Dr. PRIYADHARSHINI M

Definition

Any pregnancy where the fertilized ovum gets implanted & develops in a site other than the normal endometrial cavity.

Serious hazard to a woman’s health and reproductive potential, requiring prompt recognition & early aggressive intervention

Ovulation ovum picked up by fimbria swept by ciliary action towards ampulla fertilization.

Zygote cleavage division in (3 -4 days) morula (8-32 cell stage)embryo to uterine cavity for up to 72 hours D6 enters uterusimplantation- uterine cavity in normal positioned pregnancy .

hCG (trophoblast)mother’s serum 1 week after implantation, level doubles every 36-48 hours

Delay or obstruction of the passage of fertilized egg down the fallopian tube to the uterusimplantation in tube or ovary or peritoneal cavityectopic pregnancy

Eventually fails to develop

hCG fails to raise dramatically

1-2 % of total pregnancy

Recurrence rate – 15% after 1st, 25% after 2 ectopics

Increasing incidence

4th leading cause of maternal mortality overall (4%)

MC cause of maternal mortality I trimester

Types:

1. Tubal(95-98%)

2. Non tubal(2-5%)

3. Heterotropic(1/1000)

IMPLANTATION SITES

TUBAL

(97%)

AMPULLARY 70%

INFUNDIBULAR

11%

INTERSTITIAL

2%

ISTHMUS 12%

ABDOMINAL

(0.1)

SECONDARY

INTRAPERITONEAL

MC

EXTRAPERITONEAL

(broad lig)

PRIMARY

(rare)

OVARIAN

(0.5)

EXTRA

UTERINE

UTERINE

(1.5)

ANGULAR

CERVICAL <1%

CORNUAL

CS SCAR <1%

Improved technology

The rising incidence of risk factors-

acute & chronic salpingitis

induced abortion

tubal ligation

tubal reconstructive surgery

ART

Conservative management of tubal pregnancy,

Congenital: long narrow tube, diverticulae , accessory ostia.

Traumatic: operation on the tube –salpingoplasty ,tubal reversal following ligation.

Inflammatory: Chronic salpingitis

Neoplastic: Narrowing of the tube by a fibroid or a broad ligament tumor.

Functional: As tubal spasm or antiperistalticcontractions.

Endometriosis in the tube. encourages embedding of the fertilized ovum.

Separation of the gestational sac from

the tubal wall

Degeneration

Fall of hCG level,

Regression of the corpus luteum

Drop in the oestrogen & progesterone level

Separation of the uterine decidua with uterine bleeding

Risk Factor Risk %

High Risk

PID *

Tubal corrective surgery

Tubal sterilization

Previous EP

In utero DES exposure

IUD **

Documented tubal

pathology

Moderate Risk

Infertility

Previous genital infection

Multiple partners

Slight risk

Previous pelvic or

abdominal surgery

Smoking

Douching

Intercourse before 18 years

25

21.0

9.3

8.5

5.6

4.2-45

3.8-21

2.5-21

2.5-3.7

2.1

0.93-3.8

2.3-2.5

1.1-3.1

1.6

Up to half of women with ectopic pregnancy will have no identifiable risk factors.

Use of assisted reproductive technology (such as IVF and GIFT)

•7 fold risk after acute pelvic infection

** 4 times risk- increased protection against IU pregnancy, increased incidence of PID

RISK FACTORS

Infections chlamydia, gonorrhoea

Damage to ciliated surface of endosalpinx

intratubaladhesions partial tubal obstruction

peritubaladhesions restricted tubal motility

Alteration of tubal transport mechanisms

slow the passage of egg time to implant itself in the tube

1- Tubal mole:

sac is surrounded by blood clot & retained

chronic ectopic pregnancy/ involution

2-Tubal abortion: ampullary

Separation of sac expulsion into peritoneal cavity through ostium.

