4.ECTOPIC PREGNANCY(0) bleeding in early pregnancy

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1. DEFINITION An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity

2. SITES OF IMPLANTATION EXTRA UTERINE TUBAL(97%) OVARIAN(0.5%) ABDOMINAL(1%) UTERINE(1.5%) CERVICAL(<1%) ANGULAR CORNUAL CESAREAN SCAR TUBAL AMPULLA(55%) ISTHAMUS(25%) INFUNDIBULUM (18%) INTERSTITIAL (2%) ABDOMINAL PRIMARY SECONDARY INTRAPERITONEAL EXTRAPERITONEAL

3. RISK FACTORS History of PID History of tubal ligation Contraception failure Previous ectopic pregnancy Tubal reconstructive surgery History of infertility ART particularly if the tubes are patent but damaged IUCD use Previous induced abortion Tubal endometriosis

4. Causes Salphingitis and PID( 6-10 fold increase) Smoking Iatrogenic : 1.Contraception failure (a)IUD in situ( 7 times more) (b)Sterilization operation(15-50) (c)Use of progestin only pill or post-coital estrogen preparations 2.Tubal surgery 3.Intrapelvic adhesions following pelvic surgery 4.ART – IVF-ET & GIFT 5.Others

5. Causes 5.Others Previous ectopic pregnancy Prior induced abortion Developmental defects of the tube Trans-peritoneal migration of the ovum

6. TUBAL PREGNANCY Implantation can occur at any point along the fallopian tube . A mpulla is the most common site.

7. PHYSIOLOGY In uterine pregnancy the blastocyst embeds in the decidua and trophoblast erodes the maternal tissue anchoring the developing embryo. In tubal pregnancy the blastocyst rapidly erodes and becomes attached to the muscle layer, it grows and expands within the wall, distending the tube. Maternal blood vessels are exposed and pressure caused by resultant blood flow can destroy the embryo.

8. MODES OF TERMINATION Tubal mole: Repeated small hemorrhage occur in chorio-decidual space. The tubal mole can be completely absorbed. Expulsion through the abdominal ostium as tubal abortion with a variable amount of internal hemorrhage.

9. Tubal abortion: common mode of termination, if implantation occurs in the ampulla or infundibulum. chorio-decidual hemorrhage occurs around the ovum which is expelled into the tubal lumen. Complete abortion : tubal peristalsisexpulsion of ovum through ostium Incomplete abortion: Products remains attached to endosalpinxbleedingblood collect in pouch of douglas(to form pelvic hematocele)

10. Tubal rupture: Common in isthmic and interstitial implantation The wall is distended by the pregnancy and it rupture Isthmic rupture usually occurs at 6-8 weeks, the ampullary one at 8-12 weeks and the interstitial one at about 4 months.

11. Secondary abdominal pregnancy After tubal abortion , if the fetus is still alive, it can very rarely result in secondary abdominal pregnancy or secondary intra-ligamentous pregnancy

12. CLINICAL FEATURES

13. ACUTE ECTOPIC A short period of amenorrhea of 6-8 weeks(may exceed 10-12 weeks ) Abdominal pain due to distension of tube by blood Vaginal bleeding slight and dark colored Nausea and vomiting Syncope Shoulder pain

14. The classic triad of symptoms of disturbed tubal pregnancy are: Amenorrhea (100%) Vaginal bleeding (70%) Abdominal pain(75%)

15. On examination Pallor Features of shock ( ↑pulse,↓BP) Abdominal examination : abdomen is tense, tender and swollen. Bimanual exaination : Vagina mucosa-blanched white Uterus- normal size Tenderness on fornix No mass felt through fornix Uterus floats as if in water

16. UNRUPTURED TUBAL ECTOPIC PREGNANCY Symptoms Presence of delayed period or spotting with features suggestive of pregnancy (UPT Positive). Uneasiness on one side of the flank which is continuous and or colicky in nature Signs :Bimanual Examination Uterus is usually soft A pulsatile small, tender mass may be felt through one fornix separated from the uterus.

