ECTOPIC PREGNANCY

TUBAL…..

NON-TUBAL PUL

Dr. Mohamed Hesham Mokhtar

Prof. Obstetrics & Gynecology
AL AZHAR UNIVERSITY
Cairo-2022
 DEFINITION
Ectopic: (Ektopos) out of place or misplaced
“Any pregnancy where the fertilised ovum gets implanted &
develops outside or 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 intervention.
 IMPLANTATIONS SITES

EXTRAUTERINE UTERINE
-CERVICAL
TUBAL 95-96% OVARIAN ABDOMINAL (1:18,000)
(1:40,000) (1:10,000) -ANGULAR
-Ampulla 70% -CORNUAL
-Isthmus 12% -CAESAREAN
PRIMARY SECONDARY
-Infundibulum 11% SCAR (<1)
-Interstitial &
cornual 2% Intraperitoneal Extraperitoneal
Broad Ligament
(rare)
 INCIDENCE

• Increased due to PID, use of IUCD, Tubal surgeries,

and Assisted reproductive techniques (ART).
• Ranges from 1:25 to 1:250
• Average range is 1 in 100 normal pregnancies.
• Late marriages and late child bearing -> 2%
• ART -> 5%
• Recurrence rate - 15% after 1st, 25% after 2 ectopics
 Mechanical factors
• Congenital: long narrow tube, diverticulae and accessory ostia.

• Traumatic: operation on the tube as salpingoplasty and 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 antiperistaltic contractions.

• Endometriosis in the tube. encourages embedding of the

fertilized ovum.
ETIOLOGY:
• Any factor that causes delayed
transport of the fertilised
ovum through the tube.
CONGENITAL
• Fallopian tube favours
implantation in the tubal – Tubal Hypoplasia
muscular layer itself thus – Tortuosity
giving rise to a tubal ectopic
pregnancy. (No submucosa) – Congenital diverticuli
– Accessory ostia
• These factors may be – Partial stenosis
Congenital or Acquired. – Elongation
– Intamural polyp
– Entrap the ovum on its
way.
ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common

Contraceptive Faliure
Cu.T - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%
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
- Depends on 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

Factors facilitating nidation of ovum in tube:

- Premature degeneration of zona pellucida
- Increased decidual reaction
- Tubal endometriosis
 Outcome = Evolution
• 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:
1) The pregnancy is unable to survive owing to its poor blood supply,
thus resulting in a tubal abortion and resorption, or it is expelled
from the fimbriated end into the abdominal cavity.
2) The pregnancy continues to grow until the overdistended tube
ruptures, with resulting profuse intraperitoneal bleeding.
 Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months
 Abortion is common in ampullary pregnancies,where as rupture is in isthmic.
3) In rare instances, a tubal pregnancy will be expelled from the tube
and seed onto sites in the abdominal cavity (e.g. the omentum, the
small or large bowel, or the parietal peritoneum), and gives rise to a
viable abdominal pregnancy.
1) Tubal abortion

2) Rupture of tubal pregnancy

3) Secondary abdominal pregnancy

Pathology of Ruptured Ectopic Pregnancy
 CLINICAL APPROACH

• 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 rupture ectopic.

The classic triad is amenorrhea that is followed by pain and
vaginal bleeding.

- PAIN:- most constant feature in 95% pt

- variable in severity and nature
A dull aching pain is usually present in one iliac fossa. It is due to
distension of the tube and stretching of its peritoneal coat.

- 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.
• 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 present.

• 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.
 Classic sign: –
 adnexal or cervical motion tenderness.
 (cervical motion tenderness or jumping sign) The cervix is soft and
severe pain occurs when it is moved from side to side

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, rectal tenesmus.

• O/E:- patient look ill, varying degree of pallor,

slightly raised temperature. Features of shock are absent.

• P/A:- Tenderness and muscle guard on the lower abdomen.

