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1. Prof. M.C.

Bansal MBBS,MS,MICOG,FICOG Professor OBGY ExPrincipal & Controller Jhalawar Medical College & HospitalMahatma Gandhi
Medical College, Jaipur.

2. DEFINITIONAny pregnancy where the fertilised ovumgets implanted &


develops in a site otherthan normal uterine cavity.It represents a serious hazard
to a womanshealth and reproductive potential, requiringprompt recognition and
early aggressiveintervention.

3. Is one in which fertilized ovum is implanted & develops outside normal


uterine cavity

4. IMPLANTATIONS SITES EXTRAUTERINE UTERINE -CERVICALTUBAL


95-96% OVARIAN ABDOMINAL (1:18,000) (1:40,000) (1:10,000) -ANGULARAmpulla 70% -CORNUAL-Isthmus 12% -CAESAREAN PRIMARY SECONDARYInfundibulum 11% SCAR (<1)-Interstitial & cornual 2% Intraperitoneal
Extraperitoneal Broad Ligament (rare)

5. INCIDENCE Increased due to PID, use of IUCD, Tubal surgeries, and


Assisted reproductive techniques (ART). Ranges from 1:25 to 1:250 Average
range is 1 in 100 normal pregnancies. Late marriages and late child bearing ->
2% ART -> 5% Recurrence rate - 15% after 1st, 25% after 2 ectopics

6. These factors may be Congenital or Acquired. Fallopian tube favours


implantation in the tubal mucosa itself thus giving rise to a tubal ectopic
pregnancy. Any factor that causes delayed transport of the fertilised ovum
through the tube.ETIOLOGY:

7. CONGENITAL Tubal Hypoplasia Tortuosity Congenital diverticuli


Accessory ostia Partial stenosis Elongation Intamural polyp Entrap the ovum
on its way.ETIOLOGY

8. ACQUIRED -Pelvic Inflammatory disease (6-10 times) Chlamydia


trachomatis is most commonContraceptive Faliure CuT - 4% Progestasart -17%
Minipills -4-10% Norplant -30%

9. Tubal sterilization faliure -40% Depends on sterilization technique and


age ofthe patient Bipolar Cauterisation -65% Unipolar Cautery -17% Silicon rubber
band -29% Interval Salpingectomy -43% Postpartum Salpingectomy
-20%Reversal of sterilisation - Depends on method of sterilization, Site of tubal
occlusion, residual tubal length. - Reanastomosis of cauterised tube -15% Reversal of Pomeroys - < 3%

10. 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

11. Prev Previous induced abortion Age 35-45 yrs Other Risk factors
Fundal Fibroid Genital Tuberculosis Salpingitis Isthmica Nodosa Infertility
DES Exposure in Utero Cigarette smoking ious pelvic surgeries &
Transperitoneal migration of ovum Adenomyosis of tube

12. Iffy hypothesis Theory of reflux menstural fluid throw the fertilised
ovum into the tubeFactors facilitating nidation of ovum in tube: - Premature
degeneration of zona pellucida - Increased decidual reaction - Tubal
endometriosis

13. Tubal pregnancies rapidly invade the mucosa, feeding from the tubal
vessels, which become enlarged and engorged. The segment of the affected tube
is distended as the pregnancy grows. Possible outcomes of such abnormal
gestations are as follows:Evolution

14. Abortion is common in ampullary pregnancies,whereas rupture is in


isthmic. Isthmic 6-8 wks, Ampullary 8-12wks, Interstitial -4 months The
pregnancy continues to grow until the overdistended tube ruptures, with resulting
profuse intraperitoneal bleeding. The pregnancy is unable to survive owing to its
poor blood supply, thus resulting in a tubal abortion and resorption, or it is expelled
from the fimbriated end into the abdominal cavity.

15. In rare instances, a tubal pregnancy will be expelled from the tube and
seed onto sites in the abdominal cavity (e.g. the omentum, the small or large
bowel, or the parietal peritoneum), and gives rise to a viable abdominal
pregnancy.

