnhart, Abdominal pregnancy,
cesarean scar pregnancy, and heterotopic pregnancy, UpToDate
19.1
• E. Kirk et al. Pregnancies of unknown location, Best Practice & Research
Clinical Obstetrics and Gynaecology 23 (2009) 493–499
• P. M. Lam et al. Unsuccessful medical treatment of cesarean scar ectopic
pregnancy with systemic methotrexate: a report of two cases, Acta Obstet
Gynecol Scand 2004: 83: 108--116
• A. Nassar et al. Cervical pregnancy after in vitro fertilization and embryo
transfer successfully treated with methotrexate and intracervical injection
of vasopressin, Acta Obstet Gynecol Scand 2004; 83: 112–114
• F. USIFO, S. THAMBAN, I. O. OPEMUYI, & S. SAHOO, Ovarian ectopic
pregnancy, Gynaecology case reports, J Obstet Gynaecol ,
www.informahealthcare.com, accessed 06/16/12
• SAMUEL LURIE,DAVID RABINERSOAN AND, ZEEVS HOHAM, The veracious
etiology of ectopic pregnancy, Acta Obstet Gynecol Scand 1998; 77: 120-
121, www.informahealthcare.com

…cnt’d
• J. O. AMAGADA and S. J. VINE, Spontaneous heterotopic pregnancy
remains a diagnostic enigma, Obstetric case reports, J Obstet
Gynaecol www.informahealthcare.com
• N. Acheson et al, Advanced abdominal pregnancy: difficulties in
diagnosis, Journal of Obstetrics and Gynaecology (1996) Vol. 16,
235-238, www.informahealthcare.com
• Radwan Faraj / Martin Steel, Review Management of cornual
(interstitial) pregnancy, Royal College of Obstetricians and
Gynaecologists 2007; 9:249–255, www.rcog.org.uk/togonline,
• Getahun kifle, An abdominal pregnancy with infected gestational
sac , 1987.ethiop. Med. J. 25,41
• Novak

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