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.
 UNRUPTURED ECTOPIC

• High degree of suspicion & ectopic minded clinician can diagnose.

• Diagnosed accidentally in Laparoscopy or Laparotomy

C/F – delayed period, spotting with discomfort in lower abdomen.

P/A – tenderness in lower abdomen

P/V – should be done gently

uterus is normal size, firm
small tender mass may be felt in the fornix
 DIAGNOSIS
• In recent years, inspite of an increase in the incidence of ectopic
pregnancy there has been a fall in the case fatality rate.

• 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 treatment.

• Now the rate of tubal rupture is as low as 20%.

“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
DIAGNOSIS :
• Patient with acute ectopic can be diagnosed clinically.

• Blood should be drawn for Hb gm%, blood grouping and cross matching, DC and
TWBC, BT, CT.

• 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 absent 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.
• Other Investigations:-
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
.
• Faced with a positive pregnancy test, a woman
can be classified into one of five categories based
on her ultrasound findings:
Defined EP: extrauterine gestational sac with
a yolk vesicle and/or embryo with or without
cardiac activity
Probable EP: heterogeneous adnexal mass or
gestational sac-like structure
PUL: absence of IUP or EP images
Probable IUP: presence of intrauterine
echogenic gestational sac
Defined IUP: intrauterine gestational sac
with yolk vesicle and/or embryo with or
without cardiac activity.
Endometrial cavity
-A trilaminar endometial pattern seen
-pseudogestational sac
-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

Gestational sac Pseudosac

Eccentric Central
Surrounded by echogenic ring of Surrounded by single layer of tissue
trophoblast-Double Decidual Sac sign
(link)
Endometrial midline echo is seen midline echo can’t be seen
separately
D.D. between Early Intra-uterine True-
& Pseudo-gestational sacs

I n tra -u te rin e T r u e -g e sta tio n a l sa c P s e u d o -g e s ta tio n a l s a c

S c a n n in g

-U /S s c a n n in g -D .D .S .S .
-S p h e ric a l.
-E c c e n tric lo c a tio n .
-W e ll-d e fin e d
o u tlin e .
-S in g le e c h o g e n ic rin g .
-A n g u la te d .
-C e n tra l lo c a tio n .
-Irre g u la r o u tlin e .

-C o lo u r D o p p le r -T y p ic a l p a tte rn o f -A ty p ic a l p a tte rn .
s tu d y p e ri-tro p h o b la stic
b lo o d flo w
-L o w re sista n c e -H ig h re s is ta n c e
a rte ria l b lo o d flo w . a rte ria l b lo o d flo w .
 DECIDUAL CYST
It is identified as an anechoic area lying with in the endometrium
but remote from the canal and often at the endometrial-myometrial
border.
 Adenxa
- 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.
 Rectouterine cul-de-sac
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.
 ‘Bagel’ sign
USG PICTURE

1.‘Bagel’ sign – Hyperechoic ring

around gestational sac in
adnexal region

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
specific.

4. Corpus luteum is useful guide

when looking for EP as
present in 85% cases in
Ipsilateral ovary.
Ectopic (tubal) Ultrasonographic Comments
pregnancy Findings
Viable extrauterine Extrauterine gestational Presence of a yolk sac or
pregnancy sac with fetal pole and fetal pole has positive
cardiac activity predictive value of almost
100% for identifying ectopic
pregnancy
Nonviable extrauterine Extrauterine gestational Fetal pole with or without
gestation sac with a fetal pole, cardiac activity seen in 13%
without cardiac activity of ectopic pregnancies
diagnosed by
ultrasonography
Ring sign Adnexal mass with a Seen in 20% of ectopic
hyperechoic ring around pregnancies diagnosed by
a gestational sac ultrasonography
Nonhomogeneous Adnexal mass separate Seen in 60% of ectopic
mass from the ovary pregnancies diagnosed by
ultrasonography; positive
predictive value ranges from
80 to 90%
 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.
Doubling sign:
-Rise of β-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .

