Professional Documents
Culture Documents
Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
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 womans
health and reproductive potential, requiring
prompt recognition and early aggressive
intervention.
IMPLANTATIONS SITES
EXTRAUTERINE
UTERINE
-CERVICAL
(1:18,000)
-ANGULAR
-CORNUAL
-CAESAREAN
SCAR (<1)
Broad Ligament
(rare)
INCIDENCE
ETIOLOGY:
ETIOLOGY
CONGENITAL
Tubal Hypoplasia
Tortuosity
Congenital diverticuli
Accessory ostia
Partial stenosis
Elongation
Intamural polyp
Entrap the ovum on its way.
ACQUIRED -
Contraceptive Faliure
CuT - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%
Reversal of sterilisation
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
CLINICAL APPROACH
UNRUPTURED ECTOPIC
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
DIAGNOSIS
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.
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
shape
borders
color flow
pattern
usually round
double ring
high
peripheral flow
along the
cavity line b/w
endometrial layers
may change,oviod
single layer
avascular
DECIDUAL CYST
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.
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.
Villi absent
Laparoscopy
No IU sac
>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
DIFFERENTIAL DIAGNOSIS
D/D of Acute Ectopic
1.
2.
3.
4.
5.
6.
7.
8.
9.
MANAGEMENT
Expectant
management
Local
(USG or Laparoscopic)
salpingocentesis
-
Medical
management
Surgical
management
Radical
Systemic
Conservative
Salpingectomy
Methotrexate
Methotrexate
Potassium chloride
Prostagladin(PGF2)
Hypersmolar glucose
Actinomycin D
Mifepristone
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbrial
expression
MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS:
SURGICAL-
SURGICALLY ADMINISTERED
MEDICAL (SAM) TREATMENT
MEDICAL TREATMENT
EXPECTANT MANAGEMENT
EXPECTANT MANAGEMENT
EXPECTANT MANAGEMENT
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
Follow up on day1, 4 and 7.
MEDICAL MANAGEMENT
METHOTREXATE:
It can be used as oral,intramuscular ,intravenous usually
along with folinic acid.
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
depends on
DEBATABLE ISSUES
Salpingectomy Vs Salpingostomy
Laparotomy Vs Laparoscopy
Reproductive outcome
SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
CONTD
Score
2
1
1
2
1
2
1
1
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
LAPAROSCOPIC SALPINGOTOMY
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
TYPE
Primary
Studifords criteria
1. Both tubes and ovaries normal
2. Absence of Uteroperitonal fistula
Secondary
Conceptus escapes out
through a rent from
primary site
Extraperitoneal
Broad ligament
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
- Ashermans 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
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
MANAGEMENT
Medical
Surgical
Radical
surgery
Hysterectomy
Conservative
D&C
Recently proposed
Single or Combination
OR
Adjunct to surgery
- Methotrexate
- Actinomycin
- KCl
- Etoposide
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 gm is sufficient to
prevent sensitization.)
Recently reported
USG slows on empty uterine cavity and gestational
sac attached low to the lower segment caesarean
scar.