Rarely, reimplantation of conceptus occurs in another abdominal structure secondary abdominal pregnancy.

3-Tubal rupture: isthmus

Rupture in anti-mesenteric border profuse bleeding →intraperitoneal haemorrhage.

rupture in mesenteric border broad ligament haematoma.

Tubal abortion

OUTCOMES

Tubal Rupture

16

•Extraperitoneal rupture (rupture through floor of the tube)broad ligament hematoma with death of the ovum, intraligamentary pregnancy.

The diagnosis often presents great difficulty

Usually missed because it is NOT suspected.

“Pregnancy in the fallopian tube is a black cat on adark night. It may make its presence felt in subtleways and leap at you or it may slip past unobserved.Although it is difficult to distinguish from cats ofother colours in darkness, illumination clearly

identifies it.”

- Mc. Fadyen - 1981

Multimodality approach including

Proper history (cycle, pregnancy, PID,infertility, gynaecological surgery, contraception)

Clinical examination (Proper general, abdominal, vaginal and vital signs)

Judicious use of investigation

Wide spectrum of presentation from asymptomatic pt to others with acute abdomen and in shock

Early symptoms - either absent/ subtle.

7.2 weeks after LMP (range 5-8 weeks)

ECTOPIC

ABNORMAL VAGINAL BLEEDING70%

ABDOMINAL PAIN

Most common

AMENORRHOEA75%

Apart from classical triad pt presents with

Features of shock

Danforth sign, cullen sign

P/A-Abdominal tenderness,guarding,BSdecreased/absent

P/S-Minimal bleeding

P/V-Uterus bulky,fornix tender full,pod full,adnexalmass, cervical motion tenderness ”JUMPING SIGN”

Bimanual examination should be very gentle with facilities for immediate surgical intervention if needed

H/O-acute attack of pain from which she has recovered

O/E-ill looking without any features of shock

P/A-irregular mass,tenderness

P/S-vaginal mucosa pale

P/V-uterus may be normal/bulky,ill defined mass may be felt through fornix

Difficult to diagnose and high degree of clinical suspiscion is needed,sometimes diagnosed accidentally during laparoscopy/laparotomy

C/F-Delayed periods,spotting with lower abdominal discomfort

P/A-tenderness in lower abdomen

P/V-Uterus normal size,small tender mass may be felt in the fornix

DIFFERENTIAL

DIAGNOSISDDX

Appendicitis (Perforated)

Acute Pancreatities

Myocardial Infarct

Pelvic Abcess

Splenic Rupture

Perforated Gastric or Duodenal Ulcer

(1) NON GYNECOLOGICAL

Septic Abortion

Threatened Abortion

Pyosalpinx

Pelvic Abcess

Twisted Ovarian Cyst

Acute pelvic inflammatory

disease

Rupture of Follicle or

Corpus Luteum Cyst

Degenerating leiomyoma

Retroverted Gravid Uterus

(2) GYNAECOLOGICAL

•Accuracy of initial clinical evaluation < 50%.

General investigations Urine pregnancy testCuldocentesisTransvaginal ultrasonographySerum beta hcgUrine beta hcgSerum progesteroneUterine currettageLaparoscopy/laparotomy

Presence of free flowing nonclotting bloodintraabdominalhaemorrhage

serous fluid negativeLack of fluid

return/clotted bloodnon- diagnostic

Negative culdocentesisdoes not exclude chance of ectopic

UPT not always positive Serum β-hCG (ELISA / RIA) detects very early pregnancy

about 10 days after fertilization i.e. before the missed period.Discriminatory zone: 1000-2000 IU/L TVS; 5000-6000 IU/L TASAbsence of uterine pregnancy abnormal pregnancy( ectopic,

incomplete abortion) β-hCG levels still below the discriminatory value, serial β-Hcg

USG should be done.Doubling sign: Normal : >66% increase levels every 48 hours (nearly 2X). Inappropriately rising serum β-hCG levels suggest (but do not

diagnose) abnormal pregnancy including ectopicDo not identify its location.

