2. ECTOPIC PREGNANCY
Definition
An Ectopic Pregnancy is one in which
fertilized ovum is implanted and develops
outside the normal uterine cavity.
Type
• Acute Ectopic
• Chronic Ectopic
5. INCIDENCE
• Recent evidence indicates that the incidence of
ectopic pregnancy has been rising in many
countries.
• USA- 5 fold: UK- 2 fold
• India - 1 in 100 deliveries
• Recurrence rate
15% after 1 ectopic pregnancy
25 % after 2 ectopic pregnancies
6. AETIOLOGY
Factors Preventing OR delaying migration
of fertilized ovum.
CHRONIC PID
DEFECT OF TUBE
IATROGENIC
TRANS PERITONIAL MIGRATION
TUBAL SPASM
7. Chronic PTD
• Loss of Cilia
• Narrowing of tubal lumen
• Adhesions between mucosal Folds
• Kinking Peritubal adhesions
Defects of tube
• Elongation
• Diverticula's
• Accessory Ostia
16. EARLY DIAGNOSIS
At 4-5 weeks:
• TVS can visualize a G-sac
• serum beta HCG levels are > 1600 mIU/ml
• When Beta HCG levels are greater than above
levels and there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.
• when the value of Beta HCG does not double
in 48 hrs, ectopic pregnancy is suggestive
17. EARLY DIAGNOSIS
After 5 weeks
• tubal ring by 6 wks.
• After 5 mm D : as a complete sonoluscent sac with the
yolksac & embryonic pole with or without fetal heart
activity.
• Demonstration of the G sac with or without a live
embryo (Begel’s sign)-
• Ruptured ectopic with fluid in POD and an empty
uterus.
color doppler, the vascular colour in a characteristic
placental shape fire pattern can be seen outside the
uterine cavity while the uterine cavity is cold in respect
to blood flow.
19. Medical
• Methotrexate, folinic acid
• GA less than 6 wks
• Tubal mass is less than 3.5cm diameter
• Fetus is dead
• Intramuscular Methotrexate 1.0mg /kg
• Alternating folinic acid 0.1mg/kg
• Monitoring of B-HCG levels daily / Alternate day
Monitor
• HMG
• RFT
• LFT
20. • Methotrexate OR Potassium Chloride into
amniotic sac through laparoscopy OR
Sonography guidance
Surgical Conservative Management
Laparoscopic
• Linear Salpingectomy
• Salpingectomy
• Segmental resection Anastomosis
• Fimbrial Evacuation – Milking
21. Surgical Treatment
• Salpingostomy/ Salpingotomy indicated when
• Pt Desire to conserve her fertility
• Patient is haemodinamically stable
• Tubal preg is accessible
• Unruptured & < 5 cm Size
• Contralateral tube absent or damaged.
• Chapron et al (1993) have described a scoring system to
decide which surgical treatment to be taken up based on
patients previous gynae history & appearance of pelvic
organs-
22. FERTILITY REDUCING FACTOR SCORE
• Antecedent one ectopic 2
• Antecedent each further ectopic 1
• Antecedent Adhesiolysis 1
• Antecedent Tubal microsugery 2
• Antecedent salpingitis 1
• Solitary tube 2
• Homolateral Adhesions 1
• Contralateral Adhesions 1
• Conservative surgery is indicated with a score of 1-4 only, while
radical treatment to be performed if score is 5 or more.
• Rationale behind the scoring system is to decide the risk of
recurrent ectopic preg.
23. • Medical Treatment by Methotrexate
• The Antineoplastic drug which acts as a folic acid antagonist and
is highly effective against rapidly proliferating trophoblast.
• Used when 1. Ectopic mass size < 3.5 cm
2. Preg < 6 wks.
3. beta HCG levels < 15,000 MIU/ ml.
• Dose – Single dose - 50 mg / m2 IM.
Measure beta HCG levels on days 4 & 7 .
If difference is > 15% : repeat weekly until undetectable
If Difference is < 15% : repeat 2nd dose of methotrexate
& begin now day 1
If fetal cardiac activity present on day 7, repeat dose &
begin day 1.
Surgical treatment if beta HCG levels not decreasing or fetal
cardiac activity present after 3 doses.
24. PERSISTENT ECTOPIC PREGNANCY (PEP)
• This is a complication of salpingotomy/
salpingostomy
• When residual trophoplast continues to survive
because of incomplete evacuation of ectopic preg.
• Diagnosis made because of raised postoperative beta
HCG.
• Treatment reoperation & Salpingectomy
Administration of IM/ oral
Methotrexate in a single dose of
50 mg/m2
25. CHRONIC ECTOPIC PREGNANCY
• INVESTIGATIONS :
1. Laboratory/ Chemical Test-
• Serial quantitative beta HCG level by RIA
• Serum progesterone level ( < 5 ng / ml in ectopic )
• Low levels of tropholastic proteins such as SPI & PAPP –
Placental protein 14 & 12.
2. USG – usually haematocele is found.
3. Laparoscopy
• TREATMENT : Mainly Surgical
• Salpingectomy of the offending tube
• If pelvic haematocele is infected, posterior colpotomy is to
be done to drain the pelvic abscess.
• Salpingoopherectomy
26. Surgical
Laparotomy Laparoscopy
• Hospital Cost More? Less?
• Post op Adhesions More Less
• Recurrence Same Same
• Future fertility Same Same
• Experience Surgeon Trained Special