Prof. M.C.BansalProf. M.C.BansalMBBS,MS,MICOG,FICOGMBBS,MS,MICOG,FICOG

Professor OBGYProfessor OBGYEx-Principal & ControllerEx-Principal & Controller

Jhalawar Medical College & HospitalJhalawar Medical College & HospitalMahatma Gandhi Medical College, Jaipur. Mahatma Gandhi Medical College, Jaipur.

DEFINITIONDEFINITION

““Any pregnancy where the fertilised ovum Any pregnancy where the fertilised ovum gets implanted & develops in a site other gets implanted & develops in a site other than normal uterine cavity”.than normal uterine cavity”.

It represents a serious hazard to a woman’s It represents a serious hazard to a woman’s health and reproductive potential, requiring health and reproductive potential, requiring prompt recognition and early aggressive prompt recognition and early aggressive interventionintervention..

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

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 ExtraperitonealBroad Ligament (rare)

INCIDENCEINCIDENCE

• Increased due to PID, use of IUCD, Tubal Increased due to PID, use of IUCD, Tubal surgeries, and Assisted reproductive surgeries, 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 normal Average 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

ETIOLOGYETIOLOGY::

Any factor that causes delayed transport Any factor that causes delayed transport of the fertilised ovum through the tube.of the fertilised ovum through the tube.

Fallopian tube favours implantation in the Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal mucosa itself thus giving rise to a tubal ectopic pregnancy.tubal ectopic pregnancy.

These factors may be These factors may be CongenitalCongenital or or AcquiredAcquired..

ETIOLOGYETIOLOGY

CONGENITALCONGENITAL

• Tubal Hypoplasia Tubal Hypoplasia • Tortuosity Tortuosity • Congenital diverticuli Congenital diverticuli • Accessory ostia Accessory ostia • Partial stenosisPartial stenosis• ElongationElongation• Intamural polyp Intamural polyp • Entrap the ovum on its way.Entrap the ovum on its way.

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%

Tubal sterilization faliure -40%Tubal sterilization faliure -40% Depends on sterilization technique and age of Depends 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 of Depends 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%

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

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

Iffy hypothesis Iffy hypothesis ––

“ “Theory of reflux” menstural fluid throw the Theory 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

EvolutionEvolution

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

The pregnancy is unable to survive owing The pregnancy is unable to survive owing to its poor blood supply, thus resulting in a to its poor blood supply, thus resulting in a tubal tubal abortionabortion and and resorptionresorption, or it is , or it is expelled from the fimbriated end into the expelled from the fimbriated end into the abdominal cavity.abdominal cavity.

The pregnancy continues to grow until the The pregnancy continues to grow until the overdistended tube overdistended 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

Abortion Abortion is common in is common in ampullary ampullary pregnancies,pregnancies,whereaswhereas rupture rupture is in is in isthmic.isthmic.

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

Pictures showing TUBAL ABORTION

CLINICAL APPROACHCLINICAL APPROACH

Dignosis can be done by history, detail examination Dignosis can be done by history, detail examination and judicious use of investigation.and judicious use of investigation.

H/o past PID, tubal surgery,current contraceptive H/o past PID, tubal surgery,current contraceptive measures should be askedmeasures should be asked

Wide spectrum of clinical presentation from Wide spectrum of clinical presentation from asymtomatic pt to others with acute abdomen and in asymtomatic pt to others with acute abdomen and in shock.shock.

ACUTE ECTOPIC PREGNANCYACUTE ECTOPIC PREGNANCY

Classical triadClassical triad is present in 50% of pt with is 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, syncope Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to reflex vasomotor disturbance.attack(10%) due to reflex vasomotor disturbance.

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 lower abdomen tense, tender mostly in lower abdomen,shifting dullness, rigidity may be abdomen,shifting dullness, rigidity may be present.present.

P/S:-P/S:- minimal bleeding may be present minimal bleeding may be present

P/V:-P/V:- uterus may be bulky, deviated to opposite uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain on side, 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.

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 from Patient had previous attack of acute pain from which she has recovered.which she has recovered.

She may have amenorrhoea, vaginal bleeding She may have amenorrhoea, vaginal bleeding with dull pain in abdomen,and with bladder and with dull pain in abdomen,and with bladder and bowel complaints like dysuria,frequency or bowel complaints like dysuria,frequency or retention of urine, rectal tenesmus.retention of urine, rectal tenesmus.

O/E:-O/E:- patient look ill, varying degree of pallor, patient look ill, varying degree of pallor, slightly raised temperature. Features of shock slightly raised temperature. Features of shock are absent.are absent.

