ANDANDITS MANAGEMENTITS MANAGEMENT

DR ASIFA SIRAJDR ASIFA SIRAJ

CONSULTANT GYNAE/OBGCONSULTANT GYNAE/OBG

MH RAWALPINDIMH RAWALPINDI

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

IMPLANTATIONS SITESIMPLANTATIONS SITES

EXTRAUTERINE UTERINE

TUBAL 97%

-Ampulla 80%-Isthmus 12%-Infundibulum 6%-Interstitial 2%

OVARIAN(1:40,000)

ABDOMINAL(1:10,000)

-CERVICAL(1:18,000)-ANGULAR-CORNUAL

PRIMARY SECONDARY

Intraperitoneal ExtraperitonealBroad Ligament (rare)

INCIDENCEINCIDENCE

Increased due to PID, use of IUCD, Tubal surgeries, Increased due to PID, use of IUCD, Tubal surgeries, and Assisted reproductive techniques (ART).and Assisted reproductive techniques (ART).

Ranges from 1:25 to 1:250Ranges from 1:25 to 1:250

Average range is 1 in 100 normal pregnencies.Average range is 1 in 100 normal pregnencies.

Late marriages and late child bearing -> 2%Late marriages and late child bearing -> 2%

ART -> 5%ART -> 5%

ETIOLOGYETIOLOGY::

*Pelvic Inflammatory disease (6-10 times)*Pelvic Inflammatory disease (6-10 times)

Chlamydia trachomatis is most commonChlamydia trachomatis is most common

*Contraceptive Faliure*Contraceptive Faliure

CuT -4%CuT -4%

Progestasart -17%Progestasart -17%

Minipills -4-10%Minipills -4-10%

Norplant -30%Norplant -30%

*Tubal sterilization faliure -40%*Tubal sterilization faliure -40%

Depends on sterilization technique and age of Depends on sterilization technique and age of the patientthe patient

Bipolar Cauterisation -65%Bipolar Cauterisation -65%

Unipolar Cautery -17% Unipolar Cautery -17%

Silicon rubber band -29%Silicon rubber band -29%

Interval Salpingectomy -43%Interval Salpingectomy -43%

Postpartum Salpingectomy -20%Postpartum Salpingectomy -20%

*Reversal of sterilisation*Reversal of sterilisation - - Depends on method of sterilization, Site of Depends on method of sterilization, Site of tubal occlusion, residual tubal length.tubal occlusion, residual tubal length. - Reanastomosis of cauterised tube -15%- Reanastomosis of cauterised tube -15% - Reversal of Pomeroy’s - < 3%- Reversal of Pomeroy’s - < 3%

*Tubal reconstructive surgery (4-5 times)*Tubal reconstructive surgery (4-5 times)

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

*Previous Ectopic Pregnancy*Previous Ectopic Pregnancy - - 7-15% chances of repeat ectopic pregnancy7-15% chances of repeat ectopic pregnancy - - IfIf first pregnancyfirst pregnancy is ectopic then 30% chance is ectopic then 30% chance of repeat ectopicof repeat ectopic

*Developmental defects of tube*Developmental defects of tube elongation, diverticulum, accessory ostia, elongation, diverticulum, accessory ostia,

intamural polyp, entrap the ovum on its way.intamural polyp, entrap the ovum on its way.

*Other Risk factors*Other Risk factors - Age 35-45 yrs- Age 35-45 yrs

- Previous induced abortion- Previous induced abortion

- Previous pelvic surgeries- Previous pelvic surgeries

- Cigarette smoking- Cigarette smoking

- DES Exposure in Utero- DES Exposure in Utero

- Infertility- Infertility - Salpingitis Isthmica Nodosa- Salpingitis Isthmica Nodosa - Genital Tuberculosis- Genital Tuberculosis - Fundal Fibroid & Adenomyosis of tube- Fundal Fibroid & Adenomyosis of tube - Transperitoneal migration of ovum- Transperitoneal migration of ovum - Iffy hypothesis – “Theory of reflux” - Iffy hypothesis – “Theory of reflux” menstural fluid throw the fertilised ovum into menstural fluid throw the fertilised ovum into the tubethe tube

Factors facilitating nidation of ovum in tube:Factors facilitating nidation of ovum in tube:

- Premature degeneration of zona pellucida- Premature degeneration of zona pellucida - Increased decidual reaction- Increased decidual reaction - Tubal endometriosis- Tubal endometriosis

