Advances in the Diagnosis and Management of Ectopc

ADVANCES IN THE ADVANCES IN THE DIAGNOSIS AND DIAGNOSIS AND

MANAGEMENT OF ECTOPC MANAGEMENT OF ECTOPC PREGNANCYPREGNANCYDR. A.B.A. ANDEDR. A.B.A. ANDE

MATERNO-FETAL UNIT MATERNO-FETAL UNIT

UNIBEN / UBTHUNIBEN / UBTH

ECTOPIC PREGNANCYECTOPIC PREGNANCY

DEFINITIONDEFINITION

Any pregnancy where the fertilised Any pregnancy where the fertilised ovum gets implanted and develops in ovum gets implanted and develops in a site other than normal uterine a site other than normal uterine cavity.cavity.

INCIDENCEINCIDENCE

> 1 in 100 pregnancies> 1 in 100 pregnancies

Recent evidence indicates that the incidence of ectopic Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countriespregnancy has been rising in many countries

- USA - USA – 5 fold– 5 fold

- UK- UK – 2 fold– 2 fold

- France - France – 15/1000– 15/1000

- India - India – 1 in 100 deliveries– 1 in 100 deliveries

- Nigeria - Nigeria – 2-3% of gynecological emergencies– 2-3% of gynecological emergencies Recurrence rate – 15% after 1st, 25% after 2 ectopicsRecurrence rate – 15% after 1st, 25% after 2 ectopics

HISTORYHISTORY

963 AD – Albucasis first described Ectopic 963 AD – Albucasis first described Ectopic PregnancyPregnancy

1884 -- Robert Lawson Tait of Birmingham 1884 -- Robert Lawson Tait of Birmingham performed the forst successful performed the forst successful Salpingectomy operationSalpingectomy operation

1953 – Stromme – Conservatice surgery of 1953 – Stromme – Conservatice surgery of SalpingostomySalpingostomy

1973 – Shapiro & Adller – Laparoscopic 1973 – Shapiro & Adller – Laparoscopic SalpingectomySalpingectomy

1991 – Young et al – Laparoscopic 1991 – Young et al – Laparoscopic Salpingotomy Salpingotomy

AETIOLOGYAETIOLOGY

Any factor that causes delayed Any factor that causes delayed transport of the fertilised ovum transport of the fertilised ovum through the fallopian tube favours through the fallopian tube favours implantation in the tubal mucosa, implantation in the tubal mucosa, giving rise to a tubal ectopic giving rise to a tubal ectopic pregnancy.pregnancy.

These factors may be Congenital or These factors may be Congenital or Acquired.Acquired.

AETIOLOGYAETIOLOGY

CONGENITAL – Tubal Hypolasia, Tortuosity, CONGENITAL – Tubal Hypolasia, Tortuosity, Congenital diverticuli, Accessory ostia, Partial Congenital diverticuli, Accessory ostia, Partial stenosis.stenosis.

AQUIRED –AQUIRED –- Inflammatory: PID, Septic Abortion, Puerperal - Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (Intraluminal adhesion)Sepsis, MTP (Intraluminal adhesion)- Surgical: Tubal reconstructive surgery, - Surgical: Tubal reconstructive surgery, Recanalisation of tubesRecanalisation of tubes- Neoplastic: Broad ligament myoma, Ovarian - Neoplastic: Broad ligament myoma, Ovarian tumour.tumour.- Miscellaneous Causes: IUCD, Endometriosis, ART - Miscellaneous Causes: IUCD, Endometriosis, ART (IVF & GIFT), Previous ectopic.(IVF & GIFT), Previous ectopic.

SITES OF ECTOPIC SITES OF ECTOPIC PREGNANCYPREGNANCY

1) Fimbrial 2) Ampullary 3) Isthmic 4) Interstitial 5)Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament10) Primary abdominal

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Ectopic Pregnancy remains asymptotic Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two until it ruptures when it can present in two variations – Acute and Chronicvariations – Acute and Chronic

SYMPTOMSSYMPTOMS- Amenorrhea- Amenorrhea- Abdominal Pain- Abdominal Pain- Syncope- Syncope- Vaginal Bleeding- Vaginal Bleeding- Pelvic Mass- Pelvic Mass

DIAGNOSISDIAGNOSIS

““Pregnancy in the fallopian tube is a black Pregnancy in the fallopian tube is a black cat on a dark night. It may make its cat on a dark night. It may make its presence felt in subtle ways and leap at presence felt in subtle ways and leap at you or it may slip past unobserved. you or it may slip past unobserved. Although it is difficult to distinguish from Although it is difficult to distinguish from cats of other colours in darkness, cats of other colours in darkness, illumination clearly identifies it.”illumination clearly identifies it.”