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 location.

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 hormonal 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.
 SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive

Transvaginal USG

IU sac No IU sac
Quantitative S-hCG
+ S progesterone

< 66% rise in 48 hr or >66% rise in 48 hr or

S progesterone < 5-10 ng/ml S progesterone > 5-10 ng/ml
D&C Repeat S-hCG in 48 hrs
till USG discrimination zone
Villi present Villi absent

Incomplete Laparoscopy No sac IU sac

abortion
Continue to monitor
 DIFFERENTIAL DIAGNOSIS

D/D of Acute Ectopic D/D OF CHRONIC (SUB ACUTE) ECTOPIC

1. Pelvic abscess
1. Rupture corpus luteum of
pregnancy
2. Pyosalpinx
2. Rupture of chocolate cyst
3. Twisted ovarian cyst
3. Subserous uterine fibroid
4. Torsion / degeneration of
pedunculated fibroid
4. Salpingintis
5. Incomplete abortion
6. Acute Appendicitis 5. Retroverted gravid uterus
7. Perforated peptic ulcer
8. Renal colic 6. Appendicular lump
9. Splenic rupture
 MANAGEMENT
Expectant Medical Surgical
management management management

Local Systemic Radical Conservative

(USG or Laparoscopic) Salpingectomy
salpingocentesis
Methotrexate
-Salpingostomy
- Methotrexate
- Potassium chloride
-Salpingotomy
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Segmental
- Actinomycin D
resection
- Mifepristone
-Milking or fimbrial
expression
 I- MANAGEMENT OF RUPTURED ECTOPIC

PRINCIPLE: Resuscitation and Laparotomy

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

LAPAROTOMY:
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.
II- MANAGEMENT OF UNRUPTURED ECTOPIC
PREGNANCY
OPTIONS: -
1) SURGICAL-
2) SURGICALLY ADMINISTERED MEDICAL (SAM)
TREATMENT
3) MEDICAL TREATMENT
4) EXPECTANT MANAGEMENT
Algorithm for the diagnosis of unruptured ectopic pregnancy
without laparoscopy.
 4) EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA (Ylostalo et al , 1993)- :
1. Tubal ectopic pregnancies only

2. Haemodynamically stable

3. Haemoperitoneum < 50ml

4. Adnexal mass of < 3.5 cm without heart beat.

5. Initial β HCG <1000 IU/L and falling in titre

SUCCESS RATE - Up to 60%

PROTOCOL:
- 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.

EXPECTANT MANAGEMENT
• 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
pregnant level.
• 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.
• Successful in 67% (2/3) of women.
• Favourable outcome with lower
initial hCG and a rapidly decreasing
hCG level, lack of an identifiable
extrauterine gestational sac on TVS,
and a reduction in the average
diameter of the adnexal mass by
day 7.
• Follow-up:
* Twice weekly hCG and weekly TVS
to ensure a rapidly decreasing hCG
level (ideally < 50% of its initial level
within 7 days) and a reduction in
the size of adnexal mass.
* Thereafter, weekly hCG and TV
USS until serum hCG levels are < 20
IU/L.
 3) MEDICAL MANAGEMENT

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
 Follow up on day1, 4 and 7.
 MEDICAL MANAGEMENT
METHOTREXATE:
• It can be used as oral,intramuscular
,intravenous usually along with folinic
acid.
• 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.
Patient selection
1) patient hemodynamically stable
2) absence of tubal rupture sign or
hemoperitoneum
3) Absent fetal pulsation
4) an adnexal mass with a diameter < or = 5
cm
5) an amenorrhea < or = 6 weeks
6) HCG levels < or = 10,000 mIU/ml ??/ 5,000

