Without intervention, an ectopic tubal pregnancy can lead to tubal

abortion, tubal rupture, or spontaneous resolution. Tubal abortion is

the expulsion of products through the fimbrial end. This tissue can then
either regress or reimplant in the abdominal cavity. With
reimplantation, bleeding or pain necessitating surgical intervention is a
common complication. Tubal rupture is associated with significant
intraabdominal hemorrhage. With spontaneous resolution, small
ectopic pregnancies die and are resorbed without adverse patient
effects. As with the ending of any early pregnancy, Rh status is
assessed. If a woman is D negative and her partner has a blood group
that is either D positive or unknown, then 300 μg anti-D immune
globulin is given to prevent anti-D isoimmunization.
Expecting managemant

Medical management

Surgical management

Emergency management
1
Criteria for selection
 Asymptomatic pt
 Hemodynamically stable
 <100 ml fluid in the pouch of Douglas
 Lower beta hcg value<1000 IU/ml
 Adnexal mass <3cm without cardiac activity
 Pregnancy of unknown location
They must be fully compliant and must be willing to accept the
potential risks of tubal rupture.
Success rate is 60% with decreasing beta hcg titre
 Initial follow up
• twice weekly with serial Hcg measurements
• weekly by TVS
By the first week
• drop in HCG level
• Adnexal mass size
Otherwise reassess the options (Medical/Surgical)

 If the fall of HCG & reduction in size of adnexal mass satisfactory

weekly hCG & TVS till HCG falls <20 IU
45-70% of PUL resolve spontaneously with expectant management

Ectopic pregnancy was subsequently diagnosed in14–28% of PUL

Intervention (laparoscopic salpingostomy) has been shown to be required in

23- 29% of cases
2
criteria for medical management
Selection criteria
Minimal symptoms/ hemodynamically stable
No signs or symptoms of active bleeding / haemoperitoneum.
HCG<3000(RCOG)
Normal CBC,RFT,LFT
Size<4cm
Absence of cardiac activity
Persistent ectopic after conservative surgery
Good compliance and follow up can be assured
Women should be given clear information(preferably written)about the
possible need for further Tt and adverse effects following Tt
Exclusion criteria
Any hepatic dysfunction, thrombocytopenia (<100,000), blood
dyscrasia(WBC <2000).
Difficulty/unwillingness of patient for prolonged follow-up (avg follow-
up 35days).
Ectopic mass >4cm
presence of cardiac activity
Women on concurrent corticosteroid therapy
Methotrexate
This folic acid antagonist competitively inhibits the binding of dihydro
folic acid to the enzyme dihydrofolate reductase. This leads to reduced
amounts of purines and thymidylate and thereby an arrest of DNA,
RNA, and protein synthesis . It inhibits fast-growing tissue and is used
for cancer chemotherapy and for early IUP termination. The drug can
be given orally, intravenously, or intramuscularly (IM) or can be directly
injected into the ectopic pregnancy sac. Currently, IM methotrexate
administration is used most commonly for tubal ectopic pregnancies.
Prior to therapy, serum creatinine and β-hCG levels, a
complete blood count, liver function tests, and blood type and
Rh status are obtained . Moreover, all except blood typing are
repeated prior to additional doses .
With administration, women are counseled to avoid the
following until treatment is completed: folic acid-containing
supplements, which can competitively reduce methotrexate
binding to dihydrofolate reductase; nonsteroidal
antiinfammatory drugs, which reduce renal blood flow and
delay drug excretion; alcohol, which can predispose to
concurrent hepatic enzyme elevation; sunlight, which can
provoke methotrexate-related dermatitis; and coitus, which
can rupture the ectopic pregnancy
1.single dose regimen:
MTX 50mg/m2 on day 0
Measure B-hCG level on days 4 & 7
If level drops by 15%, monitor B-hCG weekly until non pregnant level.
If levels do not drop by 15%, repeat dose of MTX & measure B-hCG on
days 4 & 7
87% success rate
Advantages:
• Increased pt compliance
• Simplified administration
• Safe & effective
• Less expensive
• Less monitoring
2.Multidose Methotrexate.
MTX 1mg/kg IM on 1,3,5,7 days
Leucovorin 0.1mg/kg on 2,4,6,8 days
Measure B-hCG levels on days 1,3,5,7 until 15% decrease between
2 measurement
Once B-hCG level drops 15%, stop MTX & monitor B-hCG weekly until
non pregnant level
Dose & frequency dependent (30-40%)
 nausea, vomiting
 Stomatitis,
 abdominal pain
 bone marrow suppression
 Alopecia
 dermatitis & pneumonitis.
 Deranged LFT
outcome
90% successful treatment with single dose regime.
10 – 20%. Recurrent ectopic pregnancy rate
80%. Tubal patency rate
75% abdominal pain-separation pain.(D3-D7)
14 % of medical management 2nd dose of MTX
10% finally require surgical management