Specificity 94%,sensitivity 38%

TVS superior to TAS

Failure to see Gestational sac at 4-5 wks gestation and at beta hcg 1500iu/l i.e. the discriminatory zone

Observation of g.sac, embryo, cardiac activity outside the uterus

In some cases no sac is found either intrauterine/extrauterine

7-20% proved to be ectopic

25% of ectopic presents with PUL

Intrauterine pregnancy in which the sac is not developed, collapsed or aborted.

Ectopic too small to be detected

Transvaginal USG

Positive β-hCG test + empty uterus by sonar ±adnexal mass Ectopic pregnancy.

Endometrial cavity shows trilaminar echo pattern

Identification of double decidual sac sign(DDSS) is the

best method to differentiate true sacs from pseudosacs

Pseudogestational sac seen formed by the sloughing of decidua creating an intracavitary fluid collection.it differs from true g.sac in having only one layer and midline location where as true sac is usually eccentric

Decidual cast sometimes seen

Decidual cyst anechoic area at the endometrium-myometrium border

Pouch of douglas may contain free fluid

Presence of corpus luteal cyst in ipsilateral ovaries is a useful marker

Appx 60%-seen as inhomogenous mass/blob sign adjacent to ovary, moving separetely from it

Appx 20%-as adnexal hyperechoic ring/bagel sign (fluid sacs with thick echogenic ring)

Appx 13%-as obvious gestational sac with fetal pole/cardiac activity

Doppler improve the accuracy & identify the placental

shape ( ring of fire pattern) & blood flow outside the

uterine cavity

Value >25ng/ml normal intrauterine pregnancy

Value<5ng/ml nonviable intrauterine pregnancy/ extrauterine pregnancy

Most of ectopic pregnancy value ranges 10-25 ng/ml

Diagnostic laparoscopy

Gold standard

for diagnosis of

ectopic pregnancy

Diagnosis &

removal of ectopic

mass can be done

at the same time

Presence of villi excludes ectopic pregnancy not heterotopicpregnancy

Absence of villi and presence of Ariastella reaction suggests ectopic pregnancy

OTHERS- VEGF, CA125, creatinekinase, fetal fibronectin, placental protein, Estradiol, maternal AFP, relaxin

Suspected ectopic

UPT+

S/S STABLE

ECTOPIC Non diagnostic

Serum beta HCG

>1500

CURETTAGE

VILLI

ABORTION

NO VILLI

<1500

Repeat B HCG

Intrauterine pregnancy

ABORTION

TVS

UNSTABLE

SURGICALMANAGEMENT

1• EXPECTANT MANAGEMENT

2• MEDICAL MANAGEMENT

3• SURGICAL MANAGEMENT

4• EMERGENCY MANAGEMENT

EXPECTANTMANAGEMENT

1

Criteria for selection (RCOG-green top-21-guideline)

Asymptomatic pt

Hemodynamically stable

<100 ml fluid in the pouch of Douglas

Lower beta hcg value<1000 IU/ml

Adnexal mass <3cm without cardiac activity

Pregnancy of unknown location

They must be fully compliant and must be willing to accept the potential risks of tubal rupture.

• Success rate is 60% with decreasing beta hcg titre

Initial follow up

twice weekly with serial Hcg measurements

weekly by TVS

By the first week

drop in HCG level

Adnexal mass size

Otherwise reassess the options (Medical/Surgical)

If the fall of HCG & reduction in size of adnexalmass satisfatory

weekly hCG & TVS till HCG falls <20 IU

MONITORING

45–70% of PUL resolve spontaneously with expectant management

Ectopic pregnancy was subsequently diagnosed in 14–28% of PUL

Intervention(laparoscopic salpingostomy) has been shown to be required in 23–29% of cases

MEDICAL

2

CRITERIA FOR MEDICAL MANAGEMENTS

elec

tio

n c

rite

ria Minimal symptoms/

hemodynamically stable

No signs or symptoms of active bleeding / haemoperitoneum.