-- Mc. Fadyen – 1981.-- Mc. Fadyen – 1981.

DIAGNOSISDIAGNOSIS

In recent years, in spite of an increase in the In recent years, in spite of an increase in the incidence of ectopic pregnancy, there has incidence of ectopic pregnancy, there has been a fall in the case fatality rate.been a fall in the case fatality rate.

This is due to the widespread introduction of This is due to the widespread introduction of diagnostic tests and an increased awareness diagnostic tests and an increased awareness of the serious nature of this disease.of the serious nature of this disease.

This has resulted in early diagnosis and This has resulted in early diagnosis and effective treatment.effective treatment.

Now the rate of tubal rupture is as low as 20 Now the rate of tubal rupture is as low as 20 %.%.

METHODS OF EARLY METHODS OF EARLY DIAGNOSISDIAGNOSIS

Immunoassy utilising monoclonal Immunoassy utilising monoclonal antibodies to antibodies to ββ-HCG.-HCG.

Ultrasound scanning – Abdominal & Ultrasound scanning – Abdominal & Vaginal including Colour DopplerVaginal including Colour Doppler

LaparoscopyLaparoscopy Serum progesterone estimation not helpfulSerum progesterone estimation not helpful

A combination of these methods have to A combination of these methods have to be employed.be employed.


TVS can visualise a gestational sac as TVS can visualise a gestational sac as early as 4 – 5 weeks from LMP.early as 4 – 5 weeks from LMP.

During this time, the lowest serum During this time, the lowest serum ββ HCG HCG is 2000 IU/L.is 2000 IU/L.

When When ββ HCG level is greater than this and HCG level is greater than this and there is an empty uterine cavity on TVS, there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected.ectopic pregnancy can be suspected.

In such a situation, when the value of In such a situation, when the value of ββ HCG does not double in 48 hours ectopic HCG does not double in 48 hours ectopic pregnancy will be confirmed.pregnancy will be confirmed.


Ultrasound features of ectopic pregnancy Ultrasound features of ectopic pregnancy after 5 weeks can be any of the following:after 5 weeks can be any of the following:

1.1. Demonstration of the gestational sac with Demonstration of the gestational sac with or without a live embryo (Begel’s sign) – or without a live embryo (Begel’s sign) – The GS appears as an intact well defined The GS appears as an intact well defined tubal ring by 6 weeks when it measures 5 tubal ring by 6 weeks when it measures 5 mm in diameter. Afterwards it can be mm in diameter. Afterwards it can be seen as a complete sonolucent sac with seen as a complete sonolucent sac with the yolk sac and the embryonic pole with the yolk sac and the embryonic pole with or without heart activity inside.or without heart activity inside.


Ultrasound features of ectopic pregnancy after 5 Ultrasound features of ectopic pregnancy after 5 weeks can be any of the following:weeks can be any of the following:

2.2. Poorly defined tubal ring possibly containing Poorly defined tubal ring possibly containing echogenic structure and POD contaaining fluid echogenic structure and POD contaaining fluid or blood.or blood.

3.3. Ruptured ectopic with fluid in the POD and an Ruptured ectopic with fluid in the POD and an empty uterus.empty uterus.

4.4. In Colour Doppler, the vascular colour in a In Colour Doppler, the vascular colour in a characteritic placental shape, the so-called fire characteritic placental shape, the so-called fire pattern, can be seen outside the uterine cavity pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to while the uterine cavity is cold in respect to blood flowblood flow

MANAGEMENTMANAGEMENT

Depends on the stage of the disease Depends on the stage of the disease and the condition of the patient at and the condition of the patient at diagnosis.diagnosis.