MODE OF TERMINATIONMODE OF TERMINATION

1. Tubal mole1. Tubal moleComplete absorption

Abortion Pelvic haematocele

2. Tubal Abortion (18-20%)

Complete Pelvic haematocele

Incomplete Diffuse Intraperitoneal haemorrhage

3. Tubal RuptureRoof Diffuse Intraperitoneal haemorrhage

Floor Intraligamentary haematoma(Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months)

4. Tubal Perforation Roof Secondary Abdominal pregnancy

Floor Secondary Intraligamentary pregnancy

5.Continuation of Pregnancy rarest

CLINICAL APPROACHCLINICAL APPROACH

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

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

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

ACUTE ECTOPIC PREGNANCYACUTE ECTOPIC PREGNANCY

Classical triadClassical triad is present in 50% of pt with is present in 50% of pt with rupture ectopic.rupture ectopic.

- - PAIN:- PAIN:- most constant feature in 95% ptmost constant feature in 95% pt - variable in severity and nature- variable in severity and nature

- - AMENORRHOEA:- AMENORRHOEA:- 60-80% of pt60-80% of pt - there may be delayed period or slight - there may be delayed period or slight spotting at the time of expected menses.spotting at the time of expected menses.

- - VAGINAL BLEEDING: - VAGINAL BLEEDING: - scanty dark brownscanty dark brown

Feeling of nausea,vomiting,fainting attack, syncope Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to reflex vasomotor disturbance.attack(10%) due to reflex vasomotor disturbance.

O/EO/E:-:- patient is restless in agony, looks blanched, patient is restless in agony, looks blanched, pale, sweating with cold clammy skin.pale, sweating with cold clammy skin. Features of shock, tachycardia, hypotension.Features of shock, tachycardia, hypotension.

P/A:P/A:-- abdomen tense, tender mostly in lower abdomen tense, tender mostly in lower abdomen shifting dullness, rigidity may be abdomen shifting dullness, rigidity may be present.present.

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

P/V:-P/V:- uterus may be bulky, deviated to opposite uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain on side, fornix is tender, excitation pain on movement of cervix.movement of cervix. POD may be full, uterus floats as if in water.POD may be full, uterus floats as if in water.

CHRONIC ECTOPIC PREGNANCYCHRONIC ECTOPIC PREGNANCY

It can be diagnosed by high clinical suspicion.It can be diagnosed by high clinical suspicion.

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

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

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

P/A:-P/A:- Tenderness and muscle guard on the lower Tenderness and muscle guard on the lower abdomen.abdomen. A mass may be felt, irregular and tender.A mass may be felt, irregular and tender.

P/V:-P/V:- Vaginal mucosa pale, uterus may be normal Vaginal mucosa pale, uterus may be normal in size or bulky, ill defined boggy tender in size or bulky, ill defined boggy tender mass may be felt in one of the fornix.mass may be felt in one of the fornix.

P/R:-P/R:- Corrobarate the pelvic findings. Corrobarate the pelvic findings.

UNRUPTURED ECTOPICUNRUPTURED ECTOPIC

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

Diagnosed accidentally in Laparoscopy or Diagnosed accidentally in Laparoscopy or LaparotomyLaparotomy

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

P/AP/A – tenderness in lower abdomen– tenderness in lower abdomen

P/VP/V – should be done gently – should be done gently uterus is normal size, firmuterus is normal size, firm small tender mass may be felt in the fornixsmall tender mass may be felt in the fornix

DIAGNOSISDIAGNOSIS

Patient with acute ectopic can be diagnosed Patient with acute ectopic can be diagnosed clinically.clinically.

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

Should be catheterized to know urine output.Should be catheterized to know urine output.

Bed side testBed side test:-:-

1. 1. Urine pregnancy testUrine pregnancy test:- positive in 95% cases.:- positive in 95% cases. ELISA is sensitive to 10-50 mlU/ml of ELISA is sensitive to 10-50 mlU/ml of ββ hCG and hCG and can be detected on 24can be detected on 24thth day after LMP. day after LMP.

2. 2. CuldocentesisCuldocentesis:- (70-90%):- (70-90%)

- Can be done with 16-18 G lumbar - Can be done with 16-18 G lumbar puncture needle through posterior fornix puncture needle through posterior fornix into POD.into POD. - Positive tap is 0.5ml of non clotting blood.- Positive tap is 0.5ml of non clotting blood.