HCG<3000(RCOG)

Normal CBC,RFT,LFT

Size<4cm

Absence of cardiac activity

Persistent ectopic after conservative surgery

Good compliance and follow up can be assured(RCOG)

Women should be given clear information(preferably written)about the possible need for further Tt and adverse effects following Tt (RCOG)

Exc

lusi

on

cri

teri

a Any hepatic dysfunction, thrombocytopenia (<100,000), blood dyscrasia(WBC <2000).

Difficulty/unwillingness of patient for prolonged follow-up (avg follow-up 35days).

Ectopic mass >4cm

presence of cardiac activity

Women on concurrent corticosteroid therapy

• Methotrexate

SYSTEMIC

( IV, IM or orally )

• RU-486

• PgF2 alpha, MTX

• KCl , hyperosmolar glucose

• Actinomycin D

LOCALLYSALPHINGOCENTESIS

(laparoscopic direct injection, retrograde

salpingography)

Other agents- not recommended because their safety & accuracy are not

well documented

Advantage:

Increased conc at local site

lesser systemic s/e

Increased fertility

Shorter hospital stay

Follow up:

Beta hcg twice wkly till<10iu/l

TVS weekly till 4-6 wk

Hcg after 6 month

Methotrexate:

folic acid antagonist inhibits DHFR enzyme thus depleting the stores needed for DNA/RNA synthesis during trophoblast proliferation

first used by Tanaka et al(1982)-interstitial ectopic pregnancy

Methotrexate-IM(buttock or lateral thigh)

Prior tests- CBC,LFT,RFT,CXR repeated after 1 week

1.Multidose regimen –

MTX 1mg/kg IM on 1,3,5,7 days

Leucovorin 0.1mg/kg on 2,4,6,8 days

Measure B-hCG levels on days 1,3,5,7 until 15% decrease between 2 measurement

Once B-hCG level drops 15%, stop MTX & monitor B-hCG weekly until non pregnant level

2.Single dose regimen:

MTX 50mg/m2 on day 0

Measure B-hCG level on days 4 & 7

If level drops by 15%, monitor B-hCG weekly until non pregnant level. If levels do not drop by 15%, repeat dose of MTX & measure B-hCG on days 4 & 7

87% success rate

Advantages:

Increased pt compliance

Simplified administration

Safe & effective

Less expensive

Less monitoring

3.Two dose regimen:

MTX 50mg/m2 on days 0 & 4

Measure B-hCG levels on days 4 & 7

If levels drop by 15%, monitor B-hCG weekly until non pregnant level

If level do not drop by 15%, repeat dose of MTX on days 7 & 11 & measure B-hCG on days 7 & 11. If levels drop 15%, monitor B-hCG level weekly until non pregnant level

UNTOWARD EFFECTS:

Dose & frequency dependent

(30-40%)

nausea, vomiting

Stomatitis,

abdominal pain

bone marrow suppression

Alopecia

dermatitis & pneumonitis.

Deranged LFT

Rest up to one hour after the injection. local reaction- anti-histamine/ steroid cream (v.rare)

use reliable contraception for 3 months after MTX (barrier or hormonal)

Avoid

sexual intercourse during treatment

exposure to sunlight.

alcohol , vitamin preparations containing folate until the hormone level is back to zero.

aspirin or drugs such as Ibuprofen for one week after treatment.

FOLLOWED UP for signs of tubal rupture-( severe pain/unstable/falling Hct)- surgical intervention

90% successful treatment with single dose regime.