Options:Options:

- Surgery – Laparotomy / Laparoscopy- Surgery – Laparotomy / Laparoscopy

- Medical – Administration of - Medical – Administration of Trophotoxics at the site or systemicallyTrophotoxics at the site or systemically

- Expectant - Observation- Expectant - Observation

MANAGEMENT OF ACUTE MANAGEMENT OF ACUTE ECTOPIC PREGNANCYECTOPIC PREGNANCY

HospitalisationHospitalisation Resuscitation:Resuscitation:

- Treatment of shock- Treatment of shock

- Lie flat with the leg end raised- Lie flat with the leg end raised

- Analgesics- Analgesics

- Blood transfusion- Blood transfusion


Culdocentesis:Culdocentesis: Highly specific if performed and Highly specific if performed and

interpreted correctly: - Presence interpreted correctly: - Presence of Free – Flowing, NON-Clotting of Free – Flowing, NON-Clotting bloodblood

Negative tap inconclusiveNegative tap inconclusive Remains controversial.Remains controversial.


Laparotomy should be done at the Laparotomy should be done at the earliest.earliest.

Salpingectomy is the definitive Salpingectomy is the definitive treatment.treatment.

No benefit from removing Ovary No benefit from removing Ovary along with the tube.along with the tube.

Blood Transfusion: Auto-transfusion.Blood Transfusion: Auto-transfusion.

MANAGEMENT OF CHRONIC MANAGEMENT OF CHRONIC ECTOPIC PREGNANCYECTOPIC PREGNANCY

INVESTIGATIONS:INVESTIGATIONS: Laboratory/Chemical test:Laboratory/Chemical test:

- Serial quantitative - Serial quantitative ββ HCG level by RIA HCG level by RIA- Serum Progesterone level (<5 mg/ml in - Serum Progesterone level (<5 mg/ml in ectopic pregnancy)ectopic pregnancy)- Low levels of Trophoblastic Proteins such - Low levels of Trophoblastic Proteins such as SPI and PAPP- Placental Protein 14 & 12as SPI and PAPP- Placental Protein 14 & 12

USS – Usually haematocele is foundUSS – Usually haematocele is found LaparoscopyLaparoscopy

MANAGEMENT OF CHRONIC MANAGEMENT OF CHRONIC ECTOPIC PREGNANCYECTOPIC PREGNANCY

TREATMENT – ALWAYS SURGICALTREATMENT – ALWAYS SURGICAL Salpingectomy of the offending tubeSalpingectomy of the offending tube If pelvic haematocele is infected, If pelvic haematocele is infected,

posterior colpotomy is to be done to posterior colpotomy is to be done to drain the prelvic abcessdrain the prelvic abcess

Salpingo-oophorectomySalpingo-oophorectomy

MANAGEMENT OF MANAGEMENT OF UNRUPTURED ECTOPIC UNRUPTURED ECTOPIC

PREGNANCYPREGNANCYOPTIONS:OPTIONS: SurgicalSurgical Surgically Administered Medical Surgically Administered Medical

(SAM) treatment(SAM) treatment Medical treatmentMedical treatment Expectant managementExpectant management

SURGICAL TREATMENT OF SURGICAL TREATMENT OF ECTOPIC PREGNANCYECTOPIC PREGNANCY

Carried out either by Laparotomy / Carried out either by Laparotomy / LaparoscopyLaparoscopy

The procedures are:The procedures are:-Salpingectomy / Cornual resection / Excision-Salpingectomy / Cornual resection / Excision- Conservative Surgery (in cases of infertility - Conservative Surgery (in cases of infertility & desire for pregnancy)& desire for pregnancy)

• Linear salpingostomyLinear salpingostomy• Linear salpingotomyLinear salpingotomy• Segmental resection and anastomosisSegmental resection and anastomosis• Milking out the tubeMilking out the tube

SURGICAL TREATMENT OF SURGICAL TREATMENT OF ECTOPIC PREGNANCYECTOPIC PREGNANCY

LAPAROTOMY?LAPAROTOMY?

VSVS

LAPAROSCOPY?LAPAROSCOPY?

SALPINGECTOMY?SALPINGECTOMY?

VSVS

SALPINGOSTOMY / SALPINGOTOMYSALPINGOSTOMY / SALPINGOTOMY

COMPARING LAPAROTOMY Vs COMPARING LAPAROTOMY Vs LAPRAOSCOPYLAPRAOSCOPY

L’tomyL’tomy L’scopyL’scopy

Hospital costHospital cost More?More? Less?Less?