risk of subsequent ectopic 10% following either

MTX(MD)/salpingostomy. similar reproductive out comes
3
Indication of surgical management
 Not a suitable candidate for medical therapy.
 Failed Medical therapy.
 heterotropic pregnancy with viable intrauterine pregnancy.
 hemodynamically unstable & needs immediate treatment.
Surgical approach laparoscopy or laparotomy
hemodynamic stability
size & location of ectopic mass
 surgeons expertise
Linear salpingostomy:

• <2cm size, in distal third of tube

• Antemesenteric border incised –heals by secondary
intention
indication
unruptured ampullary ectopic pregnancy
wishes to retain potential for future fertility
Contralateral tube appears damaged
contraindications
Ruptured tube
use of extensive cautery to obtain hemostasis
severely damaged tube
recurrent ectopic pregnancy in same tube.
Salpingectomy

• Salpingectomy (tubal removal) is the principle treatment especially

where there is tubal rupture
• wedge area of outer 3rd of interstitial portion of tube is also resected
,known as cornual resection to minimize occurrence of pregnancy in
tubal stump
• Total salpingectomy is the procedure of choice:
 completed childbearing and no longer desires fertility
 history of an ectopic pregnancy in the same tube.
 severely damaged tubes
salpingestomy
Lapratomy
Laparotomy
hemodynamically unstable and an expedited abdominal entry is
required
patients with cornual, interstitial ectopics
Extensive pelvic/abdominal adhesive disease
 surgeons inexperienced & patients where laparoscopic approach is
difficult
An alternative to laparoscopy is the use of minilaparotomy incision.-
success rate similar
Management of ruptured ectopic with
collapse
PRINCIPLE: Quick Resuscitation and simulataneous arrangement for
laparotomy
definitive surgery
ANTI SHOCK TREATMENT: ABC of resuscitation
give facial oxygen
Site two IV lines (at least 16g), commence IV fluids (crystalloid)
Send blood for CBC, Clotting screen and cross-match at least 4 units of blood.
- Folleys catheterization done
- colloids for volume replacement
whilst awaiting transfer to theatre continue fluid resuscitation and ensure
intensive monitoring of haemodynamic state
 Rapid exploration of abdominal cavity done -
Salpingectomy(definitive surgery)
peritoneal toileting
record operative findings including the state of the
remaining tube/pelvis
Blood transfusion done
Anti D Ig (300 IU)given to Rh negative women
 Cervical(0.1-1%)
 Ovarian(0.5-2%)
 Abdominal(0.3-0.5%)
 Interstitial(2-3%)
 Angular
 Cornual(1:1lakh)
 Heterotropic
 Multiple ectopic pregnancy
 Ectopic in caesarean scar<1%)
 Pregnancy after hysterectomy
Pregnancy in rudimentary horn
Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.
As such a horn is capable of some hypertrophy and distension, rupture
usually does not occur before 16-20 weeks.
Management
affected pregnancy is removed by
Laparoscopic resection or
hysterectomy
Interstitial pregnancy
• Thick section of tube- expands max capacity before rupture(7-16w)
• 2.4% of all ectopics
• Late presentation rate
• Most dangerous –torrential haemorrhage(dual supply) mgt:
• MTX – stable
• Laparoscopic cornuostomy -unstable .
• Hysteroscopic resection with selective arterial embolisation, Inj kcl
• Hysterectomy(rupture)
Cervical pregnancy<1%
• Uterus smaller than the surrounding distended cervix
• External os may be open
• Visible cervical lesion often blue or purple in colour
• Profuse bleeding on manipulation of cervix
 Gestatational sac /placental tissue visualizd within cervix
 Cardiac motion noted below the level of internal os
 No intrauterine pregnancy’
 Hourglass uterine shape with ballooned cervical canal
 No movement of sac with pressure from transvaginal probe(no
sliding sign)
 Closed internal os
 Clinical- painless vaginal bleeding/crampy pain
 1/3. massive harmorrhage
 Very rarely>20 weeks
 Imaging- USG: true cervical pregnancy vs ongoing spontaneous abortion:
no sliding sign
 MRI pelvis
D/D:
Carcinoma, cervical/prolapsed submucosal leiomyoma , Trophoblastic tumor
Placenta praevia
 Management
Medical treatment with MTX,KCL
surgical dilation & curettage