10 – 20%. Recurrent ectopic pregnancy rate

80%. Tubal patency rate

75% abdominal pain-separation pain.(D3-D7)

14 % of medical management 2nd dose of MTX

10% finally require surgical management

Risk of subsequent ectopic 10% following either MTX(MD)/salpingostomy.

similar reproductive outcomes

Success rates(time to resolution ) correlates with initial serum B HCG

OUTCOME

Medical management- cheap initially

but considering the cost of follow up & the loss of work time for patient & carers no cost saving was seen at serum hCG levels above 1500 iu/l

SURGICAL

3

Not a suitable candidate for medical therapy.

Failed Medical therapy.

heterotropic pregnancy with viable intrauterine pregnancy.

hemodynamically unstable & needs immediate treatment.

Surgical approachlaparoscopy or laparotomy

hemodynamic stability

size & location of ectopic mass

surgeons expertise

Quick in and Quick out - principle

Conservative & extirpative

Linear salpingostomy:

<2cm size, in distal third of tube

Antemesenteric border incised –heals by secondary intention

FOLLOW UP

iND

ICA

TIO

NS

• unruptured ampullaryectopic pregnancy(toc),

• wishes to retain potential for future fertility

• affected fallopian tube otherwise normal

• Contralateral tube appears damaged

CO

NT

RA

IND

ICA

TIO

NS

Ruptured tube

use of extensive cauteryto obtain hemostasis

severely damaged tube

recurrent ectopic pregnancy in same

tube.

Salpingotomy

Conservative surgical management

Incision – closed with vicryl7-0

ectopic has not ruptured

the tube appears normal

Segmental resection and anastomosis: for unrupturedisthmic pregnancy

Milking /fimbrial expression: infundibular pregnancy, best reserved when products protrude out.

2X recurrence

EXTIRPATIVESalpingectomy (PARTIAL/TOTAL)

Salpingectomy (tubal removal) is the principle treatment especially where there is tubal rupture

wedge area of outer 3rd of interstitial portion of tube is also resected ,known as cornual resection to minimise occurence of pregnancy in tubal stump

Total salpingectomy is the procedure of choice: completed childbearing and no longer desires fertility history of an ectopic pregnancy in the same tube. severely damaged tubes

Cumulative inrauterine pregnancy rates and also incidence of recurrent ectopic – higher with salpingostomy

Salpingectomy Salpingotomy

• There may be a higher subsequent intrauterine pregnancy rate associated with salpingotomy but the magnitude of this benefit may be small

• Trend towards higher subsequent ectopic pregnancy

• small risk of tubal bleeding in the immediate postoperative period

• potential need for further treatment for persistent trophoblast

Salpingostomy

Chance of intrauterine pregnancy- 73%

Chance of recurrent ectopic- 15%

LaparoscopyTubal patency: 80-90%

Intrauterine preg: 55-75%

Recurrent ectopic: 10-15%

57%

10%

Laparotomy 80-90%

55-75%

10-15%

Salpingectomy

Laparotomy -

hemodynamically unstable and an expedited abdominal entry is required

patients with cornual , interstitial ectopics Extensive pelvic/abdominal adhesive disease surgeons inexperienced & patients where laparoscopic

approach is difficult

An alternative to laparoscopy is the use of minilaparotomy incision.-success rate similar

Laparoscopy

• Less intraoperative blood loss

• Shorter operation time

• Shorter hospital stay

• Lower analgesic requirement

• Future intrauterine pregnancy rate same

• Lower repeat ectopic pregnancy rate

Laparotomy

• Future intrauterine pregnancy rate same

• Preferable in the haemodynamically unstable patient

LAPROSCOPY

Tubal patency, future intrauterine pregnancy, future ectopic rates - no differences in laparoscopic salpingotomy and salpingostomy (recent cochranereview)

COMPARING systemic methotrexate with tube-sparing laparoscopic surgery, randomized trials have shown no difference in overall tubal preservation, tubal patency, repeat ectopic pregnancy, or future pregnancies(ACOG 2008)

Algorithm for the diagnosis of unrupturedectopic pregnancy without laparoscopy

ECTOPIC

RUPTURED

EMERGENCY

PRINCIPLE: Quick Resuscitation and simulataneous arrangement for laparotomy definitive surgery

ANTI SHOCK TREATMENT: ABC of resuscitation

give facial oxygen

Site two IV lines (at least 16g), commence IV fluids (crystalloid)

Send blood for CBC, Clotting screen and cross-match at least 4 units of blood.

