1. DR KARIMAH BT MOHD
O&G DEPARTMENT
HSNZ ,TRG
Seminar Gynaecology (2013)

2. 31 G3P2 at 12 week s +1 days POA
Sod ,LMP-25.6.2013 ,not on contraception
Referred from district hospital ? Molar
Pt went for RME at KK and was asymptomatic
Routine scan was done –findings multiple cyst within uterine cavity ,no iugs seen ,no
fetal echo noted ,no free fluid
No hx passing out vesicles/pv bleed /abd pain
Clinically pt stable ,pink ,comfortable
p/a soft non tender ,no palpable mass
Ve/speculum done –documented normal
Cervical excitation was +
Case was seen by mo –and scan comfirm by specialist
Findings –TAS –no iugs ,ET-6.6 mm,uterus anteverted
TVS-regular GS with fetal echo at rt adnexa ,25 mm=6 weeks 2/7
min fluid at POD
Bhcg –sent results 7513 iu/ml (retrospective review)
IMP-…………………………

3. Diagnosis was ….Leaking Ectopic pregancy
Proceed for laparoscopic left salphingectomy 18.9.2013
Findings intraop:
Hemoperitoneum 700 cc .left tubal ectopic pregnancy
Uterus normal ,both ovaries normal
Rt fallopian tube normal and intraop uneventful
Pt was dc well with advice on 20.9.2013 with tca gynae
3/12

5. •MISCARRIAGE
•HYPEREMESIS GRAVIDARUM
•CERVICAL INCOMPETENCE
ECTOPIC PREGNANCY
•MASSIVE MENSTRUAL BLOOD LOSS
•EMERGENCY CONTRACEPTION
SEVERE ACUTE PELVIC PAIN

6. DEFINITION :
 Ectopic – from Greek word ‗ektopos‘
meaning out of place
 Any implantation outside uterine cavity

7.  Rising incidence -1% of all pregnancy
 95% located in f.tube
 Always exclude ectopic pregnancy
 Delay ----------------catastrophic
 Counselling on future pregnancy : recurrence
rate 12-20% .
 Early comformation on future pregnancy
 Early usg –to confirm site of pregnancy

9. Site of ectopic pregnancy :
1. Tube ( > 95 % ) :
ampulla : 80%
isthmus : 12 %
fimbria : 5 %
cornual : 2 %
2. Uterus : intramural
, angular, cervical(0.2%),
rudimentary horn
3. Ovary : < 0.2 %
4. abdominal : 1.4 %

11. CLINICAL PRESENTATION
Can present in many ways
Most common presenting complaint :
1. Lower abdominal pain : 9 % no pain
2. Delayed or irregular menses followed by
vaginal bleeding, brownish discharge or
syncopal attack.
‘if a patient who is a few weeks pregnant complains of little pain and heavy
vaginal bleeding, the pregnancy is probably intrauterine, whereas if she
has much pain and little bleeding, she is more likely to have an ectopic’-
Stabile(1996)
Presentation : Acute or Subacute

12. Acute Presentation :
Following tubal rupture an intraperitoneal
haemorrhage.
 Acute abdominal pain
- typically referred to shoulder tip or
interscapular area
- may be provoked by lying down / inspiration
 Cardiovascular collapse :
hypotensive & tachycardia
 Peritoneal irritation
 Cervical excitation pain
 May be moderate leucocytosis
 Cullen‘s sign – bluish umbilicus; unusual sign

13. Subacute Presentation :
Frequently give rise to diagnostic confusion
Abdominal pain : Localized to one illiac fossa
Delayed menstruation
Vaginal bleeding
May be referred pain to shoulder tip
Peritoneal irritation : less marked
Bimanual Examination :
. Localized tenderness : one of the fornices
. Cervical excitation pain
. Posterior fornix tenderness : presence of affected
tube in POD
* Have to be very gentle to prevent rupturing
unruptured tube

14.  Isthmic implantation
 Narrow segment ; less distensible
 Often occurs at 6-8 weeks
 Ampullary implantation
 Usually occur at 8-12 weeks
 Wider segment
 80% of ectopic
 Interstitial implantation (cornual ectopic)
 Surrounded by myometrium; can accommodate enlarging
conceptus.
 Later stage of rupture : 12-14 weeks
 Results in damage of highly vascularized cornual end of
uterus
 Severe intraabdominal hemorrhage