• 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.
Contd……

• Advantages –
– Minimal Hospitalisation.Usually outdoor treatment
– Quick recovery
– 90% success if cases are properly selected
• Disadvantages-
– Side effects like GI & Skin
– Monitoring is essential- Total blood count, LFT & serum
HCG once weekly till it becomes negative
2) SURGICALLY ADMINISTERED MEDICAL Tt (SAM)

• Aim- trophoblastic destruction without systemic side effects

• Technique- Injection of trophotoxic substance into the ectopic

pregnancy sac or into the affected tube by-

– Laparoscopy or
– Ultrasonographically guided
• Transabdominal (Porreco, 1992)
• Transvaginal (Feichtingar, 1987)
– With Falloposcopic control (Kiss, 1993)
 SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin 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
INSTRUCTION TO THE PATIENTS

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

 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
Laparotomy.
 1) SURGICAL MANAGEMENT OF ECTOPIC
Conservative Surgery

Can be done Laparoscopically or by microsurgical laparotomy

INDICATION:
- Patient desires future fertility

- Contralateral tube is damaged or surgically removed previously

CHOICE OF TECHNIQUE: depends on:-

- Location and size of gestational sac

- Condition of tubes

- Accessibility
 VARIOUS CONSERVATIVE SURGERIES

1.Linear Salpingostomy:
- 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
vicryl sutures.

3. Segmental Resection & Anastomosis:

- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at later
date
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, analgesic requirement.

Follow up after conservative surgery

- With weekly Serum β HCG titre till it is negative.

- If titre increases methotrexate can be given.
 DEBATABLE ISSUES

? Salpingectomy Vs Salpingostomy

? Laparotomy Vs Laparoscopy

? Reproductive outcome

? Risk of Recurrent Ectopic

 SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
 All tubal pregnancies can be treated by partial or total
Salpingectomy

 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
 CONTD……

 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 salpingectomy.
 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
ectopic pregnancy.

– 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.
Laparatomy (if the mass is greater than 3.5 cm in
diametar, internal bleeding, cardiovascular
colapse)
COMPARING LAPAROTOMY Vs LAPAROSCOPY
Laparotomy Vs Laparoscopy L’tomy L’scopy
Hospital cost More? Less?
Post operative adhesions More Less
Risk of future ectopic Same Same
Future fertility Same Same
Experience of Surgeon Trained Special
Instruments General Special
- Laparoscopy is reserved for pt who are hemodynamically stable.
- Ruptured Ectopic does not necessarily require Laparotomy, but if
large clots are present Laparotomy should be considered.
Reproductive outcome
Is similar in pt treated with either Laparoscopy or Laparotomy.
Identical rates of 40% of IUP, around 12% risk of recurrent pregnancy with
either radical or conservative pregnancy.
 LAPAROSCOPIC SALPINGECTOMY
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

LAPAROSCOPIC SALPINGOTOMY
• 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 diathermy.
– Fine diathermy knife (Lundorff, 1992)
• The tubal pregnancy is then evacuated by suction irrigation.
Surgical Steps
Management of ectopic pregnancy

11- Positive pregnancy test

Lowe abdominal pain + Asymptomatic with factors

Minimal Vaginal bleeding for ectopic pregnancy

2. History + clinical examination

If sure of date of LMP and /or If unsure of date of LMP
Regular cycle, i.e. and /or irregular cycle,
>6 wks. gestation, Measure serum hCG
Arrange TV ultrasound

If hCG <1000 If Hcg >1000, use

(?early Intrauterine/ protocol for
? Ectopic pregnancy suspected
Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000

Meet criteria for Does not meet criteria

Methorexate treatment for methotrexate treatment
Laproscopic /salpingotomy/
Use methotrexate Salpingectomy ?Proceed to
protocol laparotomy OR Laparotomy if
haemodynamically unstable
  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.

Surgery Treatment Medical

(selected Asymptomatic pt)
Total or partial MTX + Leukovorin
salpingectomy
 UNCOMMON E.P.

