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AND ITS MANAGEMENT

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Title: AND ITS MANAGEMENT


1
ANDITS MANAGEMENT
ECTOPIC PREGNANCY
  • DR ASIFA SIRAJ
  • CONSULTANT GYNAE/OBG
  • MH RAWALPINDI

2
Is one in which fertilized ovum is implanted
develops outside normal uterine cavity
3
  • IMPLANTATIONS SITES

EXTRAUTERINE
UTERINE
-CERVICAL (118,000) -ANGULAR -CORNUAL
TUBAL 97 -Ampulla 80 -Isthmus
12 -Infundibulum 6 -Interstitial 2
OVARIAN (140,000)
ABDOMINAL (110,000)
SECONDARY
PRIMARY
Intraperitoneal
Extraperitoneal Broad Ligament (rare)
4
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5
  • INCIDENCE
  • Increased due to PID, use of IUCD, Tubal
    surgeries, and Assisted reproductive techniques
    (ART).
  • Ranges from 125 to 1250
  • Average range is 1 in 100 normal pregnencies.
  • Late marriages and late child bearing -gt 2
  • ART -gt 5
  • ETIOLOGY
  • Pelvic Inflammatory disease (6-10 times)
  • Chlamydia trachomatis is most common

6
  • Contraceptive Faliure
  • CuT -4
  • Progestasart -17
  • Minipills -4-10
  • Norplant -30
  • 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

7
  • Reversal of sterilisation
  • - Depends on method of sterilization, Site
    of
  • tubal occlusion, residual tubal length.
  • - Reanastomosis of cauterised tube -15
  • - Reversal of Pomeroys - lt 3
  • 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
  • - If first pregnancy is ectopic then 30
    chance
  • of repeat ectopic

8
  • Developmental defects of tube
  • elongation, diverticulum, accessory ostia,
    intamural polyp, entrap the ovum on its way.
  • Other Risk factors
  • - Age 35-45 yrs
  • - Previous induced abortion
  • - Previous pelvic surgeries
  • - Cigarette smoking
  • - DES Exposure in Utero

9
  • - Infertility
  • - Salpingitis Isthmica Nodosa
  • - Genital Tuberculosis
  • - Fundal Fibroid Adenomyosis of tube
  • - Transperitoneal migration of ovum
  • - 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

10
  • MODE OF TERMINATION
  • 1. Tubal mole

Complete absorption
Abortion
Pelvic haematocele
Complete
Pelvic haematocele
2. Tubal Abortion (18-20)
Incomplete
Diffuse Intraperitoneal haemorrhage
Roof
Diffuse Intraperitoneal haemorrhage
3. Tubal Rupture
Floor
Intraligamentary haematoma
(Isthmic 6-8 wks, Ampullary 8-12wks,
Interstitial -4 months)
Roof
Secondary Abdominal pregnancy
4. Tubal Perforation
Floor
Secondary Intraligamentary pregnancy
5.Continuation of Pregnancy
rarest
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12
  • 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.

13
  • 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.

14
  • 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.

15
  • CHRONIC ECTOPIC PREGNANCY
  • 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.

16
  • 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.
  • P/R- Corrobarate the pelvic findings.

17
  • 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

18
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19
  • DIAGNOSIS
  • Patient with acute ectopic can be diagnosed
    clinically.
  • Blood should be drawn for Hb gm, blood grouping
    and cross matching, DC and TWBC, BT, CT.
  • 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 ß
    hCG and
  • can be detected on 24th day after LMP.

20
  • 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.
  • Other Investigations-
  • 1. Ultra Sonography-
  • a) Transvaginal Sonography (TVS) is
    more
  • sensitive
  • -It detect intrauterine
    gestational sac at 4-5
  • wks and at S-ß hCG level as low
    as 1500
  • IU/L .

21
  • 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-ß hCG level at which intrauterine
    gestational
  • sac is seen by TAS is 6500 IU/L.

22
  • 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.

