Kehamilan Ektopik

KEHAMILAN EKTOPIK
Pembimbing : dr. Pande Made, Sp.OG-K

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PENGERTIAN
Kehamilan dengan fertilisasi ovum berimplantasi dan

berkembang di tempat selain cavum uteri.
Berpotensi berbahaya pada kesehatan dan organ

reporoduksi wanita, sehingga membutuhkan penanganan
segera.
Induksi Patol Obs 2017-LUG

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Is one in which fertilized ovum is implanted &

develops outside normal uterine cavity
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LETAK IMPLANTASI
EXTRAUTERINE UTERINE
-CERVICAL
TUBAL 95-96% OVARIAN ABDOMINAL (1:18,000)
(1:40,000) (1:10,000) -ANGULAR
-Ampulla 70% -CORNUAL
-Isthmus 12% -CAESAREAN SCAR (<1)
PRIMARY SECONDARY
-Infundibulum 11%
-Interstitial &cornual 2%
Intraperitoneal Extraperitoneal
Broad Ligament
(jarang)

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INSIDENSI
Meningkat pada PID, penggunaan IUCD, operasi tuba,

dan assisted reproductive techniques (ART).
Berkisar 1:25 sd 1:250
Rerata 1 dari 100 kehamilan normal.
Pernikahan lama dan melahirkan anak terlambat -> 2%
ART -> 5%
Rekuren rate - 15% setelah 1st, 25% setelah 2 ektopi

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ETIOLOGI
Faktor penyebab transportasi fertilisasi ovum tertunda

selama di tuba.
Tuba falopi implantasi di mukosa tuba fallobi favours

implantation in the tubal mucosa itself thus giving rise to
a tubal ectopic pregnancy.
Faktor-faktor lain, kemungkinan kongenital atau didapat.

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ETIOLOGY
CONGENITAL
Tubal Hypoplasia
Tortuosity
Congenital diverticuli
Accessory ostia
Partial stenosis
Elongation
Intamural polyp
Terperangkap di ovum

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ACQUIRED -
Pelvic Inflammatory disease (6-10 times)

Chlamydia trachomatis is most common
Contraceptive Faliure
CuT - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%
Tubal sterilization faliure -40% 10
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%
Reversal of sterilisation
- Depends on method of sterilization, Site of
tubal occlusion, residual tubal length.
- Reanastomosis of cauterised tube -15%
- Reversal of Pomeroys - < 3%

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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

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Other Risk factors
Age 35-45 yrs

Previous induced abortion
Previous pelvic surgeries
Cigarette smoking
DES Exposure in Utero
Infertility
Salpingitis Isthmica Nodosa
Genital Tuberculosis
Fundal Fibroid & Adenomyosis of tube
Transperitoneal migration of ovum
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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

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EVOLUTION
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:

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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.
The pregnancy continues to grow until the
overdistended tube ruptures, with resulting
profuse intraperitoneal bleeding.
Isthmic 6-8 wks, Ampullary 8-12wks,
Interstitial -4 months
Abortion is common in ampullary
pregnancies,whereas rupture is in isthmic.
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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.

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Pictures showing TUBAL ABORTION

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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.

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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.
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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.
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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.

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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.
UNRUPTURED ECTOPIC 24
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
Induksi Patol Obs 2017-LUG small tender mass may be felt in the fornix
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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 you or 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

DIAGNOSIS 28
In recent years, inspite of an increase in the

incidence of ectopic pregnancy there has been a
fall in the case fatality rate.
This is due to the widespread introduction of

diagnostic tests and an increased awareness of
the serious nature of this disease.
This has resulted in early diagnosis and effective

treatment.
Now the rate of tubal rupture is as low as 20%.

DIAGNOSIS 29
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 hCG and
can be detected on 24th day after LMP.

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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
4-5wks and at S- hCG level as low as 1500
IU/L .

Endometrial cavity
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-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
color flow high avascular
pattern peripheral flow

DECIDUAL CYST
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It is identified as an anechoic area lying with in the

endometrium but remote from the canal and often at
the endometrial-myometrial border.
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.
Rectouterine cul-de-sac
Free peritonial fluid with an adnexal mass
suggestive of ectopic pregnancy

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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.
USG PICTURE 34
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.
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Hyperechoic ring around

gestational sac in adnexal region

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Ring sign a hyperechoic ring around an extrauterine gestational sac.