- Folleys catheterization done

- colloids for volume replacement

whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive monitoring of haemodynamic state

LAPAROTOMY

- Rapid exploration of abdominal cavity done

- Salpingectomy (definitive surgery)peritoneal toileting

record operative findings including the state of the remaining tube/pelvis

Blood transfusion done

Anti D Ig (250 IU)given to Rh negative women

RCOG Guideline

factors affecting future pregnancy:

prior h/o of infertility (the most important)

treatment choice history ( whether surgical or nonsurgical)

For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.

Rate of fertility may be better following salpingostomy than salpingectomy.

Resorption/ tubal abortion- obviates need for further or medical management

Falling HCG(caution: tubal rupture can occur even with falling levels)

Low BHCG(<200mU/ml) 88%

Follow up with beta HCG

Complication of salpingotomy / salpingostomy(4-15%) when residual trophoblast continues to survive because of incomplete evacuation of ectopic pregnancy.

Mostly ruptures in post op So serial monitoring of beta hcg.(D1, every 3-7 days thereafter till

undetectable) Risks are small size<2cm, early preg<6wk, preop high

Bhcg>3000iu/l

Diagnosis : raised postoperative serum HCG If untreated, can cause life threatening hemorrhage

TREATMENT - IM / oral Methorexate single dose of 50 mg/m2 -TOC Reoperation and further evacuation / Salpingectomy

Pregnancy does not completely resolve after expectant mgt

Persistence of chorionic villi with bleeding into tubal wall slow distension , no rupture

Amenorrhoea, symptomatic pelvic mass, BHCG-low/absent, bowel/ureteral obstructive symptoms

DIAGNOSIS: USG

TREATMENT: Removal of affected tube, ovary removed

Non tubal pregnancy –types

Cervical(0.1-1%)

Ovarian(0.5-2%)

Abdominal(0.3-0.5%)

Interstitial(2-3%)

Angular

Cornual(1:1lakh)

Heterotropic

Multiple ectopic pregnancy

Ectopic in caesarean scar<1%)

Pregnancy after hysterectomy

Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.

As such a horn is capable of some hypertrophy and distension, rupture usually does not occur before 16-20 weeks.

Management -affected cornualpregnancy is removed hysteroscopicresection, hysterectomy

Thick section of tube- expands max capacity before rupture(7-16w)

2.4% of all ectopics

Late presentation rate

Most dangerous –torrential haemorrhage(dual supply)

mgt:

MTX – stable

Laparoscopic cornuostomy -unstable .

Hysteroscopic resection with selective arterial embolisation, Inj kcl

Hysterectomy(rupture)

• Uterus smaller than the surrounding distended cervix

• External os may be open

• Visible cervical lesion often blue or purple in colour

• Profuse bleeding on manipulation of cervix

Rubin1911

(following hysterectomy)

• Amenorrhoea painless bleeding

• Softened enlarged cervix to the size of uterine corpus

• Products of conception entirely confined & firmly attached to endocervix

• Closed internal os and partially open external os

PaalmanMcElin 1959

(Before hysterctomy)

Gestatational sac /placental tissue visualizd within cervix

Cardiac motion noted below the level of internal os

No intrauterine pregnancy’

Hourglass uterine shape with ballooned cervialcanal

No movement of sac with pressure from transvaginal probe(no sliding sign)

Closed internal os

Diagnosis

Clinical- painless vaginal bleeding/crampy pain

1/3massive harmorrhage

Very rarely>20 weeks

Imaging- USG: true cervical pregnancy vs ongoing spontaneous abortion: no sliding sign

MRI pelvis

D/D:

Carcinoma, cervical/prolapsed submucosal leiomyoma

Trophoblastic tumor

Placenta praevia

Evacuation and cervical packing with haemostatic agent as fibrin glue and gauze.