15. DIAGNOSIS
Early diagnosis is critically important in terms of
outcome
When detected early, major morbidity is reduced
and treatment options are enhanced
In recent years, in spite of increase in the
incidence of ectopic, the case fatality rate is
reducing.
Due to :- widespread introduction of diagnostic
tests
- awareness of the seriousness of ectopic
leading to early diagnosis and effective
treatment

16. Diagnosis : cont
1. High index of suspicion :
Any women in her reproductive age group,
sexually active with PV bleeding after a period of
delayed menses is a case of ectopic until proven
otherwise
2. Combination of TVS and serial hCG : still remain
the cornerstone for diagnosis
3. Laparoscopy : gold standard
in very early stages , ectopic is not visualised ; 3-
4% is missed.

17. Quantitative hCG
Ectopic pregnancy produces lower concentration
of hCG than normal pregnancy, but the change in
concentration provides more information.
In normal pregnancy :
Doubling time : 2 – 3.5 days during 4 – 8 weeks ,
At 6 weeks : BhCG - > 6000 – 10000 iu/L
reaching a peak around 8 – 12 weeks
2 days sampling interval is recommended
Failure of increase of at least 66 % is suggestive
of ectopic .(85%confident limit)
15% ectopic BhCG > 66% within 48H

18. Cacciatore et all 94 :
In women at high risk, absence of IUGS
( TVS ) + serum hCG > 1000iu / L
Indicates ectopic in > 80 % of women

19. Ultrasonography
1. TAS : detect IUGS – hCG > 6500 iu/L
* Absence of an IUGS on TAS in conjunction with
hCG level greater than 6500 iu/L is suggestive of
ectopic
2. TVS :
* Detect IUGS – hCG > 1000 –1500 iu/L
* Corespond to 1 week after missed period when
IUGS measurement is 2 – 4mm.
* Ectopic is suspected if TVS doesn‘t detect IUGS
when hCG level is > 1500iu / L

20. Ultrasonography : cont…
Literature provide a wide range of sensitivity &
specificity for TVS in detecting ectopic
pregnancy :
 Sensitivity ranging 69 – 99 %
 Specificity ranging 84 – 99.6 %

21. Other Diagnostic Modalities :
1. Culdocentesis :
* Rarely performed today as USG can reveal
presence of fluid in POD
* Used primarily when USG is not readily
available.
Non clotting blood on culdocentesis – strongly
suggest bleeding ectopic
Yellow or straw colour fluid – rupture ovarian
cyst
Negative test – does not exclude ectopic

22. 2. Serum progesterone:
Some clinicians continue to find it useful.
Rational is that viable intrauterine pregnancies
were associated with serum progesterone level of :
1. 11 ng/mL , in one study : sensitivity 91 %
2. 25 ng/mL , in another study : sensitivity 97.5%
Although level less than 11 ng/mL is indicative of
an abnormal pregnancy, it doesn’t distinguish
between an ectopic and failing intrauterine
pregnancy.
In addition, ectopic pregnancy are known to occur
when serum progesterone level is > 25 ng/mL &
there are reports of several woman with
documented very low serum progesterone ( < 5
ng/mL ) who delivered normal baby at term

23. 3. Other Markers of ectopic :
 Cervical fetal fibronectin
 Serum creatine kinase
 Vascular cell adhesion molecule – 1
 Vascular Endothelial Growth Factors
• All are found to be not useful except Vascular Endothelial
Growth Factors, which showed encouraging result,
however the sample size of the study was small which
limits the ability to generalize.
• There is active research going on to find ―ectopic
pregnancy hormone.” If found, it will revolutionize the
diagnosis and management of this problem.

24.  Ruptured corpus luteum cyst
 Threatened / incomplete miscarriage
 Pelvic Inflammatory Disease
 Degeneration of fibroid

25. MANAGEMENT
1. Once diagnosed, should be admitted and
evaluated.
2. Options :
a. Controlled expectant Mx
b. Medical
c. Surgery : commonest
d. Combination.
Surgery remains the mainstay of treatment.
Expectant and medical management are possible
and should be considered in selected cases.