2. -HCG Assay- 37
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

3. Serum Progesterone 38
- 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
Induksi Patol Obs 2017-LUG ectopic mass can be done at the same time.
5. Dilatation & Curettage 39
- 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.
SUSPECTED ECTOPIC PREGNANCY 40
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 discriminatory
Villi present Villi absent zone
Incomplete Laparoscopy No sac IU sac

abortion
Continue to monitor

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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
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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
MANAGEMENT 43
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
- Actinomycin D - Segmental
- Mifepristone resection
-Milking or fimbrial
expression
MANAGEMENT OF RUPTURED ECTOPIC 44
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)
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MANAGEMENT OF UNRUPTURED 46
ECTOPIC PREGNANCY
OPTIONS: -
SURGICAL-
SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT
MEDICAL TREATMENT
EXPECTANT MANAGEMENT

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IDENTIFICATION 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 titre
SUCCESS 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

- TVS to be done twice a week.
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Spontaneous resolution occurs in 72%,while 28% will need laparoscopic

salpingostomy
In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum
HCG to return to non pregnant level.
The percentage fall in serum HCG by day 7 is a better indicator than the
percentage fall by day 2.
Warning: - Tubal pregnancies have been known to rupture even when Serum HCG
levels are low.
MEDICAL MANAGEMENT 49
Surgery is the mainstay of T/t worldwide

Medical M/m may be tried in selected cases
CANDIDATES FOR METHOTREXATE (MTX)

Unruptured sac < 3.5cm without cardiac activity
S-hCG < 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.
2017-LUG
Induksi Patol Obs
MEDICAL MANAGEMENT 50
METHOTREXATE:
It can be used as oral,intramuscular ,intravenous usually
along with folinic acid.
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 also be used for tubal pregnancy.
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.
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CONTD 52
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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SURGICALLY ADMINISTERED MEDICAL TT

(SAM)
Aim- trophoblastic destruction without systemic side effects
Technique- Injection of trophotoxic substance into the ectopic

pregnancy sac or into the affected tube by-
Laparoscopy or
Ultrasonographically guided
Transabdominal (Porreco, 1992)
Transvaginal (Feichtingar, 1987)
With Falloposcopic control (Kiss, 1993)
SURGICALLY ADMINISTERED MEDICAL Tt (SAM) 54
Trophotoxic substances used-

Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
Advantage of local MTX :
- Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up: - Serum HCG twice weekly till < 10 IU/L

- TVS weekly for 4-6 weeks
Induksi Patol Obs 2017-LUG - HCG after 6 months for tubal patency
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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.

SURGICAL MANAGEMENT OF ECTOPIC 56
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
VARIOUS CONSERVATIVE SURGERIES 57
1.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

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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.

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

SALPINGECTOMY
VS
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SALPINGOSTOMY / SALPINGOTOMY
All tubal pregnancies can be treated by partial or

total Salpingectomy
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 < 5Cm. In size
5. Contralateral tube is absent or damaged

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CONTD
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.
Making the choice Chapron et al (1993) have
described a scoring system, based on the patients
previous gynaecological history and the appearance of
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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.
Laparotomy Vs Laparoscopy 63
- 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.
LAPAROSCOPIC SALPINGECTOMY
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It is carried out by laparoscopic scissors & 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
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)
The tubal pregnancy is then evacuated by suction irrigation.
PERSISTENT ECTOPIC PREGNANACY 65
This is a complication of salpingotomy / salpingostomy

when residual trophoblast continues to survive because of
incomplete evacuation of the ectopic pregnancy.
Diagnosis is made because of a raised postoperative HCG
If untreated, can cause life threatening hemorrhage
Risk Factor: (seifer 1997)
1. Early ectopic pregnancy (< 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
(selected Asymptomatic pt)
Total or partialTreatment MTX + Leukovorin
Induksi Patol Obs 2017-LUG salpingectomy
OVARIAN ECTOPIC PREGNANCY 66
Incidence: 1:40,000
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
Unruptured
Ruptured
4. Ovarian tissue found on its wall on HP study
Laparotomy M/M Ovarian wedge resection
Ovarian Cystectomy
Induksi Patol Obs 2017-LUG Oophorectomy
ABDOMINAL PREGNANCY 67
Incidence: Rarest
MMR : 7-8 times > tubal ectopic
90 times > 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
Diagnosis: Confirmed by USG,
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CT scan, MRI, Radiography
TYPE
Primary Secondary
Studifords criteria
Conceptus escapes out
1. Both tubes and ovaries normal through a rent from
primary site
2. Absence of Uteroperitonal fistula
3. Pregnancy related to Peritoneal