Other Investigations:-Other Investigations:-

1. Ultra Sonography-1. Ultra Sonography- a) a) Transvaginal SonographyTransvaginal Sonography (TVS): is more (TVS): is more sensitivesensitive -It detect intrauterine gestational sac at 4-5 -It detect intrauterine gestational sac at 4-5 wks and at S-wks and at S-ββ hCG level as low as 1500 hCG level as low as 1500 IU/L .IU/L .

b) b) Color Doppler Sonography(TV-CDS):Color Doppler Sonography(TV-CDS):

- Improve the accuracy.- Improve the accuracy.

- Identify the placental shape - Identify the placental shape (ring-of-fire (ring-of-fire

pattern) pattern) and blood flow outside the uterine cavity.and blood flow outside the uterine cavity.

c) c) Transabdominal Sonography:Transabdominal Sonography:

- can identify gestational sac at 5-6 wks- can identify gestational sac at 5-6 wks

- S-- S-ββ hCG level at which intrauterine gestational hCG level at which intrauterine gestational

sac is seen by TAS is 6500 IU/L.sac is seen by TAS is 6500 IU/L.

USG PICTUREUSG PICTURE

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

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

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

4. Corpus luteum is useful guide when looking for 4. Corpus luteum is useful guide when looking for EP as present in 85% cases in Ipsilateral ovary.EP as present in 85% cases in Ipsilateral ovary.

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

CO RELATION BETWEEN USG & HCGCO RELATION BETWEEN USG & HCG

S hCG > 6500 IU/L

Viable Intrauterinepregnancy

Sac visible by TAS

Sac not visible

Ectopic or Non viable

S-hCG < 6500 IU/L sac not visible

- Normal pregnancy at early wks

-Abnormal IU pregnancy

-Recent abortion

-Ectopic pregnancy

-Non pregnant pt

2. 2. ββ-HCG Assay--HCG Assay-

a) Single a) Single ββ-HCG: little value-HCG: little value b) Serial b) Serial ββ-HCG: is required when result of -HCG: is required when result of initial USG is confusing.initial USG is confusing.

- When hCG level < 2000 IU/L doubling time - When hCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy.help to predict viable Vs nonviable pregnancy.

-Rise of -Rise of ββ-HCG <66% in 48 hrs indicate -HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine ectopic pregnancy or nonviable intrauterine pregnancy .pregnancy .

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

3. 3. Serum ProgesteroneSerum Progesterone – –

- level >25 ngm/ml is suggestive of normal - level >25 ngm/ml is suggestive of normal

intrauterine pregnancy.intrauterine pregnancy.

- level <15 ngm/ml is suggestive of ectopic - level <15 ngm/ml is suggestive of ectopic

pregnancy.pregnancy.

- level <5 ngm/ml indicates nonviable - level <5 ngm/ml indicates nonviable

pregnancy, irrespective of its location.pregnancy, irrespective of its location.

4. 4. Diagnostic Laparoscopy (Gold standard)–Diagnostic Laparoscopy (Gold standard)–

- - Can be done only when patient is Can be done only when patient is

haemodynamically stable.haemodynamically stable.

-It confirms the diagnosis and removal of -It confirms the diagnosis and removal of

ectopic mass can be done at the same time.ectopic mass can be done at the same time.

5. Dilatation & Curettage –5. Dilatation & Curettage – - Is recommended in suspected case of - Is recommended in suspected case of incomplete abortion vs ectopic pregnancy.incomplete abortion vs ectopic pregnancy. - Identification of decidua without chorionic - Identification of decidua without chorionic villi is suggestive of extra uterine pregnancy.villi is suggestive of extra uterine pregnancy. - “Arias-Stella” endometrial reaction is - “Arias-Stella” endometrial reaction is suggestive but not diagnostic of ectopic suggestive but not diagnostic of ectopic pregnancy.pregnancy. 6. Other hormonal Tests –6. Other hormonal Tests – - Placenta protein (PP14) decrease in EP- Placenta protein (PP14) decrease in EP

- PAPPA (Pregnancy Associated Plasma Protein A),- PAPPA (Pregnancy Associated Plasma Protein A), PAPPC (schwangerchaft protein 1) has low value PAPPC (schwangerchaft protein 1) has low value

in EPin EP

- CA-125, Maternal serum creatine kinase, - CA-125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic Maternal serum AFP elevated in ectopic pregnancy.pregnancy.