16. Pictures showing TUBAL ABORTION

17. Wide spectrum of clinical presentation from asymtomatic pt to others


with acute abdomen and in shock. H/o past PID, tubal surgery,current
contraceptive measures should be asked Dignosis can be done by history, detail
examination and judicious use of investigation.CLINICAL APPROACH

18. Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to


reflex vasomotor disturbance. 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
brownACUTE ECTOPIC PREGNANCY

19. 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. P/S:- minimal bleeding may be present P/A:- abdomen tense, tender
mostly in lower abdomen,shifting dullness, rigidity may be present. O/E:- patient
is restless in agony, looks blanched, pale, sweating with cold clammy skin.
Features of shock, tachycardia, hypotension.

20. 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. Patient had previous attack of acute pain from
which she has recovered. It can be diagnosed by high clinical
suspicion.CHRONIC ECTOPIC PREGNANCY

21. 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 forni P/A:- Tenderness and
muscle guard on the lower abdomen. A mass may be felt, irregular and tender.
O/E:- patient look ill, varying degree of pallor, slightly raised temperature. Features
of shock are absent.x.

22. High degree of suspicionUNRUPTURED ECTOPIC & 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
fornixectopic conscious clinician can diagnose.

23. 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 youor 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

24. Now the rate of tubal rupture is as low as 20%. This has resulted in
early diagnosis and effective treatment. This is due to the widespread
introduction of diagnostic tests and an increased awareness of the serious nature
of this disease. In recent years, inspite of an increase in the incidence of ectopic
pregnancy there has been a fall in the case fatality rate.DIAGNOSIS

25. 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

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

26. Other Investigations:- 1. Ultra Sonography-a) Transvaginal Sonography


(TVS): - Is more sensitive - It detect intrauterine gestational sac at 4-5wks and at
S- hCG level as low as 15002. Culdocentesis:- (70-90%) - Can be done with 1618 G lumbar puncture needle through posterior fornix into POD. - Positive tap is
0.5ml of non clotting blood.

27. 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 below the midline echo along the burried into
endometium cavity line b/w endometrial layers shape usually round may
change,oviod borders double ring single layer

28. Rectouterine cul-de-sac Free peritonial fluid with an adnexal mass


suggestive of ectopic pregnancy Adenxa - 15-30% an extrauterine yolk sac or
embryo seen in fallopian tubes confirms tubal pregnancy. - A halo or tubal ring
surrounded by a thin hypoechoic area caused by subserosal edema can be
seen.DECIDUAL CYST It is identified as an anechoic area lying with in the
endometrium but remote from the canal and often at the endometrial-myometrial
border.

29. 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- hCG level at which intrauterine gestational sac is seen by TAS is 1800
IU/L.

30. USG PICTURE1.Bagel sign Hyperechoic ring around gestational sac


in adnexal region2. 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.

31. Hyperechoic ring aroundgestational sac in adnexal region

32. Ring sign a hyperechoic ring around anextrauterine gestational sac.

33. 2. -HCG Assay- a) Single -HCG: little value b) Serial -HCG: is


required when result of initial USG is confusing. - When hCG level < 2000 IU/L
doubling time help to predict viable Vs nonviable pregnancy. -Rise of -HCG
<66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy .
Biochemical pregnancy is applied to those women who have two -HCG values
>10 IU/L

34. 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.

35. 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 - CA125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic
pregnancy.

