Ectopic Pregnancy3
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Prof. M.C.BansalProf. M.C.Bansal
MBBS,MS,MICOG,FICOGMBBS,MS,MICOG,FICOG
Professor OBGYProfessor OBGYEx-Principal & ControllerEx-Principal & Controller
Jhalaar Me!ical Colle"e & #ospitalJhalaar Me!ical Colle"e & #ospital
Mahat$a Gan!hi Me!ical Colle"e, Jaip%r.Mahat$a Gan!hi Me!ical Colle"e, Jaip%r.
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DEFINITIONDEFINITION
'n( pre"nanc( here the fertilise! o)%$'n( pre"nanc( here the fertilise! o)%$
"ets i$plante! & !e)elops in a site other"ets i$plante! & !e)elops in a site other
than nor$al %terine ca)it(*.than nor$al %terine ca)it(*.
It represents a serio%s ha+ar! to a o$ansIt represents a serio%s ha+ar! to a o$ans
health an! repro!%cti)e potential, re%irin"health an! repro!%cti)e potential, re%irin"pro$pt reco"nition an! earl( a""ressi)epro$pt reco"nition an! earl( a""ressi)e
inter)entioninter)ention..
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Is one in which fertilized ovum is implanted &develops outside normal uterine cavity
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IMPLANTATIONS SITSIMPLANTATIONS SITS
E/0'1/E0I2E 1/E0I2E
/1B'3 45-467
-'$p%lla 897-Isth$%s :;7
-Inf%n!i:?@9,999A
'BOMI2'3>:?:9,999A
-CE0=IC'3>:?:,999A-'2G13'0-CO021'3-C'ES'0E'2
SC'0 >D:A
P0IM'0Y SECO2'0Y
Intraperitoneal ExtraperitonealBroa! 3i"a$ent >rareA
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IN!I"N!IN!I"N!
• Increase! !%e to PI, %se of I1C, /%'0/A.
• 0an"es fro$ :?;5 to :?;590an"es fro$ :?;5 to :?;59
• ')era"e ran"e is : in :99 nor$al')era"e ran"e is : in :99 nor$al
pre"nancies.pre"nancies.
• 3ate $arria"es an! late chil!
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ETIOLOGYETIOLOGY::
'n( factor that ca%ses !ela(e! transport'n( factor that ca%ses !ela(e! transport
of the fertilise! o)%$ thro%"h the t%
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ETIOLOGYETIOLOGY
CO2GE2I/'3CO2GE2I/'3
/%
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'C1I0E'C1I0E --
Pelvic Inflammatory disease (6-10 times)Pelvic Inflammator y disease (6-10 times)
Chla$(!ia tracho$atis is $ost co$$onChla$(!ia tracho$atis is $ost co$$on
Contraceptive FaliureContrace ptive Faliure
C%/ - @7C%/ - @7 Pro"estasart -:87Pro"estasart -:87
Minipills -@-:97Minipills -@-:97
2orplant -H972orplant -H97
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Tubal sterilization faliure -0!Tubal sterilization faliure -0! epen!s on sterili+ation techni%e an! a"e ofepen!s on sterili+ation techni%e an! a"e of
the patientthe patient
Bipolar Ca%terisation -657Bipolar Ca%terisation -657
1nipolar Ca%ter( -:871nipolar Ca%ter( -:87
Silicon r%
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Tubal reconstructive sur#ery Tubal reconstructive sur #ery $%# times'$%# times'
$ssisted "eproductive tec%ni&ue $ssisted "eproductive tec%ni&ue
## O)%lation in!%ction, I=F-E/ an! GIF/ >@-87AO)%lation in!%ction, I=F-E/ an! GIF/ >@-87A
- 0is of heterotopic pre"nanc(>:7A- 0is of heterotopic pre"nanc(>:7A
Previous 'ctopic Pre#nancy Previous 'ct opic Pre#nancy
## 8-:57 chances of repeat ectopic pre"nanc(8-:57 chances of repeat ectopic pre"nanc(
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t%er "is factorst%er "is factors
'"e H5-