medical education for UG

1. Dr. Sourav Chowdhury
Senior Resident

2. 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.

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

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

6. 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.

7. ETIOLOGY:
 Any factor that causes delayed transport of
the fertilised ovum through the tube.
 Fallopian tube favours implantation in the
tubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.
 These factors may be Congenital or
Acquired.

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

9. ETIOLOGY
ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
Contraceptive Faliure
 CuT - 4%
 Progestasart -17%
 Minipills -4-10%
 Norplant -30%

10. •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%

11. 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

12. 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

13. 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

14. 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:

15. 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.

16. 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

17. Pictures showing TUBAL ABORTION
Ruptured ectopic

18. 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.

19. 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 pain.

20.  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.

21. 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.

22.  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.

23. 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

25. 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

26. 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%.

27. 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 posterior
fornix into POD.
 Positive tap is 0.5ml of non clotting blood.

28. 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 .

29. 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 -

30. 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

31. 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.

32. 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.

33. Hyperechoic ring around
gestational sac in adnexal region

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

35. 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

36. 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.

37. 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
 CA-125, Maternal serum creatine kinase, Maternal serum
AFP elevated in ectopic pregnancy.
 VEGF, Fetal Fibronectin, Mass spectrometry

38. 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
S progesterone < 5-10 ng/ml
D & C
Villi present Villi absent
Incomplete
abortion
Laparoscopy
>66% rise in 48 hr or
S progesterone > 5-10 ng/ml
Repeat S-hCG in 48 hrs
till USG discrimination zone
No sac IU sac
Continue to monitor

39. 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

40. 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

41. MANAGEMENT
Expectant
management
Medical
management
Surgical
management
Local Systemic
(USG or Laparoscopic)
salpingocentesis
- Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Actinomycin D
- Mifepristone
Methotrexate
Radical
Salpingectomy
Conservative
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbrial
expression

42. 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.

43. 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

45. MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
 SURGICAL-
 SURGICALLY ADMINISTERED MEDICAL (SAM)
TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT

46. 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.

47. 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.

48. 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

49. 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.

50. MEDICAL MANAGEMENT
Single dose
Mtx 50mg/m² IM
βHCG levels at days 4 & 7
•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
0, 4
Follow-up same as One dose regimen
Variable doses
1. Mtx 1gm/kg IM
D₁₃₅₇
2. Leucovorin
0.1mg/kg IM
D₂₄₆₈
Measure βHCG levels at D₁₃₅₇ . Continue alternate day regimen
until βHCG levels decrease ≥15% in 48hrs, or 4 doses of Mtx given.
Then, weekly βHCG levels until <5iu/ml

51. 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

52. 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)

53. 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
SURGICALLY ADMINISTERED MEDICAL Tt (SAM)

54. 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.

55. 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

56. 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

57. 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.

58. DEBATABLE ISSUES
? Salpingectomy Vs Salpingostomy
? Laparotomy Vs Laparoscopy
? Reproductive outcome
? Risk of Recurrent Ectopic

59. 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

60. 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.

61. 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.

62. 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.

63. 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.

64. 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.
Treatment
surgery
Total or partial
salpingectomy
Medical
(selected Asymptomatic pt)
MTX + Leukovorin

65. 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/MRuptured
Laparotomy
Oophorectomy
Unruptured
Ovarian wedge resection
Ovarian Cystectomy

66. 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

67. Diagnosis: Confirmed by USG,
CT scan, MRI, Radiography
TYPE
Primary Secondary
Studiford’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 Extraperitoneal
Broad ligament

68. 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

69. 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

70. 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

71. 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

72. MANAGEMENT
Surgical
Mainstay therapy in past
Radical
surgery
Hysterectomy
Conservative
D & 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
Medical
Recently proposed
Single or Combination
OR
Adjunct to surgery
- Methotrexate
- Actinomycin
- KCl
- Etoposide

73. 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

74. 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.)

75. 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

76. 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).

77. 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.

78. 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.

79. I was intra-
uterine….