Diagram shows the locations and incidence rates of uncommon ectopic pregnancies.
  OVARIAN ECTOPIC PREGNANCY
Incidence: 1:40,000
Risk factor: - IUCD
- Endometriosis on surface of ovary
Course:
C/F are same as tubal pregnancy
ruptures within 2-3 wks
Diagnosis: On Laparotomy
Spiegelberg’s Criteria
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
M/M Unruptured
Ruptured

Laparotomy Ovarian wedge resection

Ovarian Cystectomy
Oophorectomy
  ABDOMINAL PREGNANCY
Incidence: Rarest
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
the abdomen
O/E : - Abnormal fetal position, easy in palpating
fetal parts.
- uterus palpated separate from sac
- no uterine contraction after oxytocin
infusion
Diagnosis: Confirmed by USG,
CT scan, MRI, Radiography

TYPE

Primary Secondary
Studiford’s criteria
Conceptus escapes out
1. Both tubes and ovaries normal through a rent from
primary site
2. Absence of Uteroperitonal fistula

3. Pregnancy related to Peritoneal

Intraperitoneal Extraperitoneal
surface & young enough to rule
Broad ligament
out possibility of secondary
implantation
FATE OF SECONDARY ABDOMINAL PREGNANCY :

1. Death of ovum – complete absorption

2. Placental separation – massive intraperitoneal
haemorrhage
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)
M/M:
- 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
  CERVICAL PREGNANCY

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
- IVF
- DES exposure
- Leiomyoma
Diagnosis:
CLINICAL CRITERIA: Paulman & McEllin
1. Uterine bleeding, no cramping, following
amenorrhoea
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
 TVS Criteria Of Cervical E.P.
1) Empty uterine cavity.
2) A barrel-shaped cervix.
3) A gestational sac present below
the level of the internal cervical os.
4) The absence of the ‘sliding sign’.
5) Blood flow around the gestational
sac using colour Doppler.

RCOG guidelines, 2016

The ‘sliding sign’ enables cervical ectopic pregnancies to be distinguished from

miscarriages that are within the cervical canal. When pressure is applied to the
cervix using the probe, in a miscarriage, the gestational sac slides against the
endocervical canal, but it does not in an implanted cervical pregnancy.
HISTOPATHOLOGIC CRITERIA: Rubin’s

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.

D/d :
- Carcinoma Cx

- Cervical submucous fibroid

- Trophoblastic tumour

- Placenta previa
 MANAGEMENT

Surgical Medical
Mainstay therapy in past Recently proposed
Single or Combination
Conservative
Radical OR
surgery D&C Adjunct to surgery
(risk of torrential bleeding) - Methotrexate

Hysterectomy - Cerclage Bernstein ≈ Mc Donald’s - Actinomycin

Wharton ≈ Shirodkar’s
-Transvaginal ligation of Cx branch of - KCl
uterine artery
- Angiographic uterine A embolisation - Etoposide

- Intracervical vasopressin inj

- Foley’s catheter as tamponade
  CORNUAL PREGNANCY

SITE: Implantation occurs in rudimentary horn of Bicornuate

uterus

COURSE :Rupture of horn occurs by

12-20 wks

D/D :
1. Interstitial tubal pregnancy
2. Painful leiomyoma along with
pregnancy
3. Ovarian tumor with pregnancy
4. Asymmetrical enlargement of uterus.
Implantation into cornu of normal uterus is sometime
called Angular pregnancy .

TREATEMENT:
- Affected cornu with pregnancy is removed
- Hysterectomy
- Hysteroscopically guided suction curettage if
communication with Cx is patent
Surgical Steps (Cornuel Wedge
Resection )
).
Surgical Steps (Cornuostomy).
  HETEROTYPIC PREGNANCY

Co-existing intrauterine and extra uterine pregnancies

Incidence: 1 : 30,000
With ART – 1:7000
With ovulation induction – 1:900
More likely:
a) Ass. reproductive technique
b) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomy

M/M :
Depends on the site. Ectopic site may be removed
with continuation of IU pregnancy

(Rh Immunoglobulin: dose of 50 μ gm is sufficient to

prevent sensitization.)
  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
subsequent pregnancy.