36. SUSPECTED ECTOPIC PREGNANCY Urine Pregnancy test positive


Transvaginal USG IU sac No IU sac Quantitative S-hCG + S progesterone < 66%
rise in 48 hr or >66% rise in 48 hr or S progesterone < 5-10 ng/ml S progesterone
> 5-10 ng/ml D&C Repeat S-hCG in 48 hrs till USG discrimination zone Villi
present Villi absentIncomplete Laparoscopy No sac IU sac abortion Continue to
monitor

37. DIFFERENTIAL DIAGNOSISD/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

38. 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

39. MANAGEMENT Expectant Medical Surgical management management


management Local Systemic Radical Conservative(USG or Laparoscopic)
Salpingectomy salpingocentesis Methotrexate -Salpingostomy - Methotrexate -

Potassium chloride -Salpingotomy - Prostagladin(PGF2) - Hypersmolar glucose Segmental - Actinomycin D resection - Mifepristone -Milking or fimbrial expression

40. MANAGEMENT OF RUPTURED ECTOPICPRINCIPLE: Resuscitation


and LaparotomyANTI 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 replacementLAPAROTOMY: 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.

41. EXPECTANT MANAGEMENT MEDICAL TREATMENT


SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT SURGICALMANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCYOPTIONS: -

42. EXPECTANT MANAGEMENTIDENTIFICATION CRITERIA (Ylostalo et


al , 1993)- : 1. Tubal ectopic pregnancies only 2. Haemodynamically stable 3.
Haemoperitoneum < 50ml 4. Adnexal mass of < 3.5 cm without heart beat. 5.
Initial HCG <1000 IU/L and falling in titreSUCCESS RATE - Upto
60%PROTOCOL: - Hospitalization with strict monitoring of clinical symptom - Daily
Hb estimation - Serum HCG monitoring 3-4 days until it is <10 IU/L

43. Warning: - Tubal pregnancies have been known to rupture even when
Serum HCG levels are low. The percentage fall in serum HCG by day 7 is a
better indicator than the percentage fall by day 2. In spontaneous resolution, it
may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant
level. Spontaneous resolution occurs in 72%,while 28% will need laparoscopic
salpingostomyEXPECTANT MANAGEMENT

44. Unruptured sacMEDICAL MANAGEMENTSurgery is the mainstay of


T/t worldwideMedical M/m may be tried in selected casesCANDIDATES FOR
METHOTREXATE (MTX) < S-hCG3.5cm without cardiac activity < Follow up on
day1, 4 and 7. Anti-D Ig if pt is Rh negative Obtain informed consent
Transvaginal USG within 48 hrs CBC, LFT, RFT, S-hCG Persistant Ectopic
after conservative surgeryPHYSICIAN CHECK LIST10,000 IU/L

45. Mechanism of action-Methotrexate is a folic acid antagonist that


inactivates the enzyme dihydrofolate reductase.Interferes with the DNA synthesis
by inhibiting the synthesis of pyrimidines leading to trophoblastic cell death. Auto
enzymes and maternal tissues then absorb the Mostly used for early resolution of
placental tissue in abdominal pregnancy.Can also be used for tubal pregnancy.

Resolution of tubal pregnancy by systemic administration of Methotrexate was first


described by Tanaka et al (1982) It can be used as oral,intramuscular
,intravenous usually along with folinic acid.MEDICAL
MANAGEMENTMETHOTREXATE:

46. Disadvantages- Side effects like GI Advantages Minimal


Hospitalisation.Usually outdoor treatment Quick recovery 90% success if cases
are properly selectedContd & Skin Monitoring is essential- Total blood
count, LFT & serum HCG once weekly till it becomes negative

47. Transvaginal (Feichtingar, 1987) With Falloposcopic control (Kiss,


1993) Transabdominal (Porreco, 1992) Technique- Injection of trophotoxic
substance into the ectopic pregnancy sac or into the affected tube by-
Laparoscopy or Ultrasonographically guided Aim- trophoblastic destruction
without systemic side effectsSURGICALLY ADMINISTERED MEDICAL Tt (SAM)