17. SUB ACUTE (CHRONIC ) ECTOPIC Amenorrhea Lower abdominal pain Vaginal bleeding Other symptoms: dysuria, frequency or retention of urine, rise in temperature.

18. On examination patient look ill, varying degree of pallor, slightly raised temperature. Features of shock Per abdominal examination Tenderness A mass may be felt, irregular and tender. Cullen’s sign may be present( bruising or discoloration around the umbilicuss ) Bimanual examination Vaginal mucosa pale, Uterus may be normal in size or bulky Extreme tenderness on the cervix

19. Investigations for the diagnosis of tubal ectopic pregnancy Blood Examination Hb ABO and Rh grouping Total WBC and differential count ESR Estimation of β hCG Sonography Combination of quantitative β hCG values & sonography Laprocscopy Culdocentesis Dilatation & Curettage Serum progesterone ˂ 5ng/ml suggests ectopic or abnormal intrauterine pregnancy Laparotomy

20. MANAGEMENT Some clinical feature β- hCG Negative Some clinical feature β- hCG Positive β- hCG Positive Strong clinical feature Patient in shock/unstable

21. Some clinical feature β- hCG Negative Repeat β- hCG in 1 week Negative Pregnancy excluded 1

22. Some clinical feature β- hCG Positive USS/TVS β- Hcg on TVS=1500 mLU/Ml Empty uterine cavity with adnexal mass Intrauterine Sac Determine viability β- hCG ↑>60% in 48 Hrs Sr.Progesterone >25ng/ml Repeat USG Intrauterine pregnancy Laparoscopy Unruptured Tubal ectopic pregnancy Expectant management Medical management Surgical management 2

23. Unruptured Tubal ectopic pregnancy Medical Expectant (observation) Surgical Initial β hCG <1000 I/L Falling hCG titer Ectopic mass diameter is <4cm No evidence of bleeding or rupture on TVS No cardiac activity Direct local(laparoscopy/USS guided systemic Methotrexate Pottassium chloride MTX Actinomycine Segmental resection salpingectomy conservative extirpative Expressing out from distal tubes Salpingostomy salpingectomy β - hCG follow up to detect persistent trophoblastic disease

24. β- hCG Positive Strong Clinical features Patient in shock/unstable hemodynamically Resuscitation and laparotomy Ruptured tubal ectopic pregnancy Salpingectomy 3

25. Resumption of ovulation and contraception: 15%- ovulate by 19 days 25%- by 30 th postoperative day Contraception- ideally commenced at the time of hospital discharge.

26. Multidose regimen is used for advanced cases or those with embryonic cardiac activity. Multidose methotrexate includes MTX – 1 mg/kg IM on D1,3,5,7 Leukovorin 0.1 mg/kg IM on D2,4,6&8 Serum hCG is monitoried weekly until <5.0 mIU /ml.

27. INTERSTITIAL PREGNANCY It is the rarest variety of tubal pregnancy. The usual termination is rupture. It is associated with massive intra peritoneal haemorrhage due to its combined vascularisation by the uterine and ovarian arteries.

28. Interstitial pregnancy USG diagnostic criteria Uterine cavity empty Gestational sac is located laterally in the intramural part of the fallopian tube GS is surrounded by a thin layer of myometrial mantle Presence of interstitial line sign Thin echogenic line extending from the central uterine cavity to the interstitial sac

29. Myometrial mantle: the section of the uterus (including the endometrium and myometrium ) from the gestational sac to the external uterine wall .

30. Management Expectant management When Serum βhCG level low or falling Medical management Methotrexate Surgical management Cornuostomy /Cornual resection Hysterectomy

31. ABDOMINAL PREGNANCY

32. DEFINITION Abdominal pregnancy means ectopic pregnancy in the abdominal cavity

33. ABDOMINAL PREGNANCY PRIMARY: Primary implantation of the fertilized ovum on the peritoneal surface. SECONDARY: the conceptus escapes out through the rent in the uterine scar.