26. Controlled Expectant Management
Not all ectopic pregnancies progress & pose a risk to the
mother.
7 observational studies ( 478 pt ), managed expectantly
showed 67 % resolved spontaneously.
Spontaneous resolution more likely if :
1. Initial hCG is low ( < 1000-2000 iu/L ) and level
progressively declining (15% fall in initial BhCG).
2. Hemoperitoneum < 50 ml
3. Tubal mass < 2 cm
4. Absence of recognizable fetal parts on U/S
5. Absence of clinical symptoms.

27. Surgical Treatment
1. Laparotomy vs Laparoscopy
Laparoscopy is inappropriate if patient is in shock
In 3 RCT : Laparoscopic approach is associated with :
1. Significantly less blood loss
2. Lower analgesic requirement
3. Shorter hospital stay
4. Quicker post operative recovery time
5. Subsequent IUP of 70 % (55 % in laparotomy)
6. Recurrent ectopic of 5 % (16.6% - laparotomy)
7. Less adhesion ( p < 0.001 )

28. b) Salpingectomy vs Salpingotomy
In meta-analysis of 40 studies, salpingectomy is
associated with :
1. IUP rate of 44 % ( 46 % salpingotomy )
2. Repeat ectopic of 10 % (15 % in salpingotomy)
3. Almost no cases of persistant trophoblastic tissue
( 4.4 – 11 % in salpingotomy )
Suturing of salpingotomy incision : No benefit (
Grade A )

29. RCOG :
1. Salpingectomy is to be preferred to salpingotomy
when the contralateral tube is healthy as it is
associated with lower rate of persistant
trophoblastic tissue and subsequent repeat
ectopic while having a similar IUP rate (Grade B)
2. Salpingotomy is reasonable when there is only
one tube but it is associated with 20 % rate of
further ectopic. Whenever possible patient should
be councelled about it.

30. Management In Cases Of
Haemodynamic Shock
 In UK between 94 – 96, there were 12 deaths due
to ruptured ectopic, of which 2 were associated
with laparoscopic treatment.
 It is important to remember that when a patient
is in shock, she must be operated upon as
rapidly as possible, and by the fastest method –
open laparotomy is usually the preferred
method

31. MEDICAL MANAGEMENT
Use of Methotrexate :50mg/m2
check BhCG on Day 4 and 7
expected 15% reduction of BhCG
14% need second dose of MTX
<10% need surgical intervention
Route : - Systemic ( IV, IM, oral )
- Local injection ( U/S / laparoscopic
guidance or hysteroscopically inserted
intra-tubal catheter )
Methods of Administration :
1. IM : 3 trials ( 172 pts ) : single dose of 50 mg/m2
- resorption rate : 92 %
- subsequent IUP : 58 %
- recurrent ectopic : 9 %

32.  Haemodynamically stable , no active bleeding , no
haemoperitoneum , minimal or no pain
 No contraindications to MTX
 Non laparoscopic diagnosis of ectopic
 Initial pretreatment BhCG level < 10,000 IU/L
 Tubal diameter < 2cm
 Absence of fetal heartbeat
 Able to return for follow up care for several weeks
 General anaestheisa poses a significant risk

33.  Symptomatic patients
 Haemodynamically unstable patients
 Presence of haemoperitoneum
 Initial BhCG > 10,000 IU/L
 Tubal diameter > 2 cm
 FH+
 Evidence of liver disease, renal insufficiency or
myelosuppresion
 Patient poor compliance

35. SUMMARY :
1.Incidence of ectopic is raising, while case fatality
is reducing.
2. Early diagnosis is the key to less invasive
treatment.
3.The trend is towards conservative treatment.
4. Unruptured ectopic – laparoscopic approach may
be the choice of management
5.Ruptured ectopic should be operated
immediately, and open laparotomy usually
preferred.

36.  24 GIP0 at 10 weeks POA
 Dx as pregnanc y with
ovarian cyst –under Sg.Buloh
f/up
 Admitted 15.9.2013
 Sudden onset LIF pain in
morning ,pricking nature,
 Pain score 10/10
 Vomittingx5
 No uti sx /urti sx/fever /pv
loss
 At ED given iv nubain 10 mg
stat ,iv morphine 2 mg
stat..pain not resolve ..
 o/e vital sign stable
 Mile pale ,lethargic
 p/a soft not distended
 Mass felt at left side tender
,no guarding
 Ps/ve –
 Tas –intrauterine pregnancy
with fetal heart seen
 Left adnexa –multiloculated
cyst 9.8x 5 cm

37.  What is the differential
diagnosis ?
 How do you manage this
case ?
 What is the definitive
treatment ?
 -Conservative /surgery
 What is the effect of
surgery towards
pregnancy ?
 How do you counselled
this patient ?
 In pregnancy with ovarian
cyst when is the best time
for surgery if indicated

38.  Dx was twisted ovarian cyst
 Risk of intra and post op
explain to pt and relatives
Pt underwent laparotomy
salphingoophorectomy
Intraop findings :
Uterus 10 week ,min ascites fluid
(peritoneal reaction –
inflammatory)
Left ovarian cyst twisted x 3
,gangrenous and blackish ,tissue
was not viable. left tube also
oedematous and gangrenous
-sent for HPE
 Patient was dc well 17.9.2013
 Usg done before dc
 Pt was given tca 2/12 –f/up
and review HPE

40.  Definition - ―the acute clinical syndrome
associated with ascending spread of
microorganism (unrelated to pregnancy and
surgery) from the vagina or cervix to the
endometrium, fallopian tubes and/or
contiguous structure‖
Weström & W lner-Hanssen 1993
 Includes endometritis,salppigitis,tuboovarian
abscess and pelvic peritonitis

41.  Mild disease
 Fallopian tubes (FT) appears reddened (hyperemic) and are
edematous.
 FT freely mobile with
 Patent lumen

42.  Moderately severe disease
 more pronounced edema and inflammation of FT
 Limited tubal motility.
 Patchy fibrin deposits are seen on the serosal surface
and
 loose adhesions between the pelvic and abdominal
viscera.
 The distal end of the fallopian tubes are often phimotic
and may not be patent.

44.  Severe disease –
 occlusion of the tubal ostia
 formation of a pyosalphinx.
 distorted anatomy.
 congested pelvic peritoneum and the
 pelvic organs become adherent causing formation of a complex
inflammatory mass.
 If the infection has not been sealed off in the fallopian tubes,
then a tubo-ovarian abscess developed

45.  Most women recover completely after an episode of
PID.
 The likelihood of developing tubal factor infertility
following PID is determined by the severity and
number of episodes of the disease.
 Follow-up of the Lund cohort indicates tubal factor
infertility occur in woman with PID:
 8% after one episode
 19.5% after two episode
 40% after three or more

46.  In this same series the ectopic pregnancy rate was 9.1%
compared to a rate of 1.4% in the control group
(Weström et al 1992).
 chronic abdominal pain which occur frequently and
contributes to the high rate of hospitalization and a 10-
fold increase in hysterectomy rate seen in women
following PID (Buchan et al 1993).

47.  PID has a wide clinical spectrum, which
extends from a woman with little evidence of
systemic upset to a seriously ill woman with
life-threatening pelvic sepsis.

48.  Subacute dull lower abdominal pain and usually bilateral
 fever
 purulent vaginal discharge
 Deep dyspareunia
 Abn vaginal bleeding ,including post coital ,IMB and menorrhagia
 bilateral adnexal tenderness
 cervical excitation on bimanual examination
 Fever (>38 C)
 elevated ESR but could be non specific .

49.  It is now evident that historical, clinical and laboratory
findings are not consistently useful in the diagnosis of
PID, either individually or in combination (Kahn et al
1991).
 It has therefore been proposed that the criteria should
be all that required to trigger early antibiotic treatment
for probable PID in women with milder presentations
(Rolfs 1991).
 Although in this approach, some unnecessary
antibiotics will be administered, this would set against
the potential benefits of earlier intervention in a larger
number of cases of PID.

50.  PID may be symptomatic /asx .clinical sn & sx
lack of sensitivity and specificity (PPV of clinical
dx 65-90% compared to laparoscopic dx
 Testing for gonorrhea and chlamyidia in lower
genital tract is recommended since positive report
support the diagnosis. However the absence of
infection does not exclude PID .
 Elevated ESR/CRP –support dx but non specific
 The absence of endocervical or vaginal pus cells a
good negative predictive value (95%) for dx PID
but their presence is non specific.

51.  In women with a more severe presentation,
hospitalization is required for further
investigations.
 Important competing diagnoses such as ectopic
pregnancy and appendicitis should be ruled
out and treated accordingly.