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

Transvaginal USG

IU sac No IU sacQuantitative S-hCG

+ S progesterone

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

D & C

Villi present Villi absent

Incomplete abortion

Laparoscopy

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

Repeat S-hCG in 48 hrs till USG discrimination zone

No sac IU sac

Continue to monitor

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

D/D of Acute EctopicD/D of Acute Ectopic 1. Rupture corpus luteum of pregnancy1. Rupture corpus luteum of pregnancy 2. Rupture of chocolate cyst 2. Rupture of chocolate cyst 3. Twisted ovarian cyst3. Twisted ovarian cyst 4. Torsion / degeneration of pedunculated fibroid4. Torsion / degeneration of pedunculated fibroid 5. Incomplete abortion5. Incomplete abortion 6. Acute Appendicitis6. Acute Appendicitis 7. Perforated peptic ulcer7. Perforated peptic ulcer 8. Renal colic8. Renal colic 9. Splenic rupture9. Splenic rupture

D/D OF CHRONIC (SUB ACUTE) ECTOPICD/D OF CHRONIC (SUB ACUTE) ECTOPIC

1. Pelvic abscess1. Pelvic abscess

2. Pyosalpinx2. Pyosalpinx

3. Subserous uterine fibroid3. Subserous uterine fibroid

4. Salpingintis4. Salpingintis

5. Retroverted gravid uterus5. Retroverted gravid uterus

6. Appendicular lump6. Appendicular lump

MANAGEMENTMANAGEMENT

Expectant management

Medicalmanagement

Surgicalmanagement

Local Systemic(USG or Laparoscopic)

salpingocentesis

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

Methotrexate

Radical

Salpingectomy

Conservative

-Salpingostomy

-Salpingotomy

- Segmental resection

-Milking or fimbrial expression

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENTCRITERIA:CRITERIA: 1. Haemodynamically stable1. Haemodynamically stable

2. Haemoperitoneum < 50ml2. Haemoperitoneum < 50ml

3. Adnexal mass of < 3.5 cm without heart beat.3. Adnexal mass of < 3.5 cm without heart beat.

4. Initial 4. Initial ββ HCG <1000 IU/L and falling in titre HCG <1000 IU/L and falling in titre

SUCCESS RATESUCCESS RATE - Upto 60% - Upto 60%

PROTOCOL:PROTOCOL: - Hospitalization with strict monitoring of clinical symptom- Hospitalization with strict monitoring of clinical symptom

- Daily Hb estimation- Daily Hb estimation

- Serum - Serum ββ HCG monitoring 3-4 days until it is <10 IU/L HCG monitoring 3-4 days until it is <10 IU/L

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

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

Surgery is the mainstay of T/t worldwideSurgery is the mainstay of T/t worldwideMedical M/m may be tried in selected casesMedical M/m may be tried in selected cases

CANDIDATES FOR METHOTREXATE (MTX)CANDIDATES FOR METHOTREXATE (MTX) Unruptured sac < 4cm without cardiac activityUnruptured sac < 4cm without cardiac activity or < 3.5 cm with cardiac activityor < 3.5 cm with cardiac activity S-hCG < 10,000 IU/LS-hCG < 10,000 IU/L Persistant Ectopic after conservative surgeryPersistant Ectopic after conservative surgery

PHYSICIAN CHECK LISTPHYSICIAN CHECK LIST CBC, LFT, RFT, S-hCGCBC, LFT, RFT, S-hCG Transvaginal USG within 48 hrsTransvaginal USG within 48 hrs Obtain informed consentObtain informed consent Anti-D Ig if pt is Rh negativeAnti-D Ig if pt is Rh negative Follow up on day1, 4 and 7.Follow up on day1, 4 and 7.

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

MethotrexateMethotrexate (Systemically – IM, IV, Oral)

Single dose(recent)

50mg/m2 IM

-D1 – β-HCG, CBC, LFT, RFT-D4 - β-HCG-D7 - β-HCG, CBC, LFT, RFT

• If β-HCG decrease is < 15% D4 – D7 then repeat the MTX dose• If decline is > 15% then weekly measure β-HCG until level is < 15 IU/L.

Multiple dose(in the past)

MTX 1mg/kg IM on D 1,3,5,7 +Citrovorum 0.1mg/kg on D 2,4,6,8

• Weekly β-HCG till negative titre

Advantage of local MTX : - Increase tissue concentration at local site - Decrease systemic side effects - Decrease hospitalization - Greater preservation of fertility Follow up: - Serum β HCG twice weekly till < 10 IU/L - TVS weekly for 4-6 weeks - HCG after 6 months for tubal patency

SURGICALLY ADMINISTERED MEDICAL Tt (SAM)

By Salpingocentesis, MTX (1mg/kg), KCL, PGF2α, Hyperosmolar glucose, mifepristone, Anti hCG Ab is injected into sac by transvaginally under USG guidance, Laparoscopy, transcervical tubal cannulization

INSTRUCTION TO THE PATIENTSINSTRUCTION TO THE PATIENTS

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

Refrain from alcohol, sunlight, multivitamins with Refrain from alcohol, sunlight, multivitamins with folic acid, and sexual intercourse until S-hCG is folic acid, and sexual intercourse until S-hCG is negative.negative.