Post operative adhesionsPost operative adhesions MoreMoreLessLess

Risk of futuer ectopicRisk of futuer ectopic SameSame SameSame

Future fertilityFuture fertility Same Same SameSame

Experience of SurgeonExperience of Surgeon TrainedTrained SpecialSpecial

InstrumentsInstruments GeneralGeneral Special Special

SALPINGECTOMY Vs SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTOSALPINGOSTOMY/SALPINGOTO

MYMY All tubal pregnancies can be treated by All tubal pregnancies can be treated by

partial or total Salpingectomypartial or total Salpingectomy Salpingostomy / Salpingostomy is only Salpingostomy / Salpingostomy is only

indicated when:indicated when:1.1. The patient desires to conserve her fertilityThe patient desires to conserve her fertility

2.2. Patient is haemodynamically stablePatient is haemodynamically stable

3.3. Tubal pregnancy is accessiblyTubal pregnancy is accessibly

4.4. Unruputed and < 5 cm in sizeUnruputed and < 5 cm in size

5.5. Contra lateral tube is absent or damagedContra lateral tube is absent or damaged


MYMY The choice of surgical treatment does not The choice of surgical treatment does not

influence the post treatment fertily, but influence the post treatment fertily, but prior history of infertility is associated with a prior history of infertility is associated with a marked reduction in fertility after treatmentmarked reduction in fertility after treatment

Making the choice: Chapron et al (1993) Making the choice: Chapron et al (1993) have described a scoring system, based on have described a scoring system, based on the patient's previous gynaecological the patient's previous gynaecological history and the appearance of the pelvic history and the appearance of the pelvic organs, to deicde between salpingostomy / organs, to deicde between salpingostomy / salpingotomy and salpingectomy.salpingotomy and salpingectomy.


MYMYFertility reducing factorFertility reducing factor

ScoreScore• Antecedent one Ectopic pregnancyAntecedent one Ectopic pregnancy 22• Antecedent each further Ectopic pregnancyAntecedent each further Ectopic pregnancy 11• Antecedent adhesiolysisAntecedent adhesiolysis 11• Antecedent Tubal micro surgeryAntecedent Tubal micro surgery 22• Solitary tubeSolitary tube 22• Antecedent SalpingitisAntecedent Salpingitis 11• Homolateral AdhesionsHomolateral Adhesions 11• Contralateral AdhesionsContralateral Adhesions 11


MYMY The rationale behind the scoring The rationale behind the scoring

system is to decide the risk of system is to decide the risk of recurrent ectopic pregnancy.recurrent ectopic pregnancy.

Conservative surgery is indicated Conservative surgery is indicated with a score of less than 5, while with a score of less than 5, while radical treatment is to be performed radical treatment is to be performed if the score is 5 or more.if the score is 5 or more.

LAPAROSCOPIC LAPAROSCOPIC SALPINGECTOMYSALPINGECTOMY

It is carried out by laparoscopic It is carried out by laparoscopic scissors and diathermy or Endo-loop.scissors and diathermy or Endo-loop.

After passing a loop of No. 1 catgut After passing a loop of No. 1 catgut over the ectopic pregnancy, the over the ectopic pregnancy, the stitch is tightened and then the tubal stitch is tightened and then the tubal pregnancy is cut distal to the loop pregnancy is cut distal to the loop stitch.stitch.

The excised tissue is removed piece The excised tissue is removed piece meal or in a tissue removal bag.meal or in a tissue removal bag.

LAPAROSCOPIC LAPAROSCOPIC SALPINGOTOMYSALPINGOTOMY

To reduce blood loss, first 10 – 40 IU of To reduce blood loss, first 10 – 40 IU of Vasopressin diluted in 10 ml of normal saline is Vasopressin diluted in 10 ml of normal saline is injected into the mesosalpinx.injected into the mesosalpinx.