23
Hyperechoic ring around gestational sac in
adnexal region
24
  • CO RELATION BETWEEN USG HCG

S-hCG lt 6500 IU/L sac not visible
S hCG gt 6500 IU/L
  • - Normal pregnancy at
  • early wks
  • Abnormal IU pregnancy
  • Recent abortion
  • Ectopic pregnancy
  • Non pregnant pt

Sac not visible
Sac visible by TAS
Ectopic or Non viable
Viable Intrauterine pregnancy
25
  • 2. ß-HCG Assay-
  • a) Single ß-HCG little value
  • b) Serial ß-HCG is required when result
    of
  • initial USG is confusing.
  • - When hCG level lt 2000 IU/L doubling
    time
  • help to predict viable Vs nonviable
    pregnancy.
  • -Rise of ß-HCG lt66 in 48 hrs indicate
  • ectopic pregnancy or nonviable
    intrauterine
  • pregnancy .
  • Biochemical pregnancy is applied to those
  • women who have two ß-HCG values gt10 IU/L

26
  • 3. Serum Progesterone
  • - level gt25 ngm/ml is suggestive of
    normal
  • intrauterine pregnancy.
  • - level lt15 ngm/ml is suggestive of
    ectopic
  • pregnancy.
  • - level lt5 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.

27
  • 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 hormonal 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.

28
  • SUSPECTED ECTOPIC PREGNANCY
  • Urine Pregnancy test
    positive

Transvaginal USG
IU sac
No IU sac
Quantitative S-hCG
S progesterone
lt 66 rise in 48 hr or S progesterone lt 5-10 ng/ml
gt66 rise in 48 hr or
S progesterone gt 5-10 ng/ml
D C
Repeat S-hCG in 48 hrs till USG discrimination
zone
Villi present
Villi absent
Laparoscopy
IU sac
No sac
Incomplete abortion
Continue to monitor
29
  • 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

30
  • 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

31
  • MANAGEMENT

Expectant management
Medical management
Surgical management
Radical
Conservative
Local
Systemic
(USG or Laparoscopic)
Salpingectomy
salpingocentesis
Methotrexate
  • Salpingostomy
  • Salpingotomy
  • - Segmental
  • resection
  • Milking or fimbrial
  • expression
  • Methotrexate
  • - Potassium chloride
  • - Prostagladin(PGF2a)
  • - Hypersmolar glucose
  • Actinomycin D
  • Mifepristone

32
  • EXPECTANT MANAGEMENT
  • CRITERIA
  • 1. Haemodynamically stable
  • 2. Haemoperitoneum lt 50ml
  • 3. Adnexal mass of lt 3.5 cm without heart
    beat.
  • 4. Initial ß HCG lt1000 IU/L and falling in
    titre
  • SUCCESS RATE - Upto 60
  • PROTOCOL
  • - Hospitalization with strict monitoring of
    clinical symptom
  • - Daily Hb estimation
  • - Serum ß HCG monitoring 3-4 days until it
    is lt10 IU/L

33
  • 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 lt 4cm without cardiac activity
  • or lt 3.5 cm with cardiac activity
  • S-hCG lt 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.

34
  • MEDICAL MANAGEMENT
  • Methotrexate

(Systemically IM, IV, Oral)
Single dose (recent)
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
50mg/m2 IM
  • D1 ß-HCG, CBC, LFT, RFT
  • D4 - ß-HCG
  • D7 - ß-HCG, CBC, LFT, RFT
  • Weekly ß-HCG till negative titre
  • If ß-HCG decrease is lt 15 D4 D7
  • then repeat the MTX dose
  • If decline is gt 15 then weekly measure
  • ß-HCG until level is lt 15 IU/L.

35

SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
By Salpingocentesis, MTX (1mg/kg), KCL, PGF2a,
Hyperosmolar glucose, mifepristone, Anti hCG Ab
is injected into sac by transvaginally under USG
guidance, Laparoscopy, transcervical tubal
cannulization
Advantage of local MTX -
Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up - Serum ß HCG twice weekly till lt 10
IU/L - TVS weekly for 4-6
weeks - HCG after 6 months for
tubal patency
36
  • 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.

37
  • MANAGEMENT OF RUPTURED ECTOPIC
  • PRINCIPLE Resuscitation and Laparotomy
  • ANTI SHOCK TREATEMENT
  • - IV line made patent, crystalloid is started
  • - Blood sample for Hb, blood grouping cross
    matching, BT, CT
  • - Folleys 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.

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39
  • MANAGEMENT OF UNRUPTURED 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

40
  • VARIOUS CONSERVATIVE SURGERIES
  • 1.Linear Salpingostomy
  • - Indicated in unruptured ectopic lt2cm 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

41
  • 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 ß HCG titre till it is
    negative.
  • - If titre increases methotrexate can be
    given.

