Ectopic pregnancy

Obstetrics

2. History
Lawson Tait–first successful
salpingectomy;1884
Stromme–first conservative
surgery(salpingostomy); 1953

3. Medical Management
Surgical Management
Surgically administered medical
management
Expectant Management

4. In case of unrupturedpregnancies.
Methotrexate
Antineoplasticdrug
Acts as a Folic acid antagonist
ADVANTAGES:
Avoids surgery and anaesthesia
Less expense
Less tubal damage
More chance of future fertlity

5. CRITERIA FOR SELECTION
Haemodynamicallystable
No intrauterine pregnancy on ultrasound
No tubal rupture
Size of ectopic < 4cm
If there is fetal cardiac activity use with caution
βhCGlevel preferably < 3000 IU/L

6. Investigations : Full blood count, LFT and
RFT
Exposure to sun should be avoided
Folic acid tablets should not be given
‘Seperationpain’
If medical management fails surgery is
indicated and it becomes necessary in
about 10% women
After methotrexateadministration, βhCGis
better for monitoring and ultrasound is not
used

7. SINGLE DOSE REGIMEN
Single dose of methotrexate
MULTIPLE DOSE REGIMEN
Methotrexate& Leucovorinon alternate days to a
maximum of 4 doses
TWO DOSE REGIMEN
Second dose of methotrexateon day 4

9. Both conservative surgery & salpingectomycan
be performed at laparoscopy and laparotomy.
Laparoscopy is preferable.
But the laparoscopic experience of the surgeon
and the haemodynamicstability of the patient
matters.
Conservative measures are indicated when the
woman has not completed her family.Butin 5%
cases, persistent ectopic has been noted and
hence serial serum βhCGis indicated.

10. LINEAR SALPINGOSTOMY
In ampullaryectopic
A linear incision is made on the antimesentericborder of
the tube immediately over the ectopic and the products
will extrude out.
SEGMENTAL RESECTION
When the ectopic is at the isthmus
Segmental resection is followed by isthmoampullary
anastomosis, if necessary.

11. SALPINGECTOMY
The safest and complete method ,provided the other tube is
normal. Ipsilateralovary should be conserved.
INDICATIONS:
 When the tube is not salvageable
 Uncontrolled bleeding from the tube
 Recurrent ectopic occurs in the same tube
 Childbearing is complete
 Previous sterilisation
PERSISTENT ECTOPIC
Diagnosed by plateauingor rising serum βhCGvalues
following salpingostomy.

12. Under ultrasound guidance, direct injection of
a drug is given into the ectopic.
Methotrexate, patassiumchloride,
hyperosmolarglucose and PGF2αcan be used.
Direct injection of KClinto the sac can be
combined with medical management , in case
of a live ectopic otherwise suited for medical
management.
This is not much employed today.

13. Option for clinically stable asymptomatic
women with an ultrasound diagnosis of ectopic
pregnancy and initial serum βhCGbelow the
discriminatory zone (preferably <1000 IU/L) and
subsequent falling levels.
These women should be counselledproperly and
should be within easy reach of the hospital.
Monitoring should be with serial serum βhCGtwice
weekly.

14. Infertility (fertility rate around 65%)
Repeat Ectopic (risk of a future ectopic is about
12%)

15. HeterotopicPregnancy
Interstitial and CornualPregnancy
IntraligamentousPregnancy
Abdominal Pregnancy
Cervical Pregnancy
Ovarian Pregnancy

17. An ectopic pregnancy coexists with an
intraabdominalpregnancy.
Incidence has increased from 1 in
30,000 pregnancies in the past to 1 in
100 pregnancies.
Serial monitoring of serum βhCGis not
helpful.
Management : Surgical

18. Interstitial : In the proximal intramural part of the
tube
Cornual: In the upper and lateral uterine cavity
Involves myometriumand advance to a
later
stage (even upto16 weeks).
USG shows a bulge in the cornualarea, with an
extremely thin myometrialmantle surrounding
gestational sac. The sac should be located more
than 1cm from the endometrial echo.
The pregnancy can also be in a rudimentary horn of
a bicornuateuterus, usually the horn is non
communicating. If diagnosed earlier, excision of
the rudimentary horn and the tube of the affected
side can be done.

19. Within the broad ligament
Rare; due to penetration of the tubal wall
by the trophoblastand its advancement
between the two layers of the broad
ligament.

20. Usually secondary; after early tubal
rupture or abortion. The fertilisedovum
implants on the peritoneum and continues
to grow.
A primary abdominal pregnancy is
extremely rare.
STUDIFORD CRITERIA
Both tubes and ovaries should be normal
Uteroperitonealfistula should not be seen
The pregnancy is related exclusively to the peritoneal
surface.

21. In abdominal pregnancy,
Nausea and abdominal pain
Malpresentationsand superficial fetal parts
Braxton-Hicks contractions not felt
USG : Absence of uterine outline over the fetus
Management : Laparotomyand removal of fetus
Complications : Torrential haemorrhagedue to lack of
constriction of open vessels after placental seperation
Unless placenta is implanted over vital structures or
major blood vessels it should be removed. Or else
left in situ and autolysis awaited.
Monitored by serial ultrasound and serum βhCG
levels.
Methotrexatecan be given.

22. Implantation in the endocervicalcanal below
the internal os.
Predisposing factors
Previous dilatation and curettage
Previous caesarean section
Most common symptom –Painless vaginal
bleeding
Usually diagnosed incidentally during a
routine scan or during evacuation of a
suspected abortion.
Blood flow around the sac is more suggestive
of a true cervical pregnancy.
Colourdopplercan be used to differentiate
between a true cervical pregnancy and an
intact gestational sac passing through cervix.

23. Rubin Criteria:
There should be cervical glands opposite the placental
attachment.
Attachment of placenta to cervix should be below the
entrance of the uterine vessels or below the peritoneal
reflection.
Fetal elements should not be present in the corpus uteri.
Ultrasound Criteria:
Empty uterus
Hourglass shape of uterus
Ballooned out cervical canal
Gestational sac and placental tissue
in the cervical canal
Closed internal os

24. First choice : Medical treatment with
multiple dose methotrexate.
Radiological uterine artery embolisation
followed by evacuation. Bilateral internal
iliac artery ligature has also been tried.
Hysterectomy

25. Implantation in the ovary
Very rare
Usual consequence : Rupture at an early
stage
Management : Surgery; ovariotomy
Methotrexateif
diagnosed earlier
SpiegelbergCriteria:
The tube on the affected side should be intact.
Fetal sac should occupy the position of the ovary.
Ovary should be connected to the uterus by the
ovarian ligament.
Definite ovarian tissue should be found in the sac
wall.

26. In women with a previous caesarean section.
Diagnostic criteria:
An empty uterine cavity
A gestational sac located anteriorlyat the level of
the internal oscovering the visible or presumed
site of the previous lower uterine segment
caesarean section scar
Evidence of functional trophoblastic/placental
circulation on Doppler examination
An absent “sliding sign” (inability to displace the
gestational sac from its position at the level of
internal osusing gentle pressure applied by the
transvaginalprobe)