P/A:-P/A:- Tenderness and muscle guard on the lower Tenderness 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 normal Vaginal mucosa pale, uterus may be normal in size or bulky, ill defined boggy tender in 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.

UNRUPTURED ECTOPICUNRUPTURED ECTOPIC

High degree of suspicion & ectopic conscious High degree of suspicion & ectopic conscious clinician can diagnose.clinician can diagnose.

Diagnosed accidentally in Laparoscopy or Diagnosed 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

DIAGNOSISDIAGNOSIS

““Pregnancy in the fallopian tube is a black Pregnancy in the fallopian tube is a black cat on a dark night. It may make its cat on a dark night. It may make its

presence felt in subtle ways and leap at you presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is or it may slip past unobserved. Although it is

difficult to distinguish from cats of other difficult to distinguish from cats of other colours in darkness, illumination clearly colours in darkness, illumination clearly

identifies it.” identifies it.” --Mc. Fadyen - 1981--Mc. Fadyen - 1981

DIAGNOSISDIAGNOSIS In recent years, inspite of an increase in the In recent years, inspite of an increase in the

incidence of ectopic pregnancy there has been a incidence 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 of This is due to the widespread introduction of

diagnostic tests and an increased awareness of diagnostic 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 effective This 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%.

DIAGNOSISDIAGNOSIS Patient with acute ectopic can be diagnosed Patient with acute ectopic can be diagnosed

clinically.clinically.

Blood should be drawn for Hb gm%, blood grouping Blood 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 of ELISA is sensitive to 10-50 mlU/ml of ββ hCG and hCG and can be detected on 24can be detected on 24thth day after LMP. day after LMP.

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 fornix puncture 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 1500 hCG level as low as 1500 IU/L .IU/L .

Endometrial cavity Endometrial 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 endometrial All pregnancies induce an endometrial

decidual reaction, and sloughing of the decidua can decidual reaction, and sloughing of the decidua can create an intracavitary fluid collection called a create an intracavitary fluid collection called a pseudosacpseudosac

Early gestational sacEarly gestational sac PseudosacPseudosac locationlocation below the midline echo along the below the midline echo along the burried into endometium cavity line b/wburried into endometium cavity line b/w endometrial layersendometrial layers shapeshape usually round may change,oviod usually round may change,oviod borders borders double ring single layer double ring single layer color flow color flow high avascularhigh avascular patternpattern peripheral flow peripheral flow

DECIDUAL CYSTDECIDUAL CYST It is identified as an anechoic area lying with in the It is identified as an anechoic area lying with in the

endometrium but remote from the canal and often at endometrium but remote from the canal and often at the endometrial-myometrial border.the endometrial-myometrial border.

Adenxa Adenxa - 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 be hypoechoic area caused by subserosal edema can be seen.seen.

Rectouterine cul-de-sacRectouterine cul-de-sac Free peritonial fluid with an adnexal mass Free peritonial fluid with an adnexal mass suggestive of ectopic pregnancysuggestive of ectopic pregnancy

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 flow and 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 gestational hCG level at which intrauterine gestational sac is seen by TAS is 1800 IU/L.sac is seen by TAS is 1800 IU/L.

USG PICTUREUSG PICTURE

1.‘Bagel’ sign – Hyperechoic ring around gestational 1.‘Bagel’ sign – Hyperechoic ring around gestational sac in adnexal regionsac in adnexal region

2. ‘Blob’ sign – Seen as small inconglomerate mass 2. ‘Blob’ sign – Seen as small inconglomerate mass next to ovary with no evidence of sac or next to ovary with no evidence of sac or embryo.embryo.

3. Adnexal sac with fetal pole and cardiac activity is 3. Adnexal sac with fetal pole and cardiac activity is most specific.most specific.

4. Corpus luteum is useful guide when looking for 4. 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.

Hyperechoic ring around Hyperechoic ring around gestational sac in adnexal regiongestational sac in adnexal region

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

2. 2. ββ-HCG Assay--HCG Assay-

a) Single a) Single ββ-HCG: little value-HCG: little value b) Serial b) 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 intrauterine ectopic pregnancy or nonviable intrauterine pregnancy .pregnancy .

Biochemical pregnancy is applied to those Biochemical pregnancy is applied to those women who have two women who have two ββ-HCG values >10 IU/L-HCG values >10 IU/L

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 is Can 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.

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 ectopic suggestive 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 value PAPPC (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 ectopic Maternal serum AFP elevated in ectopic pregnancy.pregnancy.