48. Actinomycin DAdvantage of local MTX : - Increase tissue concentration


at local site - Decrease systemic side effects - Decrease hospitalization - Greater
preservation of fertilityFollow up: - Serum HCG twice weekly tillHyper osmolar
glucose solution PGF2 (Limblom, 1987) Mifiprostone (RU 486) Potassium
Chloride (Robertson, 1987) Methtrexate (Pansky, 1989) SURGICALLY
ADMINISTERED MEDICAL Tt (SAM)Trophotoxic substances used- < 10 IU/L TVS weekly for 4-6 weeks - HCG after 6 months for tubal patency

49. Chance of tubal rupture in 5-10 % require emergency Laparotomy.


Failure of medical therapy require retreatment Report immediately when vaginal
bleeding, abdominal pain, dizziness, syncope (mild pain is common called
separation pain or resolution pain) Refrain from alcohol, sunlight, multivitamins
with folic acid, and sexual intercourse until S-hCG is negative. If T/t on outpatient
basis rapid transportation should be availableINSTRUCTION TO THE PATIENTS

50. SURGICAL MANAGEMENT OF ECTOPIC Conservative SurgeryCan


be done Laparoscopically or by microsurgical laparotomyINDICATION: - Patient
desires future fertility - Contralateral tube is damaged or surgically removed
previouslyCHOICE OF TECHNIQUE: depends on - Location and size of
gestational sac - Condition of tubes - Accessibility

51. VARIOUS CONSERVATIVE SURGERIES1.Linear Salpingostomy: Indicated in unruptured ectopic <2cm 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

52. 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 HCG titre till it is negative. - If titre
increases methotrexate can be given.

53. DEBATABLE ISSUES? Salpingectomy Vs Salpingostomy? Laparotomy


Vs Laparoscopy? Reproductive outcome? Risk of Recurrent Ectopic

54. Salpingostomy / Salpingotomy is only indicated when: 1. The patient


desires to conserve her fertility 2. Patient is haemodinamically stable 3. Tubal
pregnancy is accessible 4. Unruptured and All tubal pregnancies can be treated
by partial or total SalpingectomySALPINGECTOMY VS SALPINGOSTOMY /
SALPINGOTOMY < 5Cm. In size 5. Contralateral tube is absent or damaged

55. Making the choice Chapron et al (1993) have described a scoring


system, based on the patients previous gynaecological history and the
appearance of the pelvic organs, to decide between salpingostomy / salpingotomy
and salpingectomy. The choice of surgical treatment does not influence the post
treatment fertility, but prior history of infertility is associated with a marked
reduction in fertility after treatment.CONTD

56. Fertility reducing factor Score Antecedent one Ectopic pregnancy 2


Antecedent each further Ectopic pregnancy 1 Antecedent Adhesiolysis 1
Antecedent Tubal micro surgery 2 Antecedent Salpingitis 1 Solitary tube 2
Homolateral Adhesions 1 Contralateral Adhesions 1 The rationale behind the
scoring system is to decide the risk of recurrent ectopic pregnancy. Conservative
surgery is indicated with a score of 1-4 only, while radical treatment is to be
performed if the score is 5 or more.

57. 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.

58. LAPAROSCOPIC SALPINGECTOMYIt is carried out by laparoscopic


scissors & The tubal pregnancy is then evacuated by suction irrigation. 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) To reduce blood loss, first 10-40 IU of
vasopressin diluted in10 ml of normal saline is injected into the
mesosalpinx.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 tissue removal
bag LAPAROSCOPIC SALPINGOTOMY

59. If untreated, can cause life threatening hemorrhageRisk Factor: (seifer


1997) 1. Early ectopic pregnancy ( Diagnosis is made because of a raised
postoperative HCG This is a complication of salpingotomy / salpingostomy
when residual trophoblast continues to survive because of incomplete evacuation
of the ectopic pregnancy.PERSISTENT ECTOPIC PREGNANACY< 6 wks
amenorrhoea) 2. Smaller size < 2 cm (Incomplete removal) 3. Preoperative high
serum HCG (> 3,000 IU/L) and postoperative Day1 titre is < 50% of preoperative
level, is predictor of persistent EP. 4. Implantation medial to the salpingostomy
site. surgery Medical Treatment (selected Asymptomatic pt) Total or partial MTX +
Leukovorin salpingectomy