34. ABDOMINAL PREGNANCY

35. Signs & Symptoms Lower abdominal pain Nausea, Vomiting, Constipation, Painful fetal movements Abnormal fetal lie

36. MRI & Computed tomography – confirm diagnosis Elevated serum β – hCG and USG/MRI – diagnosis.

37. MANAGEMENT Early pregnancy – laproscopy &systemic methotrexate Advanced pregnancy- Urgent laparotomy irrespective of period of gestation

38. OVARIAN PREGNANCY

39. DEFINITION An abnormal pregnancy that takes place within the ovary itself due to the development of a fertilized ovum still lodged within an ovarian follicle

40. SPIEGELBERG’S CRITERIA Tube on the affected side must be intact The gestation sac must be in the position of the ovary The gestation sac is connected to the uterus by the ovarian ligament The ovarian tissue must be found on its wall on histological examination

41. Treatment Medical Methotrexate Surgical Laproscopic method of removal of conceptus , enucleation or wedge resection is the preferred method. Oophorectomy – excessive bleeding or co-existing ovarian pathology. Salphingo-oophorectomy – in ruptured cases

42. CORNUAL PREGNANCY

43. DEFINITION Pregnancy occurring in rudimentary horn of a bicornuate uterus, is called cornual pregnancy. Incidence 1 in 76,000 pregnancies

44. Cornual pregnancy

45. Diagnosis : USG Termination by rupture is inevitable between 12-20 weeks with massive intraperitoneal haemorrhage.

46. Cornual pregnancy

47. MANAGEMENT SUEGERY: Surgery includes removal of the rudimentary horn by laproscopy / laparotomy . If the pedicle is short and attachment is wide, hysterectomy may have to be done.

48. CERVICAL PREGNANCY

49. DEFINITION The implantation occurs in the endocervical canal at or below the internal os . if it is implanted closer to the uterine cavity it is called cervico-isthmic pregnancy

50. INCIDENCE 1 in 16,000 pregnancies

51. Signs and symptoms In cervical pregnancy bleeding is usually painless and the uterine body lies above the distended cervix. Intractable bleeding occurs following evacuation or expulsion of the products.

52. Clinical Diagnostic Criteria (Rubin-1983) Soft, enlarged cervix equal to or larger than the fundus Uterine bleeding following amenorrhoea , without cramping pain Products of conception entirely confirmed within and firmly attached to the endocervix A closed internal os and partially opened external os

53. DIAGNOSIS Sonography Confirmation is done by histological evidence of the presence of villi inside the cervical stroma

54. MANAGEMENT Medical management: Systemic Methotrexate, local injection with KCL. Surgical management: bleeding is life-threatening D&C Uterine artery ligation Uterine arterial embolization (UAE)

55. MANAGEMENT Other procedures Intraervical vasopressin injection Hemostatic cervical sutures on lateral aspects of the cervix Folley balloon catheter tamponade (bleeding after curettage .) Hysteroscopic resection with Uterine Artery Embolization . Hystrectomy

56. CESAREAN SCAR PREGNANCY Cesarean scar pregnancy is defined as implantation into myometrial defect in the site of the previous uterine scar. Incidence 1 in 2500-3000 pregnancies.

57. CESAREAN SCAR PREGNANCY Diagnosis MRI &USG Types Type 1- Endogenic – growing towards the uterine cavity Type 2- Exogenic - growing outwards Risk of ruptur is high in exogenic

58. CESAREAN SCAR PREGNANCY Treatment Medical management : Methotrexate as systemic(IM) or location injection. Surgical management : Evacuation or excision pregnancy by open or laparoscopic or hysteroscopic method.

59. HETEROTYPIC PREGNA NCY Intrauterine pregnancy may be coexistent with tubal or rarely with cervical or ovarian pregnancy. Incidence is 1 in 8,000 pregnancies Diagnosis is difficult Common following ART

60. Management Methotrexate Local injection: KCL or hyperosmolar glucose with aspiration of the sac contents(feticide). Surgery : removal of ectopic pregnancy, in hemodynamically unstable patients following simultaneous resuscitation. Expectant management : non viable heterotopic pregnancy Anti –D immunoglobulin

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