DR.

CHADUVULA SURESH BABU

PROFESSOR
DEPT.OF OBGYN
College of Medicine, Abha, KKU, KSA
 Definition:

 Anypregnancy where the fertilized ovum OR

blastocyst is implanted and developed
outside the normal uterine cavity
 Incidence – 1 in 150 to 300 deliveries
 Incidence is increasing because of
 1] Ovulation induction
 2] IVF technologies
 3] Tubal surgeries
 4] IUCD usage
 5] Increase in PID or STDs
 6] Early diagnosis
 15% with 1 ectopic

 25% with 2 ectopics

 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 , Tortuosity
, Congenital diverticuli , Accessory ostia
, Partial stenosis
 ACQUIRED -
 Inflammatory: PID, Septic Abortion, Puerperal
Sepsis, MTP (lntraluminal adhesion)
 Surgical: Tubal reconstructive surgery, Recanalisation
of tubes
 Neoplastic: Broad ligament myoma, Ovarian tumour
 Miscellaneous Causes: IUCD , Endometriosis, ART (IVF
& & GIFT), Previous ectopic
 SITES OF ECTOPIC PREGNANCY
Abdomen (< 2%)
Ampulla (>85%)
Isthmus (8%)

Cornual (< 2%)

Ovary (< 2%)

Cervix (< 2%)

1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial

5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn
8)Secondary abdominal 9)Broad ligament 10)Primary
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 EctopicPregnancy remains asymptotic until it
ruptures when it can present in two variations - Acute
&. Chronic
 SYMPTOMS-
 Amenorrhea
 Abdominal Pain
 Syncope
 Vaginal Bleeding
 Pelvic Mass
SIGNS- Abdominal tenderness, Cullen’s sign, Adnexal
tenderness, Cervical motion tenderness

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 Severe abdominal pain
 Cullen’s sign – Periumbilical bruising
 Rebound tenderness and guarding
 Abdominal fullness with decreased bowel
sounds
 Vaginal exam: Fullness in pouch of douglas
 Appendicitis
 Threatened Abortion
 Ruptured ovarian cyst
 PID
 Salpingitis
 Endometritis
 Nephrolithiasis
 Ovarian torsion
 Intrauterine pregnancy
 Immunoassay utilising monoclonal antibodies to
beta HCG
 Ultrasound scanning – Abdominal & Vaginal
including Colour Doppler
 Laparoscopy
 Serum progesterone estimation not helpful

A combination of these methods may have to

be employed.

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At 4-5 weeks-

TVS can visualise a gestational sac as early as

4-5 weeks from LMP.
During this time the lowest serum beta HCG is
2000 IU/Lt.
When beta HCG level is greater than this and
there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.
In such a situation, when the value of beta HCG
does not double in 48 hours ectopic pregnancy
will be confirmed.

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 Empty Uterus
 Free fluid
 Distended portion of left
Fallopian tube
 No evidence of rupture
 Adenexal mass:
 1.7 x 1.6cm adjacent
and anterior to left
ovary
 Cervical excitation
 Tenderness over left iliac
fossa on deep palpation
with the probe
 Complete blood count
 Leukocytosis

 Urinalysis with microscopic exam

 Blood Type and Rhesus

 A negative
 Therefore, must give anti-D (RhoGAM) prior to surgery
 Depends on the stage of the disease and the
condition of the patient at diagnosis.
 Options-
 Surgery – Laparoscopy / Laparotomy
 Medical – Administration of drugs at the site /
systemically
 Expectant – Observation

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OPTIONS: -
 SURGICAL-
 SURGICALLY ADMINISTERED MEDICAL (SAM)
TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT

Ectopic Pregnancy 07/03/2014 16:07 17

 Trophotoxic substances used-
 Methtrexate (Pansky, 1989)
 Potassium Chloride (Robertson, 1987)
 Mifiprostone (RU 486)
 PGF2 (Limblom, 1987)
 Hyper osmolar glucose solution
 Actinomycin D

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 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 be used for
tubal pregnancy as well
 Mechanism of action- Interferes with the DNA
synthesis by inhibiting the synthesis of
pyrimidines leading to trophoblastic cell death.
Auto enzymes and maternal tissues then absorb
the trophoblast.