Lateral cervical suture placement

Cervical cerclage

Angiographic Arterial embolization

Laparotomy-uterine artery& internal iliac artery ligation

If bleeding continues or extensive rupture occurs hysterectomy is needed.

Cervical pregnancy-Management

Medical treatment with MTX,KCL

surgical dilation & curettage

feta

l ca

rdia

c

activity-

MultidoseMTX+KCL injection

MC type of non tubal ectopic

Aetiology:

* Pelvic adhesions.

* Favourable ovarian surface for implantation as in ovarian endometriosis.

Pathogenesis:

* Fertilization of the ovum inside the ovary or,

* implantation of the fertilized ovum in the ovary.

Spiegelberg criteria(1878)

* The gestational sac located in the region of the ovary,

* the ectopic attached to the uterus by the ovarian ligament,

* ovarian tissue in the wall of the gestational sac is proved histologically,

* the tube on the

involved side is intact.

Misdiagnosis very common(Ruptured corpus lutealcyst75%)

Laparotomy ovarian cystectomy/wedge resection for unruptured and oophorectomy for ruptured.

Treatment with MTX and prostaglandin injection has also been reported

primaryabdominal pregnancy

• Studifords criteria for diagnosis • Presence of normal tubes & ovaries with no evidence of recent or

past pregnancy

• No e/o uteroplacental fistula

• presence of a pregnancy related exclusively to the peritoneal surface & early enough to eliminate the possibility of secondary implantation after primary tubal nidation

Secondary

• usually after tubal rupture or abortion

• conceptus escapes out through a rent from primary site –Intraperitoneal or Extraperitoneal broad ligament

Intraligamentouspregnancy

• type of abdominal but extraperitoneal pregnancy. It develops between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the myometrium) pregnancy.

Diagnosis:

History: amenorrhoea an attack of lower abdominal pain & slight vaginal bleeding which subsided spontaneously., painful FM

Abdominal examination:

Unusual transverse or oblique lie.

Foetal parts are felt very superficial with no uterine muscle wall around.

Vaginal examination:

The uterus is soft, about 8 weeks and separate from the foetus.

Displaced uterine cervix

No presenting part in the pelvis.

Special investigations:

Plain X-ray: shows abnormal lie. In lateral view, the foetus overshadows the maternal spines .

Ultrasound: diagnoses only 40%,shows no uterine wall around the foetus

(MRI): has a particular importance in preoperative detection of placental anatomic relationships.

If pregnancy continues to termPerinatal mortality& morbidity is also increased(IUGR, congenital anomalies, fetal pulmonary hypoplasia, pressure deformities)maternal morbidity& mortality highly increased(7-8X, 50X)

laparotomy with removal of sac,fetus,placenta,membranes

placenta if attached to vital structures -left in situ

after ligating base

Placental involution serial USG, BHCG

MTX treatment contraindicated -high rate of complications due to rapid tissue necrosis

ANGULAR PREGNANCY

Implantation at lateral angle of

uterine cavity just medial to

uterotubal junction

In true sense not variety of

ectopic pregnancy

Confused with interstitial

pregnancyround ligament lies

medial to it.

intrauterine+ extrauterinepregnancy coexist

1:1001:30000

ART patients

Delayed diagnosis

Serial B HCG NOT useful

Surgical treatment of ectopic & intrauterine if desired Continue

Spontaneous abortion high

Newly highlighted

Prior CS csar, outside normal uterine cavity

Completely surrounded by myometrium & fibrous

I: 1:800-1:2200

Imaging: sac well perfused(i/c/t avascular aborting GS)