Intraperitoneal Extraperitoneal
surface & young enough to rule
Broad ligament
out possibility of secondary
implantation

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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
CERVICAL PREGNANCY 70
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
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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 opened
USG 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
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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
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MANAGEMENT
Surgical Medical
Mainstay therapy in past Recently proposed
Single or Combination
Conservative
Radical OR
surgery D&C Adjunct to surgery
(risk of torrential bleeding) - Methotrexate
Hysterectomy - 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

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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
communication with Cx is patent

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HETEROTYPIC PREGNANCY
Co-existing intrauterine and extra uterine pregnancies

Incidence: 1 : 30,000
With ART 1:7000
With ovulation induction 1:900
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 gm is sufficient to

prevent sensitization.)

INTERSTITAL PREGNANCY (2%) 76
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

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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).
78
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.

79
SUMMARY - KEY POINTS
Incidence of ectopic pregnancy is rising while maternal mortality from it is falling.
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
The choice today is Laparoscopic treatment of unruptured ectopic pregnancy.
Careful monitoring and proper counselling of patients is mandatory.

80

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Kehamilan Ektopik

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KEHAMILAN EKTOPIK

Pembimbing : dr. Pande Made, Sp.OG-K

Kehamilan dengan fertilisasi ovum berimplantasi dan

Berpotensi berbahaya pada kesehatan dan organ

Induksi Patol Obs 2017-LUG

Is one in which fertilized ovum is implanted &

Induksi Patol Obs 2017-LUG

Induksi Patol Obs 2017-LUG

Meningkat pada PID, penggunaan IUCD, operasi tuba,

Induksi Patol Obs 2017-LUG

Faktor penyebab transportasi fertilisasi ovum tertunda

Tuba falopi implantasi di mukosa tuba fallobi favours

Faktor-faktor lain, kemungkinan kongenital atau didapat.

Induksi Patol Obs 2017-LUG

Pelvic Inflammatory disease (6-10 times)

Depends on sterilization technique and age of the patient

Induksi Patol Obs 2017-LUG

Tubal reconstructive surgery (4-5 times)

Assisted Reproductive technique

Previous Ectopic Pregnancy

- 7-15% chances of repeat ectopic pregnancy

Induksi Patol Obs 2017-LUG

Other Risk factors

Age 35-45 yrs

Theory of reflux menstural fluid throw the fertilised

Factors facilitating nidation of ovum in tube:

- Premature degeneration of zona pellucida

- Increased decidual reaction

Induksi Patol Obs 2017-LUG

Tubal pregnancies rapidly invade the mucosa, feeding

Induksi Patol Obs 2017-LUG

The pregnancy is unable to survive owing

In rare instances, a tubal pregnancy will be expelled from

Induksi Patol Obs 2017-LUG

Induksi Patol Obs 2017-LUG

Pictures showing TUBAL ABORTION

Induksi Patol Obs 2017-LUG

Dignosis can be done by history, detail examination

H/o past PID, tubal surgery,current contraceptive

Wide spectrum of clinical presentation from

Induksi Patol Obs 2017-LUG

ACUTE ECTOPIC PREGNANCY

Classical triad is present in 50% of pt with

- PAIN:- most constant feature in 95% pt

- VAGINAL BLEEDING: - scanty dark brown

Feeling of nausea,vomiting,fainting attack, syncope

O/E:- patient is restless in agony, looks blanched,

P/A:- abdomen tense, tender mostly in lower

P/S:- minimal bleeding may be present

P/V:- uterus may be bulky, deviated to opposite

CHRONIC ECTOPIC PREGNANCY

It can be diagnosed by high clinical suspicion.

Patient had previous attack of acute pain from

She may have amenorrhoea, vaginal bleeding

Induksi Patol Obs 2017-LUG

O/E:- patient look ill, varying degree of pallor,

P/A:- Tenderness and muscle guard on the lower

P/V:- Vaginal mucosa pale, uterus may be normal

High degree of suspicion & ectopic conscious clinician

Diagnosed accidentally in Laparoscopy or

C/F delayed period, spotting with discomfort in

P/A tenderness in lower abdomen

P/V should be done gently