Rupture – Hysterectomy is indicated

INTERSTITIAL ECTOPIC PREGNANCY.

(a) Oblique transvaginal US image

(b) Transverse transvaginal color
Doppler US image at the uterine
fundus

(c, d)
Transverse transvaginal US image (c)
and same image with color
contouring (d)
(*) the myometrial mantle sign.

(e, f) Sagittal transabdominal US

image (e)
and same image with color
contouring (f)
The myometrium (*) is seen draping
around the gestational sac.
 Interstitial pregnancy
Interstitial pregnancy Intrauterine pregnancy located in the
upper lateral part of uterine
cavity(angular pregnancy)
Gestational sac is surrounded by thin Endometrial myometrial junction extend
myometrial mantle around the sac.
Narrow communication between the Communication between the gestational
gestational sac and endometrial cavity sac and uterine cavity is wide.
At laparoscopy the pregnancy is located
medial to the round ligament

• Criteria by Timor-Tritsch
1) an empty uterine cavity
2) a gestational sac >1 cm from the most lateral point of the endometrial cavity*
3) a gestational sac surrounded by a thin myometrial layer
Most useful diagnostic feature is Interstitial line sign –
*a strict application of a 1-cm cut-off may lead to an interstitial pregnancy being misdiagnosed as
intrauterine pregnancy
-Hafner T, Aslam N, Ross JA, Zosmer N, Jurkovic D. The effectiveness of non-surgical management of early interstitial pregnancy: a report of ten cases and review of the
literature. Ultrasound Obstet Gynecol 1999; 13: 131–136.
  CAESAREAN SCAR ECTOPIC PREGNANCY

 Recently reported
 USG slows on empty uterine cavity and gestational sac attached
low to the lower segment caesarean scar.

C/F : similar to threatened or inevitable abortion

Diagnosis : Doppler imaging confirms

T/t : Methotrexate injection

Hysterectomy in a multiparous women.
In young pt resection & suturing of scar may be
done (high risk of rupture).
Transvaginal sonographic criteria for FIGURE 1
diagnosis of cesarean scar pregnancy

A, Empty uterine cavity with gestational

sac (arrow) between cavity and cervix (Cx).

B, Power Doppler of blood vessels

surrounding gestational sac.

C, Gestational sac embedded in scar. Thin

(1-3 mm) or lack of myometrium (arrow)
between sac and bladder.

D, Triangular shape of sac (on sagittal

plane) assuming shape of niche.

E-G, Prominent, richly vascular area in site

of previous cesarean delivery scar
highlighted by power Doppler.

Arrows point to vascular malformation.

American Journal of Obstetrics & Gynecology 2012 207, 44.e1-44.e13DOI: (10.1016/j.ajog.2012.04.018)

  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.
 Early pregnancy with unknown
location
• Check a serum BHCG
• If it is above the discriminatory zone (DZ)an
intrauterine pregnancy should be seen
• Then do an ultrasound to see if you see the
pregnancy
 Pregnancy of Unknown Location
+ Pregnancy of Unknown Location (PUL) is the term used to describe a situation
in which a positive pregnancy test
+ a transvaginal ultrasound (TVUS) does not show intrauterine or ectopic
gestation, nor does it show the retention of conception products
+ The incidence of PUL at centers specialized in the follow-up of early gestation
varies from 8% to 10%
+ Ultrasonography is the best examination method for identifying the location
of an early pregnancy.
+ TVUS can identify the location of the pregnancy in 91.3% of pregnant
women.
+ 89.6% were diagnosed with intrauterine pregnancies (IUPs), 1.7% were
diagnosed with ectopic pregnancies (EPs), and 8.7% were diagnosed with PUL

91
93
SUMMARY - KEY POINTS

 Incidence of ectopic pregnancy is rising while maternal mortality from it is

falling.

