1. Ectopic Pregnancy
By Rohan Kulkarni

2. Defination.
Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.
1 in 100 ( from 1:25 to 1:250) normal pregnancies (incidence)

3. Recurrence rate - 15% after 1st, 25% after 2 ectopics
Recent evidence shows that the incidence of ectopic pregnancy has been rising in many countries.
USA-5 fold
UK-2 fold
France 15/1000 pregnancies
India-1in100 deliveries
Recurrence rate - 15% after 1st, 25% after 2 ectopics

4. Overview. Incidence Increasing (Ќ 1:66 Pregnancies)
Mortality Decreasing With Better Detection
Surgical and Medical Treatment Available
Recurrence Rate ~ 15%

5. Aetiology
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.
CONGENITAL - Tubal Hypoplasia, Congenital diverticuli , Accessory ostia , Partial stenosis
Previous Ectopic Pregnancy
PID

6. Migration of the Ova Externa
Pelvic Abnormalities (Fundul Fibroma, adenomiosis of Fallopian Tubes)
Tubal Reconstrustive Surgery
Tubectomy Operation
Infertility
IUD (~4% pregnancies with IUD in Situ are Ectopic, Progestogen Containing IUD Have a 9 Fold Higher Risk of an Ectopic Pregnancy)
IVF
Induction Ovulation with Gonadotropins
Extraneous Factors (Appendicitis, Endometriosis)

7. Sites Ampulla (78-95%) Isthmus (8-12%)
Interstitial portion (2%) - very rare form
Cornua (< 2%) or in accessory horn
Ovary (0,5-3%, 20-30% in IUD users)
Abdomen (< 2%): Primary - very rare. Secondary.
Cervix (< 2%)
Combined Uterine Pregnancy and Ectopic Gestation - 1-3% in IVF, 1: :

8. 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

9. Tubal Pregnancy at USG
Detailed view of ectopic (thick, brightly echogenic, ringlike structure outside the uterus)
Tubal pregnancy circled in red
4.5 mm fetal pole (between cursors) in green
Pregnancy yolk sac in blue

10. Tubal Pregnancy
After laparoscopic resection of the tube, the tubal stump is seen at S
Close view of the
same ectopic

11. Tubal Pregnancy Right tubal ectopic pregnancy in 11 th
Same situation after rupture
Right tubal ectopic
pregnancy in 11 th
week of gestation

12. Ovarian Pregnancy Ovary is the white structure in the middle
Pregnancy is implanted on the far right side of the ovary at the "X„
Around the ovary are seen bleeding and clotted blood

13. Symptoms Amenorrhea in 75% cases
Abdominal Pain - in 95% cases. Shoulder and Epigasrtric Pain
Vaginal Bleeding
Syncope
Pelvic Mass

14. Clinical classification.
Unruptured (Progressive) - without specific sings
Tubal Abortion - minimal sings
Tubal Rupture (into the peritoneal cavity or between the leaves of broad ligaments - rare) - massive hemoperitoneum and severe shock

15. Diagnosis History and Physical Exam Vaginal Examination
Serial Quantitative -hCG (BSU)
Ultrasound TAS & TVS
Progesterone Level?
Culdocentesis
Laparoscopy
D&C

16. -hCG* Levels Double Every 48 Hrs
< 66% Rise / 48 Hrs Consistent With Ectopic Pregnancy
Single Determination Not Helpful
Best If Done Within Same Laboratory
Ultrasound Never May or May Not Be Helpful
Rules Out Ectopic Pregnanc

17. Culdocentesis
Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood
Negative Tap Inconclusive
May Obviate U/S
Most Helpful in Emergent Situations to Confirm Diagnosis, But Remains Controvers

18. Differential diagnosis
Appendicitis (Perforated) , PID
Rupture of Follicle or Corpus Luteum Cyst
Threatened Abortion
Splenic Rupture
Perforated Gastric or Duodenal Ulcer
Acute Pancreatities
Myocardial Infarct
Pyosalpinx
Septic Abortion
Pelvic Abcess
Retroverted Gravid Uterus
Twisted Ovarian Cyst, Rupture of Chocolate cyst

19. Treatment Observation Laparoscopy Laparotomy MTX (methotrexate)
Hyperosmolar Glucose
KCl
RU-486
Prostaglandin F2 alfa

20. Laprotomy Acute Ectopic Gestation Salpingoectomy
Secondary Abdominal Pregnancy
Interstial Pregnancy
Cornual Pregnancy
Cervical Pregnancy

21. Laparoscopy Allows Diagnosis and Treatment Salpingostomy
Salpingectomy (Total / Partial)
Cornual Resection
Minimally Invasive, Unlike Laparotomy
Few Contraindications: Unstable Patient (Possibly)

22. mxt Toxic to Trophoblast Cells Minimal Side Effects
May Preserve Fertility in Cases of Cervical Pregnancy
Requires Compliant Patient, Time
Pain Not Uncommon
25-50 mg into Gestational Sac
Tubal Patency is Restored in 82% cases
Oral mg (toxicity on GIT)
Intramusculary 1 mg/kg

23. Cervical Pregnancy Incidence 1:1 000
Profuse painless bleeding following a short period of Amenorrhea
PE: a patulous external os and products of conception in the cevical canal, internal os is closed and the uterus is firm and normal in size
US helps in the correct diagnisis
Treatment: - Suction Evacuation and Tamponade by inserting a distended Foley Catheter for 24 hours - Hysterectomy Hysteroscopic Resection using Resectoscope , MTX

24. Outcomes 15% Repeat Ectopic Rate Ectopics: 33% Pregnancy Rate
No Benefit To Removing Ovary Along With Tube

25. Ectopic Pregnancy is a Common, Treatable Problem
Sensitive -hCG Assays Allow Early Detection
Surgical and Medical Options Exist

26. Thank you for attention.