SUSPECTED ECTOPIC PREGNANCYSUSPECTED ECTOPIC PREGNANCY Urine Pregnancy test positiveUrine Pregnancy test positive

Transvaginal USG

IU sac No IU sacQuantitative S-hCG

+ S progesterone

< 66% rise in 48 hr orS progesterone < 5-10 ng/ml

D & C

Villi present Villi absentIncomplete abortion

Laparoscopy

>66% rise in 48 hr orS progesterone > 5-10 ng/mlRepeat S-hCG in 48 hrs till USG discrimination zone

No sac IU sac Continue to monitor

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 cyst 2. 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

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

MANAGEMENTMANAGEMENT

Expectant management

Medicalmanagement

Surgicalmanagement

Local Systemic(USG or Laparoscopic)

salpingocentesis- Methotrexate- Potassium chloride- Prostagladin(PGF2α)- Hypersmolar glucose- Actinomycin D- Mifepristone

Methotrexate

RadicalSalpingectomy

Conservative

-Salpingostomy

-Salpingotomy

- Segmental resection

-Milking or fimbrial expression

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, BT, - Blood sample for Hb, blood grouping & cross matching, BT,

CTCT - 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.

MANAGEMENT OF UNRUPTURED MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCYECTOPIC PREGNANCY

OPTIONS: -OPTIONS: - SURGICAL-SURGICAL- SURGICALLY ADMINISTERED MEDICAL SURGICALLY ADMINISTERED MEDICAL

(SAM) TREATMENT(SAM) TREATMENT MEDICAL TREATMENTMEDICAL TREATMENT EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENTIDENTIFICATION 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. Initial 5. Initial ββ HCG <1000 IU/L and falling in titre HCG <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/L HCG monitoring 3-4 days until it is <10 IU/L

- TVS to be done twice a week.- TVS to be done twice a week.

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

Spontaneous resolution occurs in 72%,while 28% will Spontaneous resolution occurs in 72%,while 28% will need laparoscopic salpingostomyneed laparoscopic salpingostomy

In spontaneous resolution, it may take 4-67 days In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non (mean 20 days) for the serum HCG to return to non pregnant level.pregnant level.

The percentage fall in serum HCG by day 7 is a The 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 known to Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low.rupture even when Serum HCG levels are low.

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

Surgery is the mainstay of T/t worldwideSurgery is the mainstay of T/t worldwideMedical 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.

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

METHOTREXATE:METHOTREXATE: It can be used as oral,intramuscular ,intravenous usually It can be used as oral,intramuscular ,intravenous usually

along with folinic acid.along with folinic acid.

Resolution of tubal pregnancy by systemic administration of Resolution 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 in Mostly used for early resolution of placental tissue in

abdominal pregnancy.Can also be used for tubal pregnancy.abdominal pregnancy.Can also be used for tubal pregnancy.

Mechanism of action-Mechanism of action-Methotrexate is a folic acid Methotrexate is a folic acid antagonist that inactivates the enzyme dihydrofolate antagonist that inactivates the enzyme dihydrofolate reductase.reductase.Interferes with the DNA synthesis by inhibiting Interferes with the DNA synthesis by inhibiting the synthesis of pyrimidines leading to trophoblastic cell the synthesis of pyrimidines leading to trophoblastic cell death. Auto enzymes and maternal tissues then absorb the death. Auto enzymes and maternal tissues then absorb the trophoblast.trophoblast.

Contd……Contd……

Advantages –Advantages –• Minimal Hospitalisation.Usually outdoor Minimal 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, LFT Monitoring is essential- Total blood count, LFT

& serum HCG once weekly till it becomes & serum HCG once weekly till it becomes negativenegative

SURGICALLY ADMINISTERED MEDICAL Tt SURGICALLY ADMINISTERED MEDICAL Tt (SAM)(SAM)

AimAim- trophoblastic destruction without systemic - trophoblastic destruction without systemic side effectsside effects

TechniqueTechnique- Injection of trophotoxic substance into - Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube the ectopic pregnancy sac or into the affected tube by-by-

• Laparoscopy orLaparoscopy or• Ultrasonographically guided Ultrasonographically guided

Transabdominal (Porreco, 1992)Transabdominal (Porreco, 1992) Transvaginal (Feichtingar, 1987)Transvaginal (Feichtingar, 1987)

• With Falloposcopic control (Kiss, 1993)With Falloposcopic control (Kiss, 1993)

Trophotoxic substances used-Methtrexate (Pansky, 1989)Potassium Chloride (Robertson, 1987) Mifiprostone (RU 486)PGF2 (Limblom, 1987)Hyper osmolar glucose solutionActinomycin 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)

INSTRUCTION TO THE PATIENTSINSTRUCTION TO THE PATIENTS

If T/t on outpatient basis rapid transportation should If T/t on outpatient basis rapid transportation should be availablebe available

Refrain from alcohol, sunlight, multivitamins with Refrain from alcohol, sunlight, multivitamins with folic acid, and sexual intercourse until S-hCG is folic 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 is abdominal 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 % require Chance of tubal rupture in 5-10 % require

emergency Laparotomy. emergency Laparotomy.