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 Ectopic pregnancy size should be < 3.5 cm.
 Can be given IV/IM/Oral, usually along with Folinic
acid
 Recent concept is to give Methtrexate IM in a single
dose of 50mg/m2 without Folinic acid. If serum HCG
does not fall to 15% with in 4-7 days, then a second
dose of Methtrexate is given and resolution
confirmed by HCG estimation

Ectopic Pregnancy 07/03/2014 16:07 20

 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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Hospitalisation
Resuscitation -
 Treatment of shock
 Lie flat with the leg end raised
 Analgesics
 Blood transfusion

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Culdocentesis: -
 Most Helpful in Emergent Situations to Confirm
Diagnosis
 Highly Specific if performed and Interpreted
Correctly: - Presence of Free-Flowing, NON-Clotting
Blood
 Negative Tap Inconclusive
 Remains Controversial

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Laparotomy should be done at the
earliest.
Salpingectomy is the definitive
treatment.
 No benefit from removing Ovary along with the tube
Ifblood is not available, auto-
transfusion can be done.

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 Carriedout either by Laparoscopy / Laparotomy.
 The procedures are: -
 Salpingectomy / Cornual resection / Excision
 Conservative surgery (in cases of Infertility & desire for
pregnancy)
 Linear salpingostomy
 Linear salpingotomy
 Segmental resection and anastomosis
 Milking of the tube

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The debate goes on

LAPAROTOMY?
VS.
LAPAROSCOPY?

SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?

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 SALPINGECTOMY
VS
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 haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 5Cm. In size
5. Contralateral tube is absent or damaged

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1. Medial tubal A.
2. Lateral tubal A.
3. Uterine A.
4. Ovarian A.
Main Risk: devascularization of the ovary
 Operate close to the tube, away from ovarian
vessels and suspensory ligament
1. Proximal tube division
 Isthmus is held upwards and
outwards
 Isthmus is cauterized
 Take care not to cauterized the
internal ovarian A. and ovarian
branch of the uterine A.
 Divide tube with scissors
2. Mesosalpinx Division
 Divide the mesosalpinx
with scissors

 Cauterize and divide the

infundibulo-ovarian
ligaments and the lateral
tubal A.
3. Extraction of the tube
 Remove tube through an
extraction bag
 Verification of hemostasis
 Careful lavage
 Removal of equipment
 Suture/ Steri-strip laparoscopic
incisions

Caution:
• Endometriosis
• Utero-peritoneal fistula
 LAPAROSCOPIC SALPINGECTOMY

 It is carried out by laparoscopic

scissors and 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 a tissue removal bag.
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 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)

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LAPAROSCOPIC SALPINGOTOMY

The tubal pregnancy is then

evacuated by suction irrigation.
Hemostasis of the trophpblastic bed
is ensured.
The tubal incision is left open.

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 INVESTIGATIONS-
 Laboratory/Chemical test –
 Serialquantitative beta HCG level by RIA
 Serum progesterone level (<5 nanog/ml in
ectopic pregnancy)
 Low levels of Trophoblastic proteins such as
SPI and PAPP-, Placental protein 14 & 12
 USG- usually haematocele is found
 Laparoscopy

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TREATMENT – ALWAYS SURGICAL

 Salpingectomy of the offending tube

 If pelvic haematocele is
infected, posterior. colpotomy is to be
done to drain the pelvic abscess
 Salpingo-oophorectomy

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 Incidence of ectopic pregnancy is rising while
maternal mortality from it is falling.
 Early diagnosis is the key to less invasive
treatment.
 The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
 The trend is towards conservative treatment.
 Careful monitoring and proper counselling of
patients is mandatory.
 Ruptured ectopics should be unusual with
compliant patients and appropriate medical
care.

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THANK YOU