Then the tube is opened through an Then the tube is opened through an anitmesenteric longitudinal incision over the anitmesenteric longitudinal incision over the tubal pregnancy by a tubal pregnancy by a

- Co- Co22 laser (Paulson, 1992) laser (Paulson, 1992)- Argon laser (Keckstein et al; 1992)- Argon laser (Keckstein et al; 1992)- Laparoscopic scissors snd ablating the - Laparoscopic scissors snd ablating the bleeding points with bipolar diathermy.bleeding points with bipolar diathermy.- Fine diathermy knife (Lundorff, 1992)- Fine diathermy knife (Lundorff, 1992)

LAPAROSCOPIC LAPAROSCOPIC SALPINGOTOMYSALPINGOTOMY

The tubal pregnancy is then The tubal pregnancy is then evacuated by suction irrigation.evacuated by suction irrigation.

Hemostasis of the trophoblastic Hemostasis of the trophoblastic bed is ensured.bed is ensured.

The tubal incision is left open.The tubal incision is left open.

PERSISTENT ECTOPIC PERSISTENT ECTOPIC PREGNANCY (PEP)PREGNANCY (PEP)

This is a complication of salpingotomy / This is a complication of salpingotomy / salpingostomy when residual salpingostomy when residual trophoblastic continues to survive trophoblastic continues to survive because of incomplete evacuation of the because of incomplete evacuation of the ectopic pregnancy.ectopic pregnancy.

Diagnosis is made because of a raised Diagnosis is made because of a raised postoperative serum postoperative serum ββ HCG HCG

If untreated, can cause life threatening If untreated, can cause life threatening hemorrhagehemorrhage

PERSISTENT ECTOPIC PERSISTENT ECTOPIC PREGNANCY (PEP)PREGNANCY (PEP)

TREATMENT is by:TREATMENT is by:

- Reoperation and futher - Reoperation and futher evacuation / Salpingectomyevacuation / Salpingectomy

- Administration of IM / oral - Administration of IM / oral Methotrexate in a single dose of 50 Methotrexate in a single dose of 50 mg/mmg/m22 of body surface of body surface

SAM TREATMENTSAM TREATMENT

Aim:Aim: Trophoblastic destruction but avoiding the Trophoblastic destruction but avoiding the systemic side effectssystemic side effects

Technique:Technique: Injection of trophotoxic substance into the Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by-ectopic pregnancy sac or into the affected tube by-- laparoscopy or - laparoscopy or - Ultrasonographically guided- Ultrasonographically guided

• Transabdominal (Porreco, 1992)Transabdominal (Porreco, 1992)• Transvaginal (Feichtinger et al, 1989)Transvaginal (Feichtinger et al, 1989)

- With Falloposcopic control (Kiss et al, 1993)- With Falloposcopic control (Kiss et al, 1993)- Hysteroscopic control (Goldenberg et al, 1992)- Hysteroscopic control (Goldenberg et al, 1992)- Hysterosalpingographic control (Risquez et al, 1990)- Hysterosalpingographic control (Risquez et al, 1990)

SAM TREATMENTSAM TREATMENT

Trophotoxic substances used:Trophotoxic substances used:

- Methotrexate (Pansky et al, 1989)- Methotrexate (Pansky et al, 1989)

- Potassium Chloride (Robertson et al, 1987)- Potassium Chloride (Robertson et al, 1987)

- Mifepristone (RU 486)- Mifepristone (RU 486)

- PGF2- PGF2 (Lindblom et al, 1987) (Lindblom et al, 1987)

- Hyper osmolar glucose solution (Lang et al, - Hyper osmolar glucose solution (Lang et al, 1992)1992)

- Actinomycin D- Actinomycin D

MEDICAL TREATMENT WITH MEDICAL TREATMENT WITH METHOTREXATEMETHOTREXATE

Resolution of tubal preganancy by Resolution of tubal preganancy by systemic administration of Methotrexate systemic administration of Methotrexate was first described by Tanaka et al (1982)was first described by Tanaka et al (1982)

Mostly used for early resolution of Mostly used for early resolution of placental tissure in abdominal pregnancy. placental tissure in abdominal pregnancy. Can be used for tubal pregnancy as wellCan be used for tubal pregnancy as well

Mechanism of action- Interferes with the Mechanism of action- Interferes with the DNA synthesis by inhibiting the synthesus DNA synthesis by inhibiting the synthesus to pyrimidines leading to trophoblasic cell to pyrimidines leading to trophoblasic cell death. Auto enzymes and maternal death. Auto enzymes and maternal tissues then absorb the trophoblast.tissues then absorb the trophoblast.