Laparotomy uterine artery& internal iliac artery ligation

If bleeding continues or extensive rupture occurs hysterectomy is

needed.
Ovarian ectopic<3%
Aetiology:
* Pelvic adhesions.
* Favourable ovarian surface for implantation as in ovarian
endometriosis.
Pathogenesis:
* Fertilization of the ovum inside the ovary or,
* implantation of the fertilized ovum in the ovary.
Treatment
• Misdiagnosis very common(Ruptured corpus luteal cyst75%)
• Laparotomy. ovarian cystectomy/wedge
resection for unruptured and
oophorectomy for ruptured.
• Treatment with MTX and prostaglandin
injection has also been reported
HETEROTOPIC PREGNANCY

A uterine pregnancy in conjunction with an extrauterine pregnancy is

termed a heterotopic pregnancy. In the past, the incidence was
estimated to be 1 in 30,000 pregnancies. In pregnancies resulting from
ART , the heterotopic pregnancies rate approximates 0.09 percent .
For a tubal pregnancy coexistent with a uterine pregnancy, potassium
chloride can be injected into the tubal pregnancy sac. Methotrexate is
contraindicated due to the detrimental effects on the normal
pregnancy. Surgical treatment of ectopic pregnancy.
OTHER ECTOPIC PREGNANCY SITES

Abdominal pregnancy is an implantation in the peritoneal cavity

exclusive of tubal, ovarian, or intraligamentous implantations. These
are rare and have an estimated incidence of 1 in 10,000 to 25,000 live
births . Ectopic placental implantations in less expected sites have been
described in case reports and include the omentum, spleen, liver, and
retroperitoneum, among others . Also rare, ectopic pregnancies have
been reported in women with prior hysterectomy . Presumably, a
vaginal cuff fistula, a prolapsed fallopian tube, or a cervical stump
after supracervical hysterectomy allows sperm to access an ovulated
ovum.
management
 laparotomy with removal of sac, fetus, placenta, membranes
 placenta if attached to vital structures -left in situ after ligating base
 Placental involution
 serial USG, BHCG
 MTX treatment contraindicated -high rate of complications due to
rapid tissue necrosis
Caecerean scar pregnancy
Implantation within the scar of a prior cesarean delivery through a
microscopic tract in the myometrium .
Similar to other ectopic pregnancies, it carries significant risks of
massive hemorrhage. the incidence of cesarean scar pregnancy (CSP)
to approximate 1 in 2000 pregnancies . These microscopic tracts can
also stem from other prior uterine surgery—curettage, myomectomy,
operative hysteroscopy—and perhaps from manual removal of the
placenta
 four sonographic criteria should be satisfied for the diagnosis:
(1) an empty uterine cavity, (2) an empty cervical canal, (3) a ges-
tational sac in the anterior part of the uterine isthmus, and (4) absence
of healthy myometrium between the bladder and gestational sac.
Management:
no role of expectant mgt –risk- uterine rupture
MTX, Hysteroscopic resection, uterus preserving wedge resection,
hysterectomy
Pregnancy of unknown location
• 7-20% proved to beectopic
• 25% of ectopic presents with PUL
• Intrauterine pregnancy in which the sac is not developed, collapsed
or aborted.
• Ectopic too small to be detected