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INCREASES WITHIN
3 MONTHS
FOLLOWING TERM
BIRTH

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 BLIGHTED OVUM-when the gestational sac is open,
fluid id commonly found surrounding a small
macerated fetus or alternately no fetus is visible
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 THREATENED ABORTION  INEVITABLE ABORTION
• Bloody discharge
• Closed cervix
• Uterine
enlargement
• Crampy pain
• 1: 4 women
• 1/2 will abort
• Increased risk of
preterm birth, LBW
& perinatal death
• Gross rupture of
the bag of water
• Cervical dilatation
• No passage of the
fetus
• Signals that
abortion is certain
• Treatment is
uterine evacuation
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 INCOMPLETE ABORTION  MISSED ABORTION
• Part of the placenta • Embryonal demise
or portions of the • No expulsion
products of
conception are
• Retained > 8 weeks
expelled • Closed cervix
• Cervix is open • Minimal or absent
• Vaginal bleeding vaginal bleeding
• Curettage with
• Uterus incompatible
evacuation is the with age
treatment • No signs & symptoms
of pregnancy

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 Presence of
anticardiolipin
antibodies and
lupus
anticoagulant
wherein one or
the other is
present in 5-
15% of women

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 UTERINE CERVICAL UTERINE SIZE
OTHER
CATEGORY CONTRA BLEEDING DILATATIO VS BOW FINDINGS
MANAGEMENT
CTION N GESTATION

THREATENE COMPATIB Bed Rest

+/- +/- + + FHT
D ABORTION +
LE Progestins

Watchful
INEVITABLE COMPATIB expectancy
+++ + + + +/- FHT
ABORTION LE Oxytocin
Curettage

INCOMPLETE INCOMPATIB -FHT

+/- + +/- _ Curettage
ABORTION LE

Not Absent
COMPLETE INCOMPATIB
_ +/- - apprec signs of Observation
ABORTION LE
iated pregnancy

Not
MISSED INCOMPATIB Prostaglandins
_ Spotting/- - apprec -FHT
ABORTION LE
iated
D and C

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 The blastocyst normally implants in the
endometrial lining of the uterine cavity.
 Implantation anywhere else is an ectopic

pregnancy.
 With earlier diagnosis, however, both

maternal survival and conservation of

reproductive capacity are enhanced.

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 Tubal pregnancy
 Abdominal pregnancy
 Broad ligament pregnancy
 Interstitial pregnancy

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 The fertilized ovum may lodge in any portion
of the oviduct, giving rise to ampullary,
isthmic, and interstitial tubal pregnancies
 The ampulla is the most frequent site,

followed by the isthmus.

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 . Abortion is common in ampullary tubal
pregnancy,
 whereas rupture is the usual outcome with

isthmic pregnancy.
 The immediate consequence of hemorrhage

is further disruption of the connection

between the placenta and membranes and
the tubal wall.

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 If the fimbriated extremity is occluded, the
fallopian tube may gradually become
distended by blood, forming a hematosalpinx

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 The invading, expanding products of
conception may rupture the oviduct at any of
several sites.
 whenever there is tubal rupture in the first

few weeks, the pregnancy is situated in the

isthmic portion of the tube.
 When the fertilized ovum is implanted well

within the interstitial portion, rupture usually

occurs later.

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 Occasionally, if larger, they may remain in the
cul-de-sac for years as an encapsulated
mass, or even become calcified to form a
lithopedion

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 When the greater portion of the placenta
retains its tubal attachment the fetus may
then survive for some time, giving rise to an
abdominal pregnancy.
 Typically in such cases, a portion of the

placenta remains attached to the tubal wall

and the periphery grows beyond the tube and
implants on surrounding structures.

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 When original zygote implantation is toward
the mesosalpinx, rupture may occur at the
portion of the tube not immediately covered
by peritoneum.
 The gestational contents may be extruded

into a space formed between the folds of the

broad ligament and then become an
intraligamentous or broad-ligament
pregnancy.

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 Implantation within the tubal segment that
penetrates the uterine wall results in an
interstitial or cornual pregnancy).
 Because the implantation site is located

between the ovarian and uterine arteries,

there is severe hemorrhage..

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 Twin tubal pregnancy has been reported with
both embryos in the same tube, as well as
with one in each tube

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 Pain
 Abnormal mesturation
 Abdominal and pelvic tenderness
 Uterine Changes
 Blood Pressure and Pulse (slight rise in blood
pressure, or a vasovagal response with
bradycardia and hypotension )
 Pelvic Mass
 Culdocentesis

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 Appendicitis
 PID
 Threatened abortion
 Twisted or ruptured ovarian new growth

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 In contemporary practice, symptoms and
signs of ectopic pregnancy are often subtle or
even absent.

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 vaginal bleeding, or "spotting."
 Severe abdominal pain.
 Vasomotor disturbances
 The posterior vaginal fornix may bulge

because of blood in the cul-de-sac, or a

tender, boggy mass may be felt to one side of
the uterus.
 Symptoms of diaphragmatic irritation.