 Ectopic pregnancy can be diagnosed early (before it ruptures) with recent

advances in Immunoassay to detect S-hCG , high resolution USG, and dignostic
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 unruptured ectopic pregnancy.

 Careful monitoring and proper counselling of patients is mandatory.

 YOU WILL REMEMBER

A LITTLE OF WHAT YOU HEAR,

SOME OF WHAT YOU READ,
CONSIDERABLY MORE OF WHAT YOU SEE,
BUT
ALMOST ALL OF WHAT YOU UNDERSTAND.
 Case Presentation
A 37 o G5P3013 with LMP 8 weeks ago presents to the
ED with RLQ pain, nausea and vomiting, and vaginal
spotting. The ED provider was concerned that the
patient may have appendicitis because of her history,
as well as her past surgical history significant for a
tubal ligation. Initial lab work revealed a positive
hCG.
 Case study 1:
• A 22-year-old woman, para 0, was admitted with mild
vaginal bleeding after 7 weeks of amenorrhoea. She had
had a positive home pregnancy test. Ultrasound scan
showed an empty uterus, with an adnexal mass around 2
cm. quantitative β-hCG was 2000 iu/ml.

At laparoscopy ectopic pregnancy was confirmed in the

ampulary part of the right tube.
Linear salpengotomy was performed. The patient was
discharged home the following day in good condition.
 Case study 2:
• A 22-year-old woman, para 0, was admitted with vaginal
bleeding after 8 weeks of amenorrhoea. She had had a
positive home pregnancy test, and described passing
some tissue per vaginum. Ultrasound scan showed an
empty uterus, although urinary B-hCG was still positive.

A presumptive diagnosis of incomplete abortion was

made, and evacuation of the uterus carries out
uneventfully. She was discharged the following day
Was readmitted that night with lower abdominal pain; a
ruptured ampullary ectopic was found at laparotomy.
Histology of curettage “ decidua with Arias-Stella type reaction, no
chorionic villi seen”.
 Case study 3:
• An 33-year old woman para 4, was brought into E.R.
collapsed with lower abdominal pain. On admission
she was shocked with blood pr. Of 60/40, a pulse of
120 bpm and tender rigid abdomen. Vaginal exam.
Revealed a slight red loss, bulky uterus and marked
cervical excitation with a tender mass in the right
fornix.

At laparotomy, 3000 ml of fresh blood was removed

from the peritoneal cavity and a ruptured right tubal ectopic
pregnancy was found. The patient was in irreversible D.I.C.
with Hb =0 .5 gm/dl and eventually died
MANAGEMENT OF ECTOPIC PREGNANCY

1. Positive pregnancy test

Asymptomatic with factors

Lowe abdominal pain + for ectopic pregnancy
Minimal Vaginal bleeding
Risk factors
Previous ectopic pregnancy
Previous PID
Tubal surgery
Tubal Surgery
Tubal pathology (PID, endometriosis
Infertility, ovarian stimulation
IUCD failure
Sterilization failure
Previous abdominal surgery
DES exposure in utero
Multiple sexual partners

2. History + clinical examination

If sure of date of LMP and /or If unsure of date of LMP
Regular cycle, i.e. and /or irregular cycle,
>6 wks. gestation, Measure serum hCG
Arrange TV ultrasound

If hCG <100 If Hcg >1000, use

(?early Intrauterine/ protocol for
? Ectopic pregnancy suspected
Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000

Meet criteria for Does not meet criteria

Methorexate treatment for methotrexate treatment
Laproscopic /salpingotomy/
Use methotrexate Salpingectomy ?Proceed to
protocol laparotomy OR Laparotomy if
haemodynamically unstable