Dr.

Sourav Chowdhury
Senior Resident
DEFINITION

“Any pregnancy where the fertilised ovum

gets implanted & develops in a site other than
normal uterine cavity”.

It represents a serious hazard to a woman’s

health and reproductive potential, requiring
prompt recognition and early aggressive
intervention.
Is one in which fertilized ovum is implanted &
develops outside normal uterine cavity
 IMPLANTATIONS SITES

EXTRAUTERINE UTERINE
1. Cervical <1
OVARIAN ABDOMINAL 2. Angular
3. Caesarean
TUBAL 95-96% 4. Cornual
•Ampulla 70%
•Isthmus 25% SECONDARY
PRIMARY
•Interstistial 18%
•Infundibulum2%
Intraperitoneal Extraperitoneal
Broad Ligament
(rare)
 INCIDENCE & MORTALITY

• Increased
• PID
• IUCD
• Tubal surgeries, and
• Assisted reproductive techniques (ART).
• Rate in India – 5.6/10000 deliveries
• Late marriages and late child bearing -> 2%
• ART -> 5%
• Recurrence rate - 15% after 1st, 25% after 2
ectopics
Innovative Journal of Medical and Health Science 4 : 1 Jan
- Feb(2014) 305-309.
ETIOLOGY
:
 Any factor that causes delayed transport of
the fertilised ovum through the tube.

 Fallopiantube favours implantation in the

tubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.

 These factors may be Congenital or

Acquired.
ETIOLOGY

 CONGENITAL

 Tubal Hypoplasia
 Tortuosity
 Congenital diverticuli
 Accessory ostia
 Partial stenosis
 Elongation
 Intamural polyp
 Entrap the ovum on its way.
ETIOLOGY

ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common

Contraceptive Faliure
 CuT - 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%
ETIOLOGY

Tubal reconstructive surgery (4-5 times)

Assisted Reproductive technique

- Ovulation induction, IVF-ET and GIFT (4-7%)
- Risk of heterotopic pregnancy(1%)

Previous Ectopic Pregnancy

- 7-15% chances of repeat ectopic pregnancy

Other Risk factors

 Age 35-45 yrs

 Previous induced abortion
 Previous pelvic surgeries
 Cigarette smoking
 DES Exposure in Utero
 Infertility
 Salpingitis Isthmica Nodosa
 Genital Tuberculosis
 Fundal Fibroid & Adenomyosis of tube
 Transperitoneal migration of ovum
Iffy hypothesis –

“Theory of reflux” menstural fluid throw the

fertilised ovum into the tube

Factors facilitating nidation of ovum in tube:

- Premature degeneration of zona pellucida

- Increased decidual reaction

- Tubal endometriosis
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:
 MORBID ANATOMY
Changes
 Implantation- intercolumnar or between mucosal flods
 Decidual change minimal
 Muscle hyperplasia & Hypertrophy min.
 Intramuscular implatation
 Pseudocapsule formation
 Trophoblast invasion-erosion of blood vessel
 The pregnancy is unable to survive owing to its poor blood supply,
thus resulting in a
 tubal abortion and
 resorption, (rare)
 Tubal Rupture

 Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months

 Abortion is common in ampullary pregnancies,whereas rupture is
in isthmic.
 ARIAS – STELLA REACTION

Arias – Stella reaction is charecterised by a benign,

focal and unusual decidual changes in the presence
of chorionic tissue,
 Loss of polarity
 Pleomorphism
 Hyperchromatic nuclei
 Vacuolated cytoplasm
 Intraluminal budding

Though seen in Ectopic Pregnancy but is not specific

for it
and can also be seen in uterine pregnancy
 Ruptured ectopic

Pictures showing TUBAL

ABORTION
 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.
- PAIN:- most constant feature in 95%
pt
- variable in severity and nature
- AMENORRHOEA:- 60-80% of pt
- there may be delayed period or slight
spotting at the time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
 Feeling of nausea,vomiting,fainting attack, syncope
attack(10%) due to reflex vasomotor disturbance.
 Abdominal pain most comm. Feature. Shoulder tip
 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.
POD may be full, uterus floats as if in
water.
 CHRONIC ECTOPIC PREGNANCY

Symptoms

 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 conscious 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
Investigations- TVS, radioimmunoassay of β-HCG
and
Laparoscopy
 DIAGNOSIS
“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

 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%.

 DIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb%, CBC, blood grouping and cross
matching,.Serology and Coagulation profile.
 Should be catheterized to know urine output.

Bed side test:-

1. Urine pregnancy test:- positive in 95% cases.

ELISA is sensitive to 10-50 mlU/ml of β hCG and
can be detected on 24th day after LMP.

2. Culdocentesis:- (70-90%)
 Can be done with 16-18 G lumbar puncture needle through
fornix into POD.
posterior
 Positive tap is 0.5ml of non clotting blood.
DIAGNOSIS

Imaging:-
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 .
 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

Early Gestational Sac Pseudosac Location

Eccentrically located Midline within E.cavity Shape Round-shape
Irregular
Border Double
Ring sign
Vascularity High Avascular Pattern Peripheral
 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
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.
 Hyperechoic ring around
gestational sac in adnexal region
Ring sign — a hyperechoic ring around an
extrauterine gestational sac.
2. β-HCG Assay-

a) Single β-HCG: little value

b) Serial β-HCG: is required when result of

initial USG is confusing.