Report immediately when vaginal bleeding, Report immediately when vaginal bleeding, abdominal pain, dizziness, syncope (mild pain is abdominal pain, dizziness, syncope (mild pain is common called separation pain or resolution pain)common called separation pain or resolution pain)

Failure of medical therapy require retreatmentFailure of medical therapy require retreatment Chance of tubal rupture in 5-10 % require Chance of tubal rupture in 5-10 % require

emergency Laparotomy. emergency Laparotomy.

MANAGEMENT OF RUPTURED ECTOPICMANAGEMENT OF RUPTURED ECTOPIC

PRINCIPLE: PRINCIPLE: Resuscitation and LaparotomyResuscitation and Laparotomy

ANTI SHOCK TREATEMENT:ANTI SHOCK TREATEMENT:

- IV line made patent, crystalloid is started- IV line made patent, crystalloid is started

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

- Folley’s catheterization done- Folley’s catheterization done

- Colloids for volume replacement- Colloids for volume replacement

LAPAROTOMY:LAPAROTOMY:

Principle is ‘Quick in and Quick out’Principle is ‘Quick in and Quick out’

- Rapid exploration of abdominal cavity is done- Rapid exploration of abdominal cavity is done

- Salpingectomy is the definitive surgery (sent for HP study)- Salpingectomy is the definitive surgery (sent for HP study)

- Blood transfusion to be given- Blood transfusion to be given

- Autotransfusion only when donated blood not available.- Autotransfusion only when donated blood not available.

MANAGEMENT OF UNRUPTURED ECTOPICMANAGEMENT OF UNRUPTURED ECTOPIC Conservative SurgeryConservative Surgery

Can be done Laparoscopically or by microsurgical laparotomyCan be done Laparoscopically or by microsurgical laparotomy

INDICATION:INDICATION: - Patient desires future fertility- Patient desires future fertility

- Contralateral tube is damaged or surgically removed - Contralateral tube is damaged or surgically removed previouslypreviously

CHOICE OF TECHNIQUE:CHOICE OF TECHNIQUE: depends on depends on

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

- Condition of tubes- Condition of tubes

- Accessibility- Accessibility

VARIOUS CONSERVATIVE SURGERIESVARIOUS CONSERVATIVE SURGERIES

1.Linear Salpingostomy1.Linear Salpingostomy: :

- Indicated in unruptured ectopic <2cm in ampullary region.- Indicated in unruptured ectopic <2cm in ampullary region.

- Linear incision given on antimesentric border over the site- Linear incision given on antimesentric border over the site

and product removed by fingers, scalpel handle or gentle and product removed by fingers, scalpel handle or gentle

suction and irrigation.suction and irrigation.

- Incision line kept open (heals by secondary intention)- Incision line kept open (heals by secondary intention)

2.2. Linear Salpingotomy :Linear Salpingotomy :

-- Incision line is closed in two layers with 7-0 interruptedIncision line is closed in two layers with 7-0 interrupted

vicryl sutures.vicryl sutures.

3. Segmental Resection & Anastomosis:3. Segmental Resection & Anastomosis:

- Indicated in unruptured isthmic pregnancy- Indicated in unruptured isthmic pregnancy

- End to end anastomosis is done immediately or at later - End to end anastomosis is done immediately or at later

datedate

4. Milking or fimbrial Expression:4. Milking or fimbrial Expression: -- This is ideal in distal ampullary or infundibular pregnancy.This is ideal in distal ampullary or infundibular pregnancy. - It has got increased risk of persistent ectopic pregnancy.- It has got increased risk of persistent ectopic pregnancy.

ADVANTAGES OF LAPAROSCOPYADVANTAGES OF LAPAROSCOPY

- It helps in diagnosis, evaluation, and treatment . - It helps in diagnosis, evaluation, and treatment . - Diagnose other causes of infertility.- Diagnose other causes of infertility. - Decreased hospitalization, operative time, recovery period,- Decreased hospitalization, operative time, recovery period, analgesic requirement.analgesic requirement.