USG criteria:

Trophoblast located b/w blader and anterior abdominal wall

Fetal pole absent in uterine cavity

Sagittal view through amniotic sac no myometrium b/w GS and bladder

Lack of continuity of anterior uterine wall

Management: no role of expectant mgt –risk- uterine rupture

MTX, Hysteroscopic resection, uterus preserving wedge resection, hysterectomy

Pregnancy after hysterectomy

Supracervicalhysterectomy provides cervical canal intraperitoneal access

Pregnancy in periop period with implantation of already fertilized ovum in tube

After TAH secondary to vaginal mucosal defect that allows sperm into abdominal cavity

Twin/multiple ectopic pregnancies- less frequent

Variety of locations and combinations

ART

Treatment: similar to others

Multiple ectopic pregnancy

• In comparing systemic methotrexate with tube-sparing laparoscopic surgery, randomized trials have shown no difference in overall tubal preservation, tubal patency, repeat ectopic pregnancy, or future pregnancies

good and consistent evidence

(Level A):

• An increase in serum hCG of < 53% in 48 hr confirms an abnormal pregnancy.

• With an hCG level of > 5,000 mIU/mL, multiple doses MTX may be appropriate.

• MTX can be considered in those women with a confirmed, or high clinical suspicion of, ectopic pregnancy who are hemodynamically stable with an unruptured mass.

• Failure of the hCG level to decrease by at least 15% from day 4 to day 7 after MTX administration treatment failure requiring therapy with either additional MTX / surgical intervention.

• Post-treatment hCG levels monitored until a nonpregnancylevel is reached

limited or inconsistent evidence

(Level B):

• If the initial hCG level is less than 200 mU/mL, 88% of patients experience spontaneous resolution.

consensus and expert opinion (Level C):

Surgical management of tubal pregnancy laparoscopic approach to the surgical management of tubal

pregnancy, in the haemodynamically stable patient, is preferable to an open approach.( A: evidence Ia)

Management of tubal pregnancy in the presence of haemodynamic instability should be by the most expedient method. In most cases this will be laparotomy.( C:evidenceIV)

In the presence of a healthy contralateral tube there is no clear evidence that salpingotomy should be used in preference to salpingectomy(B:EvidenceIIa).

Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contralateral tubal disease and the desire for future fertility. (B:EvidenceIIa).

Medical management of tubal pregnancy Medical therapy should be offered to suitable women, and units

should have treatment and follow-up protocols for the use of methotrexate in the treatment of ectopic pregnancy(B:EvidenceIIa)..

If medical therapy is offered, women should be given clear information (preferably written) about the possible need for further treatment and adverse effects following treatment. Women should be able to return easily for assessment at any time during follow-up. (B:EvidenceIIa).

Women most suitable for methotrexate therapy are those with a serum hCG below 3000 iu/l, and minimal symptoms. (B:EvidenceIIa).

Outpatient medical therapy with single-dose methotrexate is associated with a saving in treatment (A: evidenceIb)

Expectant management of pregnancy of unknown location

Expectant management is an option for clinically stable women with minimal symptoms and a pregnancy of unknown location. (C:EvidenceIII)

Expectant management is an option for clinically stable asymptomatic women with an ultrasound diagnosis of ectopic pregnancy and a decreasing serum hCG, initially less than serum 1000 iu/l. (C:EvidenceIII)

Persistent trophoblast

When salpingotomy is used for the management of tubal pregnancy, protocols should be in place for the identification and treatment of women with persistent trophoblast.( EvidenceIV)

Anti-D immunoglobulin

Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin. .( EvidenceIV)

Patient involvement

Women should be carefully advised, whenever possible, of the advantages and disadvantages associated with each approach used for the treatment of ectopic pregnancy. They should participate fully in the selection of the most appropriate treatment. .( EvidenceIV)

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