42
  • DEBATABLE ISSUES
  • ? Salpingectomy Vs Salpingostomy
  • ? Laparotomy Vs Laparoscopy
  • ? Reproductive outcome
  • ? Risk of Recurrent Ectopic

43
  • Salpingectomy Vs Salpingostomy
  • - If future fertility is a consideration
    the factors to be taken into account are status
    of Ipsilateral tube, Contralateral tube, other
    pelvic pathology.
  • - Report shows there is no significant
    difference in subsequent reproductive outcome
    with regard to IU pregnancy or recurrent Ectopic.
  • - Linear Salpingostomy is currently procedure
    of choice, when pt has unruptured Ectopic and
    wishes to retain her potential for future
    fertility.
  • - In pt with only one tube, conservative
    surgery may be appropriate but only when pt is
    aware and accept the risk involved.

44
  • 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.

45
  • PERSISTENT ECTOPIC PREGNANACY
  • Defined as continued growth of trophoblastic
    tissue after
  • conservative treatment (3 20 incidence)
  • Risk Factor
  • 1. Early ectopic pregnancy (lt 6 wks
    amenorrhoea)
  • 2. Smaller size lt 2 cm (Incomplete removal)
  • 3. Preoperative high serum ß HCG (gt 3,000
    IU/L)
  • 4. Decrease in postoperative Day1 titre is lt
    50 of
  • preoperative level, is predictor of
    persistent EP.
  • Treatment

surgery
Medical
(selected Asymptomatic pt)
Total or partial salpingectomy
MTX Leukovorin
46
  • OVARIAN ECTOPIC PREGNANCY
  • Incidence 140,000
  • Risk factor - IUCD
  • - Endometriosis on surface of
    ovary
  • Course C/F are same as tubal pregnancy
  • ruptures within 2-3 wks
  • Diagnosis On Laparotomy
  • Spiegelbergs 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/M

Unruptured
Ruptured
Ovarian wedge resection
Laparotomy
Ovarian Cystectomy
Oophorectomy
47
  • ABDOMINAL PREGNANCY
  • Incidence Rarest
  • MMR 7-8 times gt tubal ectopic
  • 90 times gt 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

48
  • Diagnosis Confirmed by USG, CT scan, MRI,
    Radiography
  • TYPE

Primary
Secondary
Studifords criteria
Conceptus escapes out through a rent from
primary site
  • Both tubes and ovaries normal
  • Absence of Uteroperitonal fistula
  • Pregnancy related to Peritoneal
  • surface young enough to rule
  • out possibility of secondary
  • implantation

Intraperitoneal
Extraperitoneal Broad ligament
49
  • 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

50
  • 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

51
  • Diagnosis
  • CLINICAL CRITERIA Paulman McEllin
  • 1. Uterine bleeding, no cramping,
    following
  • amenorrhoea
  • 2. Cervix gt Corpus, soft consistency
  • 3. POC confined to endocervix
  • 4. Internal Os is closed
  • 5. External Os is partially opened
  • USG CRITERIA American Journal of OG
  • 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

52
  • HISTOPATHOLOGIC CRITERIA Rubins
  • 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

53
  • M/M

Medical
Surgical
Recently proposed
Mainstay therapy in past
Single or Combination OR Adjunct to
surgery
Conservative
Radical surgery
D C
  • Methotrexate
  • Actinomycin
  • KCl
  • Etoposide

(risk of torrential bleeding)
Hysterectomy
  • Cerclage Bernstein Mc Donalds
  • Wharton Shirodkars
  • Transvaginal ligation of Cx branch of
  • uterine artery
  • - Angiographic uterine A embolisation
  • Intracervical vasopressin inj
  • Foleys catheter as tamponade

54
  • 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

55
  • HETEROTYPIC PREGNANCY
  • Co-existing intrauterine and extra uterine
    pregnancies
  • Incidence 1 30,000
  • With ART 17000
  • With ovulation induction
    1900
  • 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.)

56
  • 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

57
  • 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
  • T/t Methotrexate injection
  • Hysterectomy in a multiparous women.
  • In young pt resection suturing of scar
    may be
  • done (high risk of rupture).

58
  • 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.

59
  • CONCLUSION
  • Ectopic pregnancy can be diagnosed early (before
    it ruptures) with recent advances in Immunoassay
    to detect S-hCG , high resolution USG, and
    dignostic Laparoscopy.
  • There has been shift in the M/m from ablative
    surgery to conservative fertility preserving
    therapy
  • Laparotomy should be done when in doubt
  • Surgeon should not be ashamed of having negative
    abdominal exploration, rather to be disgraced for
    the mistake in diagnosis with the eventual
    fatality.

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