Follow up after conservative surgeryFollow up after conservative surgery

- With weekly Serum - With weekly Serum ββ HCG titre till it is negative. HCG titre till it is negative. - If titre increases methotrexate can be given. - If titre increases methotrexate can be given.

DEBATABLE ISSUESDEBATABLE ISSUES

?? Salpingectomy Vs SalpingostomySalpingectomy Vs Salpingostomy

?? Laparotomy Vs LaparoscopyLaparotomy Vs Laparoscopy

?? Reproductive outcome Reproductive outcome

?? Risk of Recurrent Ectopic Risk of Recurrent Ectopic

Salpingectomy Vs SalpingostomySalpingectomy Vs Salpingostomy

- If future fertility is a consideration the factors to - If future fertility is a consideration the factors to be taken into account are status of Ipsilateral tube, be taken into account are status of Ipsilateral tube, Contralateral tube, other pelvic pathology.Contralateral tube, other pelvic pathology.

- Report shows there is no significant difference in - Report shows there is no significant difference in subsequent reproductive outcome with regard to IU subsequent reproductive outcome with regard to IU pregnancy or recurrent Ectopic.pregnancy or recurrent Ectopic.

- Linear Salpingostomy is currently procedure of - Linear Salpingostomy is currently procedure of choice, when pt has unruptured Ectopic and wishes choice, when pt has unruptured Ectopic and wishes to retain her potential for future fertility.to retain her potential for future fertility.

- In pt with only one tube, conservative surgery may - In pt with only one tube, conservative surgery may be appropriate but only when pt is aware and be appropriate but only when pt is aware and accept the risk involved.accept the risk involved.

Laparotomy Vs LaparoscopyLaparotomy Vs Laparoscopy

- Laparoscopy is reserved for pt who are - Laparoscopy is reserved for pt who are hemodynamically stable.hemodynamically stable.

- Ruptured Ectopic does not necessarily require - Ruptured Ectopic does not necessarily require Laparotomy, but if large clots are present Laparotomy, but if large clots are present Laparotomy should be considered.Laparotomy should be considered.

Reproductive outcomeReproductive outcome Is similar in pt treated with either Laparoscopy or Is similar in pt treated with either Laparoscopy or

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

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

PERSISTENT ECTOPIC PREGNANACYPERSISTENT ECTOPIC PREGNANACY

Defined as continued growth of trophoblastic tissue after Defined as continued growth of trophoblastic tissue after

conservative treatment (3 – 20 % incidence)conservative treatment (3 – 20 % incidence)

Risk Factor:Risk Factor:

1. Early ectopic pregnancy (< 6 wks amenorrhoea)1. Early ectopic pregnancy (< 6 wks amenorrhoea)

2. Smaller size < 2 cm (Incomplete removal)2. Smaller size < 2 cm (Incomplete removal)

3. Preoperative high serum 3. Preoperative high serum ββ HCG (> 3,000 IU/L) HCG (> 3,000 IU/L)

4. Decrease in postoperative Day1 titre is < 50% of 4. Decrease in postoperative Day1 titre is < 50% of

preoperative level, is predictor of persistent EP.preoperative level, is predictor of persistent EP.

TreatmentTreatment

surgery

Total or partialsalpingectomy

Medical(selected Asymptomatic pt)

MTX + Leukovorin

OVARIAN ECTOPIC PREGNANCYOVARIAN ECTOPIC PREGNANCYIncidence: Incidence: 1:40,0001:40,000

Risk factor: - Risk factor: - IUCDIUCD

- Endometriosis on surface of ovary- Endometriosis on surface of ovary

Course: Course: C/F are same as tubal pregnancyC/F are same as tubal pregnancy

ruptures within 2-3 wksruptures within 2-3 wks

Diagnosis: Diagnosis: On LaparotomyOn Laparotomy

Spiegelberg’s CriteriaSpiegelberg’s Criteria

1. Ipsilateral tube is intact and separate from sac1. Ipsilateral tube is intact and separate from sac

2. Sac occupies the position of the ovary2. Sac occupies the position of the ovary

3. Connected to uterus by ovarian ligament3. Connected to uterus by ovarian ligament

4. Ovarian tissue found on its wall on HP study4. Ovarian tissue found on its wall on HP study

M/MM/M

Ruptured

Laparotomy

Oophorectomy

Unruptured

Ovarian wedge resection

Ovarian Cystectomy

ABDOMINAL PREGNANCYABDOMINAL PREGNANCY

Incidence:Incidence: RarestRarest

MMR :MMR : 7-8 times > tubal ectopic7-8 times > tubal ectopic

90 times > Intrauterine pregnancy90 times > Intrauterine pregnancy

H/OH/O : : - Irregular bleeding, spotting - Irregular bleeding, spotting

- Nausea, vomiting, flatulence, constipation, - Nausea, vomiting, flatulence, constipation,

diarrhoea, abdominal pain.diarrhoea, abdominal pain.