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 SIGNS & SYMPTOMS LABORATORY TESTS

TRIAD :  HUMAN CHORIONIC

 VAGINAL BLEEDING (60-80%) GONADOTROPIN ASSAY
 ABDOMINAL PAIN (95%)
Latex Agglutination inhibition
slide tests positive at 500-
 AMENORRHEA
800mIU/ml hCG levels
ELISA 10-20mIU/ml (99%
 CERVICAL TENDERNESS sensitivity
 ADNEXAL MASS
 PROGESTERONE
 DOUGHY UTERUS
>25 ng/ml Normal pregnancy
5-25 ng/ml Inconclusive
<5 ng/ml EP or abnormal

pregnancy

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CULDOCENTESIS

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CULDOCENTESIS
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ULTRASOUND

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ULTRASOUND

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LAPAROSCOPY

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 Systemic Methotrexate-This antineoplastic
drug acts as a folic acid antagonist and is
highly effective against rapidly proliferating
trophoblast

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 Candidates for methotrexate therapy must be
hemodynamically stable.
 Medical therapy fails in at least 5 to 10

percent of cases, and this rate is higher in >

6 weeks' gestation or with a tubal mass >4
cms
 Failure of medical therapy requires

retreatment, either medically or with elective

surgery.

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 If the woman is treated as an outpatient, rapid
transportation must be reliably available.
 Signs and symptoms of tubal rupture such as
vaginal bleeding, abdominal and pleuritic pain,
weakness, dizziness, or syncope must be
reported promptly.
 Until the ectopic pregnancy is resolved, sexual
intercourse is prohibited, alcohol avoided, and
folic acid supplements—including prenatal
vitamins—should not be taken.

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 LAPAROTOMY
LAPAROSCOPY

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 Open abdominal surgery is preferred when
the woman is hemodynamically unstable, or
when laparoscopy is not feasible.

 laparotomy is performed in a woman with

obvious abdominal hemorrhage that requires
immediate definitive treatment.

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 Laparoscopy is more cost-effective, and there
is a shorter postoperative recovery
 laparoscopy is not without risks or cost. It is

usually performed when the diagnosis of

ectopic pregnancy is fairly certain

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DIRECT VISUALIZATION OF THE PELVIC
ORGANS REMAINS THE GOLD STANDARD
IN THE DIAGNOSIS AND MANAGEMENT
OF
ECTOPIC PREGNANCY

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 CONSERVATIVE SURGERY
Desires future fertility
Hemodynamically stable
Procedures
o Salpingostomy
o Salpingotomy
o Segmental resection with or without reanastomosis

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SALPINGOSTOMY

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 RADICAL SURGERY
Involved oviduct is damaged beyond salvage
Hemodynamically unstable
Procedures
o Salpingectomy
o Hysterectomy

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 Salpingostomy- This procedure is used to
remove a small pregnancy that is usually <
2 cm in length and located in the distal
third of the fallopian tube.
 Salpingotomy - Seldom performed today

 Salpingectomy - Tubal resection can be

performed through an operative

laparoscope and may be used for both
ruptured and unruptured ectopic
pregnancies.

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 Resection of the ectopic mass and tubal
reanastomosis is sometimes used for an
unruptured isthmic pregnancy because
salpingostomy may cause scarring and
subsequent narrowing of the small isthmic
lumen

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 Hemogram
 Chorionic Gonadotropin Assays
 Serum Progesterone Levels
 Ultrasound Imaging

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 Abdominal  Vaginal Sonography
Sonography

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 ◦ Vaginal sonography.
◦ Serum -hCG—both the initial level and the
pattern of subsequent rise or decline.
◦ Serum progesterone.
◦ Uterine curettage.
◦ Laparoscopy and, less frequently, laparotomy.
 The choice of diagnostic algorithm applies
only to hemodynamically stable women;
those with presumed rupture should
undergo prompt surgical therapy

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 Ectopic pregnancy implanted in the ovary is
rare. Traditional risk factors for ovarian
ectopic pregnancy are similar to those for
tubal pregnancy

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Four criteria for differentiating ovarian froother
ectopic pregnancies:

-The gestational sac is located in the region of

the ovary.
-The ectopic pregnancy is attached to the uterus
by the ovarian ligament.
-Ovarian tissue in the wall of the gestational sac
is proved histologically.
-The tube on the involved side is intact.

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 An abdominal pregnancy is a form of an
ectopic pregnancy where the pregnancy is
implanted within the peritoneal cavity outside
the fallopian tube or ovary and not located in
the broad ligament. While rare, abdominal
pregnancies have a higher mortality rate than
ectopic pregnancies in general but, on
occasion, can lead to a delivery of a viable
infant.

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 Normal bilateral fallopian tubes and ovaries
 Absence of the utero-peritoneal fistula .
 Presence of a pregnancy related to the

peritoneal surface exclusively .

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THANK YOU

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