“Any pregnancy where the fertilised ovum
gets implanted & develops in a site other than
normal uterine cavity”.
It represents a serious hazard to a woman’s
health and reproductive potential, requiring
prompt recognition and early aggressive
Is one in which fertilized ovum is implanted &
develops outside normal uterine cavity
INCIDENCE & MORTALITY
• Tubal surgeries, and
• Assisted reproductive techniques (ART).
• Rate in India – 5.6/10000 deliveries
• Late marriages and late child bearing -> 2%
• ART -> 5%
• Recurrence rate - 15% after 1st, 25% after 2
Innovative Journal of Medical and Health Science 4 : 1 Jan -
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
Entrap the ovum on its way.
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
CuT - 4%
•Tubal sterilization faliure -40%
Depends on sterilization technique and age of the patient
•Bipolar Cauterisation -65%
•Unipolar Cautery -17%
•Silicon rubber band -29%
•Interval Salpingectomy -43%
•Postpartum Salpingectomy -20%
•Reversal of sterilisation
• method of sterilization,
• Site of tubal occlusion,
• residual tubal length.
•Reanastomosis of cauterised tube -15%
•Reversal of Pomeroy’s - < 3%
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
Other Risk factors
Age 35-45 yrs
Previous induced abortion
Previous pelvic surgeries
DES Exposure in Utero
Salpingitis Isthmica Nodosa
Fundal Fibroid & Adenomyosis of tube
Transperitoneal migration of ovum
Iffy hypothesis –
“Theory of reflux” menstural fluid throw the
fertilised ovum into the tube
Factors facilitating nidation of ovum in tube:
- Premature degeneration of zona pellucida
- Increased decidual reaction
- Tubal endometriosis
Tubal pregnancies rapidly invade the
mucosa, feeding from the tubal vessels,
which become enlarged and engorged. The
segment of the affected tube is distended as
the pregnancy grows. Possible outcomes of
such abnormal gestations are as follows:
Implantation- intercolumnar or between mucosal flods
Decidual change minimal
Muscle hyperplasia & Hypertrophy min.
Trophoblast invasion-erosion of blood vessel
The pregnancy is unable to survive owing to its poor blood supply,
thus resulting in a
tubal abortion and
Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months
Abortion is common in ampullary pregnancies,whereas rupture is
ARIAS – STELLA REACTION
Arias – Stella reaction is charecterised by a benign,
focal and unusual decidual changes in the presence of
Loss of polarity
Though seen in Ectopic Pregnancy but is not specific for it
and can also be seen in uterine pregnancy
Dignosis 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 asymtomatic pt
to others with acute abdomen and in shock.
ACUTE ECTOPIC PREGNANCY
Classical triad is present in 50% of pt with
- 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 comm. Feature. Shoulder tip pain.
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
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.
CHRONIC ECTOPIC PREGNANCY
It can be diagnosed by high clinical suspicion
Patient had previous attack of acute pain from which
she has recovered.
She may have amenorrhoea,
vaginal bleeding with
dull pain in abdomen and
with bladder and bowel complaints like dysuria,
frequency or retention of urine,
O/E:- patient look ill, varying degree of pallor,
slightly raised temperature. Features of shock
P/A:- Tenderness and muscle guard on the lower
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.
High degree of suspicion & ectopic conscious clinician
Diagnosed accidentally in Laparoscopy or Laparotomy
C/F – delayed period, spotting with discomfort in
P/A – tenderness in lower abdomen
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
“Pregnancy in the fallopian tube is a black cat
on a dark night. It may make its presence felt
in subtle ways and leap at you or it may slip
past unobserved. Although it is difficult to
distinguish from cats of other colours in
darkness, illumination clearly identifies it.”
--Mc. Fadyen - 1981
In recent years, inspite of an increase in the incidence of
ectopic pregnancy there has been a fall in the case
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
Now the rate of tubal rupture is as low as 20%.
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.
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 .
-A trilaminar endometial pattern seen
-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
Early Gestational Sac Pseudosac
Location Eccentrically located Midline within E.cavity
Shape Round-shape Irregular
Border Double Ring sign
Vascularity High Avascular
Pattern Peripheral -
It is identified as an anechoic area lying with in the
endometrium but remote from the canal and often at the
- 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.
Free peritonial fluid with an adnexal mass
suggestive of ectopic pregnancy
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 1800 IU/L.
1.‘Bagel’ sign – Hyperechoic ring around gestational sac in
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
4. Corpus luteum is useful guide when looking for EP as
present in 85% cases in Ipsilateral ovary.