- Fetal movement may be painful and high in - Fetal movement may be painful and high in

the abdomenthe abdomen

O/E :O/E : - Abnormal fetal position, easy in palpating - Abnormal fetal position, easy in palpating

fetal parts.fetal parts.

- uterus palpated separate from sac- uterus palpated separate from sac

- no uterine contraction after oxytocin - no uterine contraction after oxytocin

infusioninfusion

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

TYPETYPE

Primary SecondaryStudiford’s criteria

1. Both tubes and ovaries normal

2. Absence of Uteroperitonal fistula

3. Pregnancy related to Peritoneal surface & young enough to rule out possibility of secondary implantation

Conceptus escapes out through a rent from primary site

Intraperitoneal ExtraperitonealBroad ligament

FATE OF SECONDARY ABDOMINAL PREGNANCY :FATE OF SECONDARY ABDOMINAL PREGNANCY :

1.1. Death of ovum – complete absorptionDeath of ovum – complete absorption 2. Placental separation – massive intraperitoneal 2. Placental separation – massive intraperitoneal haemorrhagehaemorrhage 3. Infection – fistulous communication with intestine, 3. Infection – fistulous communication with intestine, bladder, vagina, or umbilicusbladder, vagina, or umbilicus 4. Fetus dies (majority) – mummification, adipocere 4. Fetus dies (majority) – mummification, adipocere formation, or calcified to lithopaedionformation, or calcified to lithopaedion 5. Rarely – continue to term (malformation)5. Rarely – continue to term (malformation)M/M:M/M: - - Urgent Laparatomy irrespective of period of gestationUrgent Laparatomy irrespective of period of gestation

- Ideal to remove entire sac fetus, placenta, membrane- Ideal to remove entire sac fetus, placenta, membrane

- Placenta may be left if attached to vital organs, get - Placenta may be left if attached to vital organs, get absorbed by aseptic autolysisabsorbed by aseptic autolysis

CERVICAL PREGNANCYCERVICAL PREGNANCY

Implantation occurs in cervical canal at or below Implantation occurs in cervical canal at or below internal Os.internal Os.

Incidence: Incidence: 1 in 18,0001 in 18,000

RISK FACTORS :RISK FACTORS :

- - Previous induced abortion Previous induced abortion

- Previous caesarean delivery- Previous caesarean delivery

- Asherman’s syndrome- Asherman’s syndrome

- IVF - IVF

- DES exposure- DES exposure

- Leiomyoma- Leiomyoma

Diagnosis:Diagnosis:CLINICAL CRITERIACLINICAL CRITERIA:: Paulman & McEllinPaulman & McEllin 1. Uterine bleeding, no cramping, following 1. Uterine bleeding, no cramping, following amenorrhoeaamenorrhoea 2. Cervix > Corpus, soft consistency2. Cervix > Corpus, soft consistency 3. POC confined to endocervix3. POC confined to endocervix 4. Internal Os is closed4. Internal Os is closed 5. External Os is partially opened5. External Os is partially opened

USG CRITERIAUSG CRITERIA: : American Journal of O&GAmerican Journal of O&G 1. Echo-free uterine cavity/ pseudo-gestational 1. Echo-free uterine cavity/ pseudo-gestational sacsac 2. Decidual reaction2. Decidual reaction 3. Hourglass uterus with ballooned cervical canal3. Hourglass uterus with ballooned cervical canal 4. Gestational sac in endocervix4. Gestational sac in endocervix 5. Closed internal Os5. Closed internal Os 6. Placental tissue in Cx canal6. Placental tissue in Cx canal

HISTOPATHOLOGIC CRITERIA:HISTOPATHOLOGIC CRITERIA: Rubin’sRubin’s 1. Cervical glands present opposite to placenta1. Cervical glands present opposite to placenta 2. Placental attachment to the cervix must be 2. Placental attachment to the cervix must be below the entrance of uterine vessels .below the entrance of uterine vessels . 3. Fetal element absent from corpus uteri.3. Fetal element absent from corpus uteri.