Ectopic pregnancy size should be <3.5 cm.Ectopic pregnancy size should be <3.5 cm. Can be given IV/IM/Oral, usually along with Can be given IV/IM/Oral, usually along with

Folinic acidFolinic acid Recent concept is to give Methotrexate IM Recent concept is to give Methotrexate IM

in a single dose of 50mg/min a single dose of 50mg/m22 without Folinic without Folinic acid. If serum HCG does not fall to 15% acid. If serum HCG does not fall to 15% within 4 – 7 days, then a second dose of within 4 – 7 days, then a second dose of Methotrexate is given and resolution is Methotrexate is given and resolution is confirmed by HCG estimationconfirmed by HCG estimation


Advantages:Advantages:- Minimal hospitalisation. Usually outpatient - Minimal hospitalisation. Usually outpatient treatment: Reduces cost.treatment: Reduces cost.- Quick recovery- Quick recovery- 90% success if cases are properly selected- 90% success if cases are properly selected

Disadvantages:Disadvantages:- Side effects like GI & Skin- Side effects like GI & Skin- monitoring is essential- Total blood count, - monitoring is essential- Total blood count, LFT & serum HCG once weekly till it LFT & serum HCG once weekly till it becomes negativebecomes negative

EXPECTANT TREATMENTEXPECTANT TREATMENT

Tubal Pregnancies are known to Abort / Tubal Pregnancies are known to Abort / ResolveResolve

Before the advent of salpingectomy in 1884, Before the advent of salpingectomy in 1884, ectopic pregnancies were being treated ectopic pregnancies were being treated expectanly with 70% mortality. (Parry, 1876) expectanly with 70% mortality. (Parry, 1876) Diagnosis made at PM!Diagnosis made at PM!

Today only selected cases are managed Today only selected cases are managed expectantly: screened and identified by high expectantly: screened and identified by high relolution ultrasound scanner and monitored relolution ultrasound scanner and monitored by serial serum by serial serum ββ HCG assay HCG assay


Identification criteria (Ylostalo et al, 1993):Identification criteria (Ylostalo et al, 1993):

- Falling level of serum - Falling level of serum ββ HCG at 2 day HCG at 2 day intervals - No sign of intrauterine pregnancy intervals - No sign of intrauterine pregnancy

- Diameter of ectopic pregnancy <4 cm- Diameter of ectopic pregnancy <4 cm

- No sign of rupture or of acute bleeding by - No sign of rupture or of acute bleeding by TVSTVS

If any deviation from the above criteria If any deviation from the above criteria occurs, then emergency treatment is occurs, then emergency treatment is necessary.necessary.


Spontaneous resolution occurs in 72%, while Spontaneous resolution occurs in 72%, while 28% will need laparoscopic salpingostomy28% will need laparoscopic salpingostomy

In spontaneous resolution, it may take 4 – In spontaneous resolution, it may take 4 – 67 days (mean 20 days) for the serum HCG 67 days (mean 20 days) for the serum HCG to return to non pregnant level.to return to non pregnant level.

The percentage fall in serum HCG by day 7 The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall is a better indicator than the percentage fall by day 2.by day 2.

Warning:- Tubal pregnancies have been Warning:- Tubal pregnancies have been known to rupture when when serum HCG known to rupture when when serum HCG levels are low.levels are low.

SUMMARY – KEY POINTSSUMMARY – KEY POINTS

Incidence of ectopic pregnancy is rising while Incidence of ectopic pregnancy is rising while maternal mortality from it is falling.maternal mortality from it is falling.

Early diagnosis is the key to less invasive Early diagnosis is the key to less invasive treatment.treatment.

The choice today is Laparoscopic treatment of The choice today is Laparoscopic treatment of unruptured ectopic pregnancy.unruptured ectopic pregnancy.

The trend is towards conservative treatment.The trend is towards conservative treatment. Careful monitoring and proper councelling of Careful monitoring and proper councelling of

patients is mandatory.patients is mandatory. Ruptured ectopics should be unususal with Ruptured ectopics should be unususal with

compliant patients and appropriate medical care.compliant patients and appropriate medical care.

Advances in the Diagnosis and Management of Ectopc

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