History

Lawson Tait – first successful

salpingectomy;1884

Stromme – first conservative

surgery(salpingostomy); 1953

Medical Management

Surgical Management

Surgically administered medical

management

Expectant Management

In case of unruptured pregnancies.

Methotrexate

Antineoplastic drug

Acts as a Folic acid antagonist

ADVANTAGES:

Avoids surgery and anaesthesia

Less expense

Less tubal damage

More chance of future fertlity

CRITERIA FOR SELECTION

Haemodynamically stable

No intrauterine pregnancy on ultrasound

No tubal rupture

Size of ectopic < 4cm

If there is fetal cardiac activity use with caution

βhCG level preferably < 3000 IU/L

Investigations : Full blood count, LFT and

RFT

Exposure to sun should be avoided

Folic acid tablets should not be given

‘Seperation pain’

If medical management fails surgery is

indicated and it becomes necessary in

about 10% women

After methotrexate administration, βhCG is

better for monitoring and ultrasound is not

used

SINGLE DOSE REGIMEN

Single dose of methotrexate

MULTIPLE DOSE REGIMEN

Methotrexate & Leucovorin on alternate days to a

maximum of 4 doses

TWO DOSE REGIMEN

Second dose of methotrexate on day 4

Both conservative surgery & salpingectomy can

be performed at laparoscopy and laparotomy.

Laparoscopy is preferable.

But the laparoscopic experience of the surgeon

and the haemodynamic stability of the patient

matters.

Conservative measures are indicated when the

woman has not completed her family.But in 5%

cases, persistent ectopic has been noted and

hence serial serum βhCG is indicated.

LINEAR SALPINGOSTOMY

In ampullary ectopic

A linear incision is made on the antimesenteric border of the tube immediately over the ectopic and the products will extrude out.

SEGMENTAL RESECTION

When the ectopic is at the isthmus

Segmental resection is followed by isthmoampullaryanastomosis, if necessary.

SALPINGECTOMY

The safest and complete method ,provided the other tube is normal. Ipsilateral ovary should be conserved.

INDICATIONS:

When the tube is not salvageable

Uncontrolled bleeding from the tube

Recurrent ectopic occurs in the same tube

Childbearing is complete

Previous sterilisation

PERSISTENT ECTOPIC

Diagnosed by plateauing or rising serum βhCG values following salpingostomy.

Under ultrasound guidance, direct injection of

a drug is given into the ectopic.

Methotrexate, patassium chloride,

hyperosmolar glucose and PGF2α can be used.

Direct injection of KCl into the sac can be

combined with medical management , in case

of a live ectopic otherwise suited for medical

management.

This is not much employed today.

Option for clinically stable asymptomatic women with an ultrasound diagnosis of ectopic pregnancy and initial serum βhCG below the discriminatory zone (preferably <1000 IU/L) and subsequent falling levels.

These women should be counselled properly and should be within easy reach of the hospital.

Monitoring should be with serial serum βhCG twice weekly.

Infertility (fertility rate around 65%)

Repeat Ectopic (risk of a future ectopic is about

12%)

Heterotopic Pregnancy

Interstitial and Cornual Pregnancy

Intraligamentous Pregnancy

Abdominal Pregnancy

Cervical Pregnancy

Ovarian Pregnancy

An ectopic pregnancy coexists with an

intraabdominal pregnancy.

Incidence has increased from 1 in

30,000 pregnancies in the past to 1 in

100 pregnancies.

Serial monitoring of serum βhCG is not

helpful.

Management : Surgical

Interstitial : In the proximal intramural part of the tube

Cornual : In the upper and lateral uterine cavity

Involves myometrium and advance to a later

stage (even upto 16 weeks).

USG shows a bulge in the cornual area, with an extremely thin myometrial mantle surrounding gestational sac. The sac should be located more than 1cm from the endometrial echo.

The pregnancy can also be in a rudimentary horn of a bicornuate uterus, usually the horn is non communicating. If diagnosed earlier, excision of the rudimentary horn and the tube of the affected side can be done.

Within the broad ligament

Rare; due to penetration of the tubal wall

by the trophoblast and its advancement

between the two layers of the broad

ligament.

Usually secondary; after early tubal

rupture or abortion. The fertilised ovum

implants on the peritoneum and continues

to grow.

A primary abdominal pregnancy is

extremely rare.

STUDIFORD CRITERIA

Both tubes and ovaries should be normal

Uteroperitoneal fistula should not be seen

The pregnancy is related exclusively to the peritoneal

surface.

In abdominal pregnancy,

Nausea and abdominal pain

Malpresentations and superficial fetal parts

Braxton-Hicks contractions not felt

USG : Absence of uterine outline over the fetus

Management : Laparotomy and removal of fetus

Complications : Torrential haemorrhage due to lack of constriction of open vessels after placental seperation

Unless placenta is implanted over vital structures or major blood vessels it should be removed. Or else left in situ and autolysis awaited.

Monitored by serial ultrasound and serum βhCGlevels.

Methotrexate can be given.

Implantation in the endocervical canal below the internal os.

Predisposing factorsPrevious dilatation and curettage

Previous caesarean section

Most common symptom – Painless vaginal bleeding

Usually diagnosed incidentally during a routine scan or during evacuation of a suspected abortion.

Blood flow around the sac is more suggestive of a true cervical pregnancy.

Colour doppler can be used to differentiate between a true cervical pregnancy and an intact gestational sac passing through cervix.

Rubin Criteria: There should be cervical glands opposite the placental

attachment.

Attachment of placenta to cervix should be below the entrance of the uterine vessels or below the peritoneal reflection.

Fetal elements should not be present in the corpus uteri.

Ultrasound Criteria: Empty uterus

Hourglass shape of uterus

Ballooned out cervical canal

Gestational sac and placental tissue

in the cervical canal

Closed internal os

First choice : Medical treatment with

multiple dose methotrexate.

Radiological uterine artery embolisation

followed by evacuation. Bilateral internal

iliac artery ligature has also been tried.

Hysterectomy

Implantation in the ovary

Very rare

Usual consequence : Rupture at an early stage

Management : Surgery; ovariotomy

Methotrexate if diagnosed earlier

Spiegelberg Criteria: The tube on the affected side should be intact.

Fetal sac should occupy the position of the ovary.

Ovary should be connected to the uterus by the ovarian ligament.

Definite ovarian tissue should be found in the sac wall.

In women with a previous caesarean section.

Diagnostic criteria:

An empty uterine cavity

A gestational sac located anteriorly at the level of

the internal os covering the visible or presumed

site of the previous lower uterine segment

caesarean section scar

Evidence of functional trophoblastic /placental

circulation on Doppler examination

An absent “sliding sign” (inability to displace the

gestational sac from its position at the level of

internal os using gentle pressure applied by the

transvaginal probe)