D/d :D/d : - - Carcinoma CxCarcinoma Cx

- Cervical submucous fibroid- Cervical submucous fibroid

- Trophoblastic tumour- Trophoblastic tumour

- Placenta previa- Placenta previa

M/MM/M

SurgicalMainstay 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

MedicalRecently proposed

Single or Combination ORAdjunct to surgery

- Methotrexate

- Actinomycin

- KCl

- Etoposide

CORNUAL PREGNANCYCORNUAL PREGNANCY

SITE:SITE: Implantation occurs in rudimentary horn of Bicornuate Implantation occurs in rudimentary horn of Bicornuate uterusuterus COURSE : COURSE : Rupture of horn occurs by 12 – 20 wksRupture of horn occurs by 12 – 20 wks

D/D : D/D : 1.1. Interstitial tubal pregnancyInterstitial tubal pregnancy 2. Painful leiomyoma along with pregnancy2. Painful leiomyoma along with pregnancy 3. Ovarian tumor with pregnancy3. Ovarian tumor with pregnancy 4. Asymmetrical enlargement of uterus. 4. Asymmetrical enlargement of uterus. Implantation into cornu of normal uterus is sometime Implantation into cornu of normal uterus is sometime called called Angular pregnancyAngular pregnancy . .

TREATEMENT:TREATEMENT: - - Affected cornu with pregnancy is removedAffected cornu with pregnancy is removed - Hysterectomy- Hysterectomy - Hysteroscopically guided suction curettage if - Hysteroscopically guided suction curettage if communication with Cx is patentcommunication with Cx is patent

HETEROTYPIC PREGNANCYHETEROTYPIC PREGNANCY

Co-existing intrauterine and extra uterine pregnanciesCo-existing intrauterine and extra uterine pregnanciesIncidence:Incidence: 1 : 30,0001 : 30,000 With ART – 1:7000With ART – 1:7000 With ovulation induction – 1:900With ovulation induction – 1:900

More likely:More likely: a) Ass. reproductive technique a) Ass. reproductive technique b) Rising HCG titre after D & Cb) Rising HCG titre after D & C c) More than 1 corpus luteum at laparotomyc) More than 1 corpus luteum at laparotomy

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

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

INTERSTITAL PREGNANCY (2%)INTERSTITAL PREGNANCY (2%)

It ruptures late at 3-4 months gestation.It ruptures late at 3-4 months gestation.

Fatal ruptureFatal rupture – severe bleeding as both uterine & – severe bleeding as both uterine &

ovarian artery supply.ovarian artery supply.

Early & UnrupturedEarly & Unruptured – Local or IM MTX with followup – Local or IM MTX with followup

Cornual resection by Laparotomy may be done.Cornual resection by Laparotomy may be done.

There is high risk of uterine rupture in There is high risk of uterine rupture in

subsequent pregnancy.subsequent pregnancy.

RuptureRupture – Hysterectomy is indicated – Hysterectomy is indicated

CAESAREAN SCAR ECTOPIC PREGNANCYCAESAREAN SCAR ECTOPIC PREGNANCY

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

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

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

Diagnosis Diagnosis :: Doppler imaging confirms Doppler imaging confirms

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

OTHER RARE TYPESOTHER RARE TYPES

1. Multiple Ectopic pregnancy1. Multiple Ectopic pregnancy

2. Pregnancy after hysterectomy2. Pregnancy after hysterectomy

3. Primary splenic pregnancy3. Primary splenic pregnancy

4. Primary hepatic pregnancy4. Primary hepatic pregnancy

5. Rectroperitoneal pregnancy5. Rectroperitoneal pregnancy

6. Diaphragmatic pregnancy6. Diaphragmatic pregnancy

MORTALITY : In general population is 10-15% mainly MORTALITY : In general population is 10-15% mainly

due to haemorrhage.due to haemorrhage.

CONCLUSIONCONCLUSION

Ectopic pregnancy can be diagnosed early (before it Ectopic pregnancy can be diagnosed early (before it ruptures) with recent advances in Immunoassay to ruptures) with recent advances in Immunoassay to detect S-hCG , high resolution USG, and dignostic detect S-hCG , high resolution USG, and dignostic Laparoscopy.Laparoscopy.

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

Laparotomy should be done when in doubtLaparotomy should be done when in doubt

Surgeon should not be ashamed of having negative Surgeon should not be ashamed of having negative abdominal exploration, rather to be disgraced for the abdominal exploration, rather to be disgraced for the mistake in diagnosis with the eventual fatality.mistake in diagnosis with the eventual fatality.