Hyperechoic ring around
gestational sac in adnexal region
Ring sign — a hyperechoic ring around an
extrauterine gestational sac.
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
Biochemical pregnancy is applied to those
women who have two β-HCG values >10 IU/L
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
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.
5. Dilatation & Curettage –
Is recommended in suspected case of incomplete
abortion vs ectopic pregnancy.
Identification of decidua without chorionic villi is
suggestive of extra uterine pregnancy.
“Arias-Stella” endometrial reaction is suggestive but not
diagnostic of ectopic pregnancy.
6. Other Novel Tests –
Placenta protein (PP14) decrease in EP
PAPPA (Pregnancy Associated Plasma Protein A),
PAPPC (schwangerchaft protein 1) has low value in EP
CA-125, Maternal serum creatine kinase, Maternal serum
AFP elevated in ectopic pregnancy.
VEGF, Fetal Fibronectin, Mass spectrometry
SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive
IU sac No IU sac
+ S progesterone
< 66% rise in 48 hr or
S progesterone < 5-10 ng/ml
D & C
Villi present Villi absent
>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
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
(USG or Laparoscopic)
- Potassium chloride
- Hypersmolar glucose
- Actinomycin D
-Milking or fimbrial
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
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.
MANAGEMENT OF ECTOPIC PREGNANCY-
Preferred method if haemodynamically stable
Tubal Patency no significant difference
Followed by similar number of uterine pregnancy
Shorter operative time
Less than 2cm size
MANAGEMENT OF UNRUPTURED
SURGICALLY ADMINISTERED MEDICAL (SAM)
IDENTIFICATION CRITERIA - :
1. Tubal ectopic pregnancies only
2. Haemodynamically 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%
- 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.
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
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.
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
It can be used as oral,intramuscular ,intravenous usually along with
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.
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
Two dose on Day
Follow-up same as One dose regimen
1. Mtx 1gm/kg IM
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
Minimal Hospitalisation.Usually outdoor treatment
90% success if cases are properly selected
Side effects like GI & Skin
Monitoring is essential-
Total blood count,
Serum HCG once weekly till it becomes negative
SURGICALLY ADMINISTERED MEDICAL TT
Aim- trophoblastic destruction without systemic
Technique- Injection of trophotoxic substance into
the ectopic pregnancy sac or into the affected tube
Transabdominal (Porreco, 1992)
Transvaginal (Feichtingar, 1987)
With Falloposcopic control (Kiss, 1993)
Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
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
SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
INSTRUCTION TO THE PATIENTS
If T/t on outpatient basis rapid transportation should be
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
SURGICAL MANAGEMENT OF ECTOPIC
Can be done Laparoscopically or by microsurgical laparotomy
- Patient desires future fertility
- Contralateral tube is damaged or surgically removed
CHOICE OF TECHNIQUE: depends on
- Location and size of gestational sac
- Condition of tubes
VARIOUS CONSERVATIVE SURGERIES
- 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
3. Segmental Resection & Anastomosis:
- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at later
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,
Follow up after conservative surgery
- With weekly Serum β HCG titre till it is negative.
- If titre increases methotrexate can be given.
? Salpingectomy Vs Salpingostomy
? Laparotomy Vs Laparoscopy
? Reproductive outcome
? Risk of Recurrent Ectopic
SALPINGOSTOMY / SALPINGOTOMY
All tubal pregnancies can be treated by partial or total
Salpingostomy / Salpingotomy is only indicated when:
1. The patient desires to conserve her fertility
2. Patient is haemodinamically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 5Cm. In size
5. Contralateral tube is absent or damaged
The choice of surgical treatment does not influence the post
treatment fertility, but prior history of infertility is associated
with a marked reduction in fertility after treatment.
Making the choice – Chapron et al (1993) have described a
scoring system, based on the patient’s previous
gynaecological history and the appearance of the pelvic
organs, to decide between salpingostomy / salpingotomy and
Fertility reducing factor Score
• Antecedent one Ectopic pregnancy 2
• Antecedent each further
Ectopic pregnancy 1
• Antecedent Adhesiolysis 1
• Antecedent Tubal micro surgery 2
• Antecedent Salpingitis 1
• Solitary tube 2
• Homolateral Adhesions 1
• Contralateral Adhesions 1
The rationale behind the scoring system is to decide the risk of recurrent
Conservative surgery is indicated with a score of 1-4 only, while radical
treatment is to be performed if the score is 5 or more.
Laparotomy Vs Laparoscopy
- Laparoscopy is reserved for pt who are
- Ruptured Ectopic does not necessarily require
Laparotomy, but if large clots are present
Laparotomy should be considered.