60. OVARIAN ECTOPIC PREGNANCYIncidence: 1:40,000Risk factor: IUCD - Endometriosis on surface of ovaryCourse:C/F are same as tubal
pregnancy ruptures within 2-3 wksDiagnosis: On LaparotomySpiegelbergs 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 Ruptured M/M Unruptured Laparotomy Ovarian wedge
resection Ovarian Cystectomy Oophorectomy

61. ABDOMINAL PREGNANCYIncidence: RarestMMR : 7-8 times > tubal


ectopic 90 times > Intrauterine pregnancyH/O : - Irregular bleeding, spotting Nausea, vomiting, flatulence, constipation, diarrhoea, abdominal pain. - Fetal
movement may be painful and high in the abdomenO/E : - Abnormal fetal position,
easy in palpating fetal parts. - uterus palpated separate from sac - no uterine
contraction after oxytocin infusion

62. Diagnosis: Confirmed by USG, CT scan, MRI, Radiography TYPE


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

63. 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

64. CERVICAL PREGNANCYImplantation occurs in cervical canal at or


below internal Os.Incidence: 1 in 18,000RISK FACTORS : - Previous induced
abortion - Previous caesarean delivery - Ashermans syndrome - IVF - DES
exposure - Leiomyoma

65. 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 openedUSG 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

66. 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

67. MANAGEMENT Surgical Medical Mainstay therapy in past Recently


proposed Single or Combination ConservativeRadical ORsurgery D&C Adjunct to
surgery (risk of torrential bleeding) - MethotrexateHysterectomy - Cerclage
Bernstein Mc Donalds - Actinomycin Wharton Shirodkars -Transvaginal
ligation of Cx branch of - KCl uterine artery - Angiographic uterine A embolisation Etoposide - Intracervical vasopressin inj - Foleys catheter as tamponade

68. CORNUAL PREGNANCYSITE: Implantation occurs in rudimentary horn


of Bicornuate uterusCOURSE :Rupture of horn occurs by 12-20 wksD/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

69. HETEROTYPIC PREGNANCYCo-existing intrauterine and extra uterine


pregnanciesIncidence: 1 : 30,000 With ART 1:7000 With ovulation induction
1:900More likely: a) Ass. reproductive technique b) Rising HCG titre after D & C c)
More than 1 corpus luteum at laparotomyM/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.)

70. 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

71. USG slows on empty uterine cavity and gestational sac attached low to
the lower segment caesarean scar.C/F : similar to threatened or inevitable
abortionDiagnosis : Doppler imaging confirmsT/t : Methotrexate injection
Hysterectomy in a multiparous women. In young pt resection Recently
reportedCAESAREAN SCAR ECTOPIC PREGNANCY & suturing of scar may be
done (high risk of rupture).

72. OTHER RARE TYPES1. Multiple Ectopic pregnancy2. Pregnancy after


hysterectomy3. Primary splenic pregnancy4. Primary hepatic pregnancy5.
Rectroperitoneal pregnancy6. Diaphragmatic pregnancyMORTALITY : In general
population is 10-15% mainly due to haemorrhage.

73. Careful monitoring and proper counselling of patients is mandatory.


The choice today is Laparoscopic treatment of unruptured ectopic pregnancy.
Laparotomy should be done when in doubt There has been shift in the M/m from
ablative surgery to conservative fertility preserving therapy Ectopic pregnancy
can be diagnosed early (before it ruptures) with recent advances in Immunoassay
to detect S-hCG , high resolution USG, and dignostic Laparoscopy. Incidence of
ectopic pregnancy is rising while maternal mortality from it is falling.SUMMARY KEY POINTS

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