- When hCG level < 2000 IU/L doubling time

help to predict viable Vs nonviable pregnancy.

-Rise of β-HCG <66% in 48 hrs indicate

ectopic pregnancy or nonviable intrauterine
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.
 DIAGNOSIS

5. Dilatation & Curettage –

 Is recommended in suspected case of incomplete
abortion vs ectopic pregnancy.
 Identification of decidua without chorionic villi is
suggestive of extra uterine pregnancy.
 “Arias-Stella” endometrial reaction is
suggestive but not
diagnostic of ectopic pregnancy.

6. Other Novel Tests –

 Placenta protein (PP14) decrease in EP
 PAPPA (Pregnancy Associated Plasma Protein
A),
PAPPC (schwangerchaft protein 1) has low
value in EP
 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

Incomplet Laparoscopy No sac IU sac

e
abortion Continue to monitor
DIFFERENTIAL DIAGNOSIS
D/D of Acute Ectopic

1. Rupture corpus luteum of pregnancy

2. Rupture of chocolate cyst
3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion
6. Acute Appendicitis
7. Perforated peptic ulcer
8. Renal colic
9. Splenic rupture
D/D OF CHRONIC (SUB ACUTE) ECTOPIC

1. Pelvic abscess

2. Pyosalpinx

3. Subserous uterine fibroid

4. Salpingintis

5. Retroverted gravid uterus

6. Appendicular lump
 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 fimbria
expression
 MANAGEMENT OF ECTOPIC-

PRINCIPLE: Resuscitation and Laparotomy/Laparoscopy

ANTI SHOCK TREATEMENT:

- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching, BT, CT
- Folley’s catheterization done
- Colloids for volume replacement

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.
 MANAGEMENT OF ECTOPIC PREGNANCY-

Laparoscopy
 Preferred method if haemodynamically stable

 Tubal Patency no significant difference

 Followed by similar number of uterine pregnancy

 Shorter operative time

Salpingostomy
 Less than 2cm size

 10-15mm incision
MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
 SURGICAL-
 SURGICALLY ADMINISTERED MEDICAL (SAM)
TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT
 EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA - :
1. Tubal ectopic pregnancies only

2. Haemodynamically stable

3. No rupture or bleeding

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

5. Initial β HCG <1000 IU/L and falling in titre (single best)

SUCCESS RATE - Upto 60%

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.
 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
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.

 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.
 MEDICAL MANAGEMENT

Single dose βHCG levels at days 4 & 7

Mtx 50mg/m² IM •If difference ≥15% repeat weekly till ≤5IU/ml
•If difference ˂15% between day 4 & 7 repeat dose & begin D₁
•If fetal Cardiac +ve at D₇ repeat D₁ Mtx
•Surgical management if βHCG not ↓ or fetal cardiac +ve after 3
doses
Two dose on Day Follow-up same as One dose regimen
0, 4

Variable doses Measure βHCG levels at D₁₃₅₇ . Continue alternate day regimen
1. Mtx 1gm/kg IM until βHCG levels decrease ≥15% in 48hrs, or 4 doses of Mtx given.
D₁₃₅₇ Then, weekly βHCG levels until <5iu/ml
2. Leucovorin
0.1mg/kg IM
D₂₄₆₈
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

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 < 5 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.
 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.
Laparotomy Vs Laparoscopy

- 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.

 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 Medical
Treatmen
t (selected Asymptomatic
Total or partial pt)
MTX + Leukovorin
salpingectomy
 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 Unruptured
Ruptured
3. Connected to uterus byM/M
ovarian ligament Ovarian wedge resection
Laparotomy
4. Ovarian tissue found on its Ovarian Cystectomy
Oophorectomy
wall on HP study
 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 Extraperitonea l
surface & young enough to
Broad ligament
rule 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

 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

6. Echo-free uterine cavity/ pseudo-gestational sac
7. Decidual reaction
8. Hourglass uterus with ballooned cervical canal
9. Gestational sac in endocervix
10.Closed internal Os
11.Placental tissue in Cx canal
 DIAGNOSIS

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 Combinati on
Conservative
Radical OR
D&C Adjunct to surgery
surgery (risk of torrential - Methotrexate
bleeding)
Hysterectomy - Cerclage Bernstein ≈ Mc Donald’s - Actinomycin
Wharton ≈ Shirodkar’s
-Transvaginal ligation of Cx branch of - KCl
uterine artery
- Angiographic uterine A - Etoposide
embolisation
- 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
 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

 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
Management:
 Methotrexate injection
 Hysterectomy in a multiparous women.

In young pt resection & suturing of scar may

be done (high risk of rupture).
 OTHER RARE TYPES

1. Multiple Ectopic pregnancy

2. Pregnancy after hysterectomy
3. Primary splenic pregnancy
4. Primary hepatic pregnancy
5. Rectroperitoneal pregnancy
6. Diaphragmatic pregnancy

MORTALITY : In general population is 10-15% mainly

due to haemorrhage.
SUMMARY - KEY POINTS

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

is falling.

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

recent advances in Immunoassay to detect β-hCG , high resolution
USG, and diagnostic Laparoscopy.

 There has been shift in the M/m from ablative surgery to conservative
fertility preserving therapy

 Laparotomy should be done when in doubt

 The choice today is Laparoscopic treatment of un-ruptured ectopic

pregnancy.

 Careful monitoring and proper counselling of patients is mandatory.

I was intra-
uterine….