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 on depends on

- Location and size of gestational sac- Location and size of gestational sac

- Condition of tubes- Condition of tubes

- Accessibility- Accessibility

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 gentle and 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

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.

DEBATABLE ISSUESDEBATABLE ISSUES

?? Salpingectomy Vs SalpingostomySalpingectomy Vs Salpingostomy

?? Laparotomy Vs LaparoscopyLaparotomy Vs Laparoscopy

?? Reproductive outcome Reproductive outcome

?? Risk of Recurrent Ectopic Risk of Recurrent Ectopic

SALPINGECTOMY SALPINGECTOMY VS VS

SALPINGOSTOMY / SALPINGOTOMYSALPINGOSTOMY / SALPINGOTOMY

All tubal pregnancies can be treated by partial or All tubal pregnancies can be treated by partial or total Salpingectomytotal Salpingectomy

Salpingostomy / Salpingotomy is only indicated Salpingostomy / Salpingotomy is only indicated when: when:

1.1. The patient desires to conserve her fertilityThe patient desires to conserve her fertility2.2. Patient is haemodinamically stablePatient is haemodinamically stable3.3. Tubal pregnancy is accessibleTubal pregnancy is accessible4.4. Unruptured and < 5Cm. In sizeUnruptured and < 5Cm. In size5.5. Contralateral tube is absent or damagedContralateral tube is absent or damaged

CONTD……CONTD……

The choice of surgical treatment does not influence the The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after associated with a marked reduction in fertility after treatment.treatment.

Making the choice –Making the choice – Chapron et al (1993) have Chapron et al (1993) have described a scoring system, based on the patient’s described a scoring system, based on the patient’s previous gynaecological history and the appearance of previous 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.

Fertility reducing factorFertility reducing factor ScoreScore• Antecedent one Ectopic pregnancyAntecedent one Ectopic pregnancy 2 2• Antecedent each further Antecedent each further Ectopic pregnancyEctopic pregnancy 1 1• Antecedent AdhesiolysisAntecedent Adhesiolysis 1 1• Antecedent Tubal micro surgeryAntecedent Tubal micro surgery 2 2• Antecedent SalpingitisAntecedent Salpingitis 1 1• Solitary tubeSolitary tube 2 2• Homolateral AdhesionsHomolateral Adhesions 1 1• Contralateral AdhesionsContralateral Adhesions 1 1

• The rationale behind the scoring system is to decide the risk of The 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 or while radical treatment is to be performed if the score is 5 or more.more.

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 present Laparotomy, 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 or Is similar in pt treated with either Laparoscopy or

Laparotomy.Laparotomy. Identical rates of 40% of IUP, around 12% risk of Identical rates of 40% of IUP, around 12% risk of

recurrent pregnancy with either radical or recurrent pregnancy with either radical or conservative pregnancy.conservative pregnancy.

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 the 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 stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch. 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 SALPINGOTOMY LAPAROSCOPIC SALPINGOTOMY To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml To 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 longitudinal Then the tube is opened through an antimesenteric longitudinal

incision over the tubal pregnancy by a incision over the tubal pregnancy by a – CoCo2 2 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 with Laparoscopic 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.

PERSISTENT ECTOPIC PREGNANACYPERSISTENT ECTOPIC PREGNANACY This is a complication of salpingotomy / salpingostomy This is a complication of salpingotomy / salpingostomy

when residual trophoblast continues to survive because of when 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 postoperative Diagnosis is made because of a raised postoperative ββ HCG HCG If untreated, can cause life threatening hemorrhageIf untreated, can cause life threatening hemorrhageRisk 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 serum 3. Preoperative high serum ββ HCG (> 3,000 IU/L) and HCG (> 3,000 IU/L) and postoperative Day1 titre is < 50% of preoperative level, is postoperative 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.