Is similar in pt treated with either Laparoscopy or
Identical rates of 40% of IUP, around 12% risk of recurrent
pregnancy with either radical or conservative pregnancy.
It is carried out by laparoscopic scissors & diathermy or Endo-loop.
After passing a loop of No.1 catgut over the ectopic pregnancy the stitch is
tightened and then the tubal pregnancy is cut distal to the loop stitch.
The excised tissue is removed by piece meal or in tissue removal bag
To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml of normal
saline is injected into the mesosalpinx.
Then the tube is opened through an antimesenteric longitudinal incision over
the tubal pregnancy by a
– Co2 laser (Paulson, 1992)
– Argon laser (Keckstein et al; 1992)
– Laparoscopic scissors and ablating the bleeding points with bipolar
– Fine diathermy knife (Lundorff, 1992)
The tubal pregnancy is then evacuated by suction irrigation.
PERSISTENT ECTOPIC PREGNANACY
This is a complication of salpingotomy / salpingostomy when
residual trophoblast continues to survive because of incomplete
evacuation of the ectopic pregnancy.
Diagnosis is made because of a raised postoperative β HCG
If untreated, can cause life threatening hemorrhage
Risk Factor: (seifer 1997)
1. Early ectopic pregnancy (< 6 wks amenorrhoea)
2. Smaller size < 2 cm (Incomplete removal)
3. Preoperative high serum β HCG (> 3,000 IU/L) and
postoperative Day1 titre is < 50% of preoperative level, is predictor
of persistent EP.
4. Implantation medial to the salpingostomy site.
Total or partial
(selected Asymptomatic pt)
MTX + Leukovorin
OVARIAN ECTOPIC PREGNANCY
Risk factor: - IUCD
- Endometriosis on surface of ovary
C/F are same as tubal pregnancy
ruptures within 2-3 wks
Diagnosis: On Laparotomy
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
Ovarian wedge resection
MMR : 7-8 times > tubal ectopic
90 times > Intrauterine pregnancy
H/O : - Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation,
diarrhoea, abdominal pain.
- Fetal movement may be painful and high in
O/E : - Abnormal fetal position, easy in palpating
- uterus palpated separate from sac
- no uterine contraction after oxytocin
Diagnosis: Confirmed by USG,
CT scan, MRI, Radiography
1. Both tubes and ovaries normal
2. Absence of Uteroperitonal fistula
3. Pregnancy related to Peritoneal
surface & young enough to rule
out possibility of secondary
Conceptus escapes out
through a rent from
FATE OF SECONDARY ABDOMINAL PREGNANCY :
1. Death of ovum – complete absorption
2. Placental separation – massive intraperitoneal
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)
- 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
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
- DES exposure
CLINICAL CRITERIA: Paulman & McEllin
1. Uterine bleeding, no cramping, following
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
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
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.
Cervical submucous fibroid
Mainstay therapy in past
D & C
(risk of torrential bleeding)
- Cerclage Bernstein ≈ Mc Donald’s
Wharton ≈ Shirodkar’s
-Transvaginal ligation of Cx branch of
- Angiographic uterine A embolisation
- Intracervical vasopressin inj
- Foley’s catheter as tamponade
Single or Combination
Adjunct to surgery
SITE: Implantation occurs in rudimentary
horn of Bicornuate uterus
COURSE :Rupture of horn occurs by
1. Interstitial tubal pregnancy
2. Painful leiomyoma along with
3. Ovarian tumor with pregnancy
4. Asymmetrical enlargement of uterus.
Implantation into cornu of normal uterus is sometime
called Angular pregnancy .
- Affected cornu with pregnancy is removed
- Hysteroscopically guided suction curettage if
communication with Cx is patent
Co-existing intrauterine and extra uterine pregnancies
Incidence: 1 : 30,000
- With ART – 1:7000
- With ovulation induction – 1:900
a) Ass. reproductive technique
b) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomy
Depends on the site. Ectopic site may be removed
with continuation of IU pregnancy
(Rh Immunoglobulin: dose of 50 μ gm is sufficient to
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
Rupture – Hysterectomy is indicated
CAESAREAN SCAR ECTOPIC PREGNANCY
USG slows on empty uterine cavity and gestational
sac attached low to the lower segment caesarean
C/F : similar to threatened or inevitable abortion
Diagnosis : Doppler imaging confirms
Hysterectomy in a multiparous women.
In young pt resection & suturing of scar may
be done (high risk of rupture).
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.
SUMMARY - KEY POINTS
Incidence of ectopic pregnancy is rising while maternal mortality from it is
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
Careful monitoring and proper counselling of patients is mandatory.