2. Ectopic pregnancy

3. CS pregnancy national library of medicine Type EP Cause – best management ? Main objective. Prevention massive blood loss Conservation of uterus

4. Cause CSP ? Embryo implanation through a small dehicence or tract into uterine wall. First CSP 1978 1978 and 2001 18 case Next 3 years 66 case

5. Expectant management woman desire to continue preg and us evidence, sac growing towards uterine cavity. termination recommended once diagnosis Ellective cs around 28-30 wk

6. Conservative medical treatment Pain free Hemodynamically stable Less then 8 wk Myometrial thickness loss 2 mm CS bladder

7. Systemic methotrexate pregnancy < 9 wk Short half life MTX Fibrous tissue surrouding scar Can limit systemic absorption MTX Delaying disappearance G-sac Local MTX have greater success

8. MTX injected locally to G-sac TV ultrasound control 20-22 gauge needle in case of concurrent embryo aspiration different embryocides kcl, hypertonic glucose Failed requiring MTX and uterine curretageVAE.

9. Combined treatment Hysterocopy : Identification G.sac, vessels coagulation Local injection techniques Rapid return to fertility Requires anesthesia, operative skills

10. Laparoscopy Laparotomy Uterine curretage An sac aspiration failure rate 70% inefective

11. Uterine artery embolization : UAE + cystemic MTX Well tolerated effective 64 blood loss 25 ml UAE + local MTX

12. 212 ( 22-25 ) Uterine arteery embolizatoin + intraarterial MTX 24-48 h suction curretage Cystemic MTX 50mg if BHCG < 50% 50mg MTX abdominal guidance 5-6 months 2 wk BHCG

13. Uterine curettage and Sac aspiration blind uterine curettage + should be discouraged under US control G week < 7 wk Myometrial thickness > 3.5mm more reports documenting U-curettage ineffective

14. 68 cases of CSP ( 40-28) TV Ultrasound guided embryo aspiration + MTX local 50 mg after on week 50 mg MTX IM Systemic MTX + curettage with hysteroscopy a week later 50 mg MTX IM 50% decreased BHCG, us indicate lower blood flow at the scare, curettage.

15. Figure 1. Ultrasound follow ‐ up at 5, 6 and 7 weeks gestation. At 5 and 6 weeks gestation (A and B), a midline sagittal transvaginal image demonstrating a gestational sac implanted at the isthmic region between the cervix and the empty uterine cavity (small arrows), i.e. anatomical location of a previous Caesarean section scar (large arrow). At 7 weeks gestation (C), a midline longitudinal transabdominal scan demonstrating an empty uterine cavity. The tip of the sac is bulging towards the bladder (large arrow).

16. Diagnosis Criteria interstitial EP Empty U-cavity G sac at least 1 cm lateral most borders U-cavity Myometrial bed thinning sac color Doppler us periphoblastic arterial flow

17. Interstitial pregnancy G-sac in uterin horn Hemodynamically stable conservative management sytemic methatrenate

18. Laparoscopic wedge resection Laparoscopy Laparoscopic salpingocentesis + MTX C-EP and I-EP systemic MTX+miferiston preserve fertility eliminate anesthesia

19. Cervical pregnancy 1/9000 pregnancy major predisposing factor D&C PCS IVF Asherman’s synd Prior EP Infertility Instrumentation on therapeutic – ab

20. Painless V-bleeding 1/3 lower ab – cramping Soft disproportionately large cervix an hour – glass shaped uterus US 81.8% correct diagnosis

21. Ushakou criteria ( C-preg ) G-sac in endocervix Intact portion C-canal between sac – endometrial Local invasion c-tissue Embryomic or fetal structures in sac Empty uterine cavity Hourglass uterus

22. On speculum examination Ex-os may be open fetal membranous, tissue pregnancy cystic lesion on cervical Lip.

23. Medical therapy : Hemodynamic stable Multidose MTX in very early cardiac activity, multidose MTX and intra Af and or intrafetal KCL Take a few months needle 22 1-5cc KCL 20%.

24. Surgical therapy main complication severe bleeding Transvaginal ligation cervical branches UA 3-9 o’clock Shirodkar cerclage, angiographic UA emb Intracervical vasopressin 20-30cc gauge needle 21 cervical stroma UAE

25. If implantation site bleeding Foley catheter (26) 30 ml balloon. After 24-48 balloon deflated gradually hours to days and removed if bleeding picks up or recurs reinflated Angiographic embolization b-internal iliac artery ligation, U-A ligation, surgical evacuation several hours to 24 h. Hystrectomy

26. An ultrasonographic sagittal view shows the viable fetus within an ectopic gestational sac in the posterior cervical stroma.

27. A visible defect (black arrow) with prolapsing fetal membranes (black arrow) was seen in the posterior cervix.

28. This ultrasonographic image, obtained 1 week after direct instillation of methotrexate into the cervical ectopic gestational sac, shows the resolving ectopic pregnancy (white arrow).