TreatmentTreatmentsurgery

Total or partialsalpingectomy

Medical(selected Asymptomatic pt)

MTX + Leukovorin

OVARIAN ECTOPIC PREGNANCYOVARIAN ECTOPIC PREGNANCYIncidence: Incidence: 1:40,0001:40,000Risk factor: - Risk factor: - IUCDIUCD - Endometriosis on surface of ovary- Endometriosis on surface of ovaryCourse: Course: C/F are same as tubal pregnancyC/F are same as tubal pregnancy ruptures within 2-3 wksruptures within 2-3 wksDiagnosis: Diagnosis: On LaparotomyOn LaparotomySpiegelberg’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/M

Ruptured

LaparotomyOophorectomy

Unruptured

Ovarian wedge resectionOvarian Cystectomy

ABDOMINAL PREGNANCYABDOMINAL PREGNANCYIncidence:Incidence: RarestRarestMMR :MMR : 7-8 times > tubal ectopic7-8 times > tubal ectopic 90 times > Intrauterine pregnancy90 times > Intrauterine pregnancyH/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 abdomenO/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

Diagnosis:Diagnosis: Confirmed by USG,Confirmed by USG, CT scan, MRI, RadiographyCT scan, MRI, Radiography

TYPETYPE

Primary SecondaryStudiford’s criteria

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 implantation

Conceptus escapes out through a rent from primary site

Intraperitoneal ExtraperitonealBroad ligament

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 intraperitoneal 2. 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, adipocere 4. 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

CERVICAL PREGNANCYCERVICAL PREGNANCY

Implantation occurs in cervical canal at or below internal Implantation 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 abortion Previous induced abortion - Previous caesarean delivery- Previous caesarean delivery - Asherman’s syndrome- Asherman’s syndrome - IVF - IVF - DES exposure- DES exposure - Leiomyoma- Leiomyoma

Diagnosis:Diagnosis:CLINICAL CRITERIACLINICAL CRITERIA:: Paulman & McEllinPaulman & McEllin 1. Uterine bleeding, no cramping, following 1. 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-gestational 1. 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

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 be 2. 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

MANAGEMENTMANAGEMENT

SurgicalMainstay therapy in past

Radical surgery

Hysterectomy

ConservativeD & 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

MedicalRecently proposedSingle or Combination ORAdjunct to surgery

- Methotrexate

- Actinomycin

- KCl

- Etoposide

CORNUAL PREGNANCYCORNUAL PREGNANCY

SITE:SITE: Implantation occurs in rudimentary horn of Bicornuate Implantation 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 with 2. 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 sometime Implantation into cornu of normal uterus is sometime called called 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 communication with Cx is patentcommunication with Cx is patent

HETEROTYPIC PREGNANCYHETEROTYPIC PREGNANCY

Co-existing intrauterine and extra uterine pregnanciesCo-existing intrauterine and extra uterine pregnanciesIncidence: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 technique a) 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 removed Depends on the site. Ectopic site may be removed with continuation of IU pregnancywith continuation of IU pregnancy

(Rh Immunoglobulin: (Rh Immunoglobulin: dose of 50 dose of 50 μμ gm is sufficient to gm is sufficient to prevent sensitization.)prevent sensitization.)

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 in There is high risk of uterine rupture in subsequent pregnancy.subsequent pregnancy.

RuptureRupture – Hysterectomy is indicated – Hysterectomy is indicated

CAESAREAN SCAR ECTOPIC PREGNANCYCAESAREAN SCAR ECTOPIC PREGNANCY

Recently reportedRecently reported USG slows on empty uterine cavity and gestational USG slows on empty uterine cavity and gestational

sac attached low to the lower segment caesarean sac attached low to the lower segment caesarean scar.scar.

C/FC/F : : similar to threatened or inevitable abortion similar to threatened or inevitable abortion

Diagnosis Diagnosis :: Doppler imaging confirms Doppler imaging confirms

T/t :T/t : Methotrexate injection Methotrexate injection Hysterectomy in a multiparous women.Hysterectomy in a multiparous women. In young pt resection & suturing of scar may be In young pt resection & suturing of scar may be done (high risk of rupture).done (high risk of rupture).

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% mainly MORTALITY : In general population is 10-15% mainly due to haemorrhage.due to haemorrhage.

SUMMARY - KEY POINTSSUMMARY - KEY POINTS

Incidence of ectopic pregnancy is rising while maternal Incidence 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 , high with 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 to There 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 unruptured The choice today is Laparoscopic treatment of unruptured ectopic pregnancy. ectopic pregnancy.

Careful monitoring and proper counselling of patients is Careful monitoring and proper counselling of patients is mandatory.mandatory.