52.  Ectopic pregnancy
 Acute appendicitis
 Endometriosis
 Complication of ovarian cyst –torsion,ruptured
–often sudden onset
 UTI –sx of uti
 Function pain –may be associatedflong
standing symptoms

53. RCOG Guidelines no 23
May 2003 & latest 2009
(www.rcog.org.uk)
Uk National Guidelines For
Management of PID (Updated June
2011)
Nice guidelines (last revised march
2013)

54. Admission should be considered in the following
situation:
1. Surgical emergency cannot be excluded
2. Lack of esponse to oral rx
3. Clinically severe disease
4. Presence of tuboovarian abcess
5. Intolerance to oral rx
6. Pregnancy

55.  Out patient regimens
 I.M ceftriaxone 500 mg single dose followed by oral doxycycline bd
+Metronidazole 400 mg bd x 14 days -Grade A (1b) )
 Oral Ofloxacin 400mg OD + oral Metronidazole 400 mg BD x 14 days -
Grade A (1b)
• Levofloxacin is the L isomer of Ofloxacin and has advantange of once daily
dosing (500 mg Odx 14 days)
Alternatives regimens ( i.e allergy,intolerance )
-I.M Ceftrixone 500 mg stat ,followed by Azithromycin 1 g/week x 2 weeks
Grade A (1b)
-Oral moxifloxacin 400 mg OD x 14 days

56.  I.v Ceftrixone 2g od + I.v doxycycline 100 mg bd
(oral Doxycycline may be used if tolerated)
followed by oral Doxycycline 100 mg bd + Oral
Metronidazole 400 mg bd x 14 days
 I.v Clindamycin 900mg tds + I.v Gentamycin (2mg
/ kg loading dose ) followed by 1.5 mg /kg tds
followed by oral Clindamycin 450 mg qid /oral
Doxycycline 100 mg bd + oral Metronidazole 400 mg
bd x 14 days .
*Genta levels need to be monitored

57.  I.v Ofloxacin 400 mg bd + I.v metronidazole
500 mg tds x 14 days.
 I.v Ciprofloxacin 200 mg bd +I.v (or oral)
Doxycycline 100 mg bd + I.v Metronidazole 500
mg tds x 14 days.

58. Treatment in pregnancy
 In an intrauterine pregnancy, PID is extremely
rare, except in the case of septic abortion.
 Treatment regimens will be dependent upon
the organisms isolated. Drugs known to be
toxic in pregnancy should be avoided e.g.
tetracyclines.
 Erythromycin and amoxycillin are not known
to be harmful in pregnancy.

59.  An intrauterine contraceptive device (IUCD)
may be left in situ in women with clinically
mild PID
 but should be removed in cases of severe
disease.

60.  surgical management
 is rarely necessary in the management of acute PID, however
 laparoscopic surgical techniques can be utilized to drain
purulent fluid, lyse bowel adhesion and excise acute and
necrotic tubo-ovarian adhesions. There is some evidence that
early laparoscopic treatment of tubo-ovarian abscess leads to
more rapid short-term recovery and preservation of normal
anatomy
 USG guided aspiration of pelvic fluid collection s is less
invasive and may be equally effective .
 Non Steroidal Anti Inflammatory Drugs
 as an adjunct to the antibacterial and surgical management of
acute PID to prevent long-term sequelae has been considered
but is still not clear.

61.  Review after 72 hs is recommended (moderate
to severe clinical presentation ),and should
show a substantial improvement in clinical
symptoms and signs .Failure to to so need
further investigation,parenteral therapy and/or
surgical intervention.
 Further review after 2/52 after therapy may be
useful to ensure.
-adequate clinical response
-compliance to antibiotics

62.  -screening of significance of PID and its
sequelae
 Repeat pregnancy test ,if clinically indicated
Repeat testing for gonorrhea or chlamydia after
2-4 weeks is appropriate in those persisting sx
,antibiotic resistance pattern ,compliance with
antibiotis and/tracing of sexual contact indicate
the possibility of persistent /recurrence infection.

64.  Quiz 1—what is level of bhcg when iugs
should be seen by TVS ?
 Quiz 2-what are the differential diagnosis for
ectopic pregnancy
 Quiz 3 –what are the differential diagnosis of
PID

65. Liver

66.  The causal organism is Chlamydia trachomatis, a
Gram-negative bacteria that behaves like a
virus that it replicates intracellularly.
 In UK it affects 3-5% of sexually active woman
 It is responsible for at least half of all cases of
non-specific genital infection, which includes
non-specific urethritis in the male and related
conditions in the female.