1. DR.CHADUVULA SURESH BABU
PROFESSOR
DEPT.OF OBGYN
College of Medicine, Abha, KKU, KSA

2.  Definition:
 Any
pregnancy where the fertilized ovum OR
blastocyst is implanted and developed
outside the normal uterine cavity

3.  Incidence
– 1 in 150 to 300 deliveries
 Incidence is increasing because of
 1] Ovulation induction
 2] IVF technologies
 3] Tubal surgeries
 4] IUCD usage
 5] Increase in PID or STDs
 6] Early diagnosis

5.  15%
with 1 ectopic
 25%
with 2 ectopics

6.  Any
factor that causes delayed transport of the
fertilised ovum through the fallopian tube favours
implantation in the tubal mucosa itself thus giving
rise to a tubal ectopic pregnancy.
 These factors may be Congenital or Acquired.

7.  CONGENITAL
- Tubal Hypoplasia , Tortuosity
, Congenital diverticuli , Accessory ostia
, Partial stenosis
 ACQUIRED 



Inflammatory: PID, Septic Abortion, Puerperal
Sepsis, MTP (lntraluminal adhesion)
Surgical: Tubal reconstructive surgery, Recanalisation
of tubes
Neoplastic: Broad ligament myoma, Ovarian tumour
Miscellaneous Causes: IUCD , Endometriosis, ART (IVF
& & GIFT), Previous ectopic

8. SITES OF ECTOPIC PREGNANCY
Abdomen (< 2%)
Ampulla (>85%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Cervix (< 2%)
1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial
5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn
8)Secondary abdominal 9)Broad ligament 10)Primary
abdominal
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9.  Ectopic
Pregnancy remains asymptotic until it
ruptures when it can present in two variations - Acute
&. Chronic
 SYMPTOMS-
Amenorrhea
 Abdominal Pain
 Syncope
 Vaginal Bleeding
 Pelvic Mass
SIGNS- Abdominal tenderness, Cullen’s sign, Adnexal
tenderness, Cervical motion tenderness

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10.  Severe
abdominal pain
 Cullen’s sign – Periumbilical bruising
 Rebound tenderness and guarding
 Abdominal fullness with decreased bowel
sounds
 Vaginal exam: Fullness in pouch of douglas

11. 








Appendicitis
Threatened Abortion
Ruptured ovarian cyst
PID
Salpingitis
Endometritis
Nephrolithiasis
Ovarian torsion
Intrauterine pregnancy

12.  Immunoassay
utilising monoclonal antibodies to
beta HCG
 Ultrasound scanning – Abdominal & Vaginal
including Colour Doppler
 Laparoscopy
 Serum progesterone estimation not helpful
A combination of these methods may have to
be employed.
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13. At 4-5 weeks-
TVS
can visualise a gestational sac as early as
4-5 weeks from LMP.
During this time the lowest serum beta HCG is
2000 IU/Lt.
When beta HCG level is greater than this and
there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.
In such a situation, when the value of beta HCG
does not double in 48 hours ectopic pregnancy
will be confirmed.
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14. 




Empty Uterus
Free fluid
Distended portion of left
Fallopian tube
No evidence of rupture
Adenexal mass:



1.7 x 1.6cm adjacent
and anterior to left
ovary
Cervical excitation
Tenderness over left iliac
fossa on deep palpation
with the probe

15.  Complete

Leukocytosis
 Urinalysis
 Blood

blood count
with microscopic exam
Type and Rhesus
A negative

Therefore, must give anti-D (RhoGAM) prior to surgery

16.  Depends
on the stage of the disease and the
condition of the patient at diagnosis.
 Options


Surgery – Laparoscopy / Laparotomy
Medical – Administration of drugs at the site /
systemically
Expectant – Observation
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17. OPTIONS:  SURGICAL SURGICALLY ADMINISTERED
MEDICAL (SAM)
TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT
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18.  Trophotoxic






substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
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19.  Resolution
of tubal pregnancy by systemic
administration of Methotrexate was first
described by Tanaka et al (1982)
 Mostly used for early resolution of placental
tissue in abdominal pregnancy. Can be used for
tubal pregnancy as well
 Mechanism of action- Interferes with the DNA
synthesis by inhibiting the synthesis of
pyrimidines leading to trophoblastic cell death.
Auto enzymes and maternal tissues then absorb
the trophoblast.
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20.  Ectopic
pregnancy size should be < 3.5 cm.
 Can be given IV/IM/Oral, usually along with Folinic
acid
 Recent concept is to give Methtrexate IM in a single
dose of 50mg/m2 without Folinic acid. If serum HCG
does not fall to 15% with in 4-7 days, then a second
dose of Methtrexate is given and resolution
confirmed by HCG estimation
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21.  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
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22. Hospitalisation
Resuscitation
-
 Treatment
of shock
 Lie flat with the leg end raised
 Analgesics
 Blood transfusion
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23. Culdocentesis:  Most
Helpful in Emergent Situations to Confirm
Diagnosis
 Highly Specific if performed and Interpreted
Correctly: - Presence of Free-Flowing, NON-Clotting
Blood
 Negative Tap Inconclusive
 Remains Controversial
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24. Laparotomy
should be done at the
earliest.
Salpingectomy is the definitive
treatment.
 No
benefit from removing Ovary along with the tube
If
blood is not available, autotransfusion can be done.
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25.  Carried
out either by Laparoscopy / Laparotomy.
 The procedures are: 

Salpingectomy / Cornual resection / Excision
Conservative surgery (in cases of Infertility & desire for
pregnancy)




Linear salpingostomy
Linear salpingotomy
Segmental resection and anastomosis
Milking of the tube
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26. The debate goes on
LAPAROTOMY?
VS.
LAPAROSCOPY?
SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?
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27. SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY


All tubal pregnancies can be treated by partial or total Salpingectomy
Salpingostomy / Salpingotomy is only indicated when:
1.
2.
3.
4.
5.
The patient desires to conserve her fertility
Patient is haemodinmically stable
Tubal pregnancy is accessible
Unruptured and < 5Cm. In size
Contralateral tube is absent or damaged
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28. 1. Medial tubal A.
2. Lateral tubal A.
3. Uterine A.
4. Ovarian A.

29. Main Risk: devascularization of the ovary
 Operate close to the tube, away from ovarian
vessels and suspensory ligament

30. 1.
Proximal tube division

Isthmus is held upwards and
outwards
Isthmus is cauterized
Take care not to cauterized the
internal ovarian A. and ovarian
branch of the uterine A.
Divide tube with scissors




31. 2.


Mesosalpinx Division
Divide the mesosalpinx
with scissors
Cauterize and divide the
infundibulo-ovarian
ligaments and the lateral
tubal A.

32. 3.
Extraction of the tube

Remove tube through an
extraction bag
Verification of hemostasis
Careful lavage
Removal of equipment
Suture/ Steri-strip laparoscopic
incisions




Caution:
•
Endometriosis
•
Utero-peritoneal fistula

33. LAPAROSCOPIC SALPINGECTOMY
 It
is carried out by laparoscopic
scissors and diathermy or Endo-loop.
 After passing a loop of No.1 catgut
over the ectopic pregnancy the stitch
is tightened and then the tubal
pregnancy is cut distal to the loop
stitch.
 The excised tissue is removed by
piece meal or in a tissue removal bag.
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34. LAPAROSCOPIC SALPINGOTOMY

To reduce blood loss, first 10-40 IU of vasopressin
diluted in10 ml of normal saline is injected into the
mesosalpinx.

Then the tube is opened through an antimesenteric
longitudinal incision over the tubal pregnancy by a
–
–
–
–
Co2 laser (Paulson, 1992)
Argon laser (Keckstein et al; 1992)
Laparoscopic scissors and ablating the bleeding points
with bipolar diathermy.
Fine diathermy knife (Lundorff, 1992)
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35. LAPAROSCOPIC SALPINGOTOMY
The
tubal pregnancy is then
evacuated by suction irrigation.
Hemostasis
of the trophpblastic bed
is ensured.
The
tubal incision is left open.
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36. INVESTIGATIONS Laboratory/Chemical
test –
 Serial
quantitative beta HCG level by RIA
 Serum progesterone level (<5 nanog/ml in
ectopic pregnancy)
 Low levels of Trophoblastic proteins such as
SPI and PAPP-, Placental protein 14 & 12
 USG-
usually haematocele is found
 Laparoscopy
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37. TREATMENT – ALWAYS SURGICAL
 Salpingectomy
of the offending tube
 If pelvic haematocele is
infected, posterior. colpotomy is to be
done to drain the pelvic abscess
 Salpingo-oophorectomy
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38.  Incidence
of ectopic pregnancy is rising while
maternal mortality from it is falling.
 Early diagnosis is the key to less invasive
treatment.
 The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
 The trend is towards conservative treatment.
 Careful monitoring and proper counselling of
patients is mandatory.
 Ruptured ectopics should be unusual with
compliant patients and appropriate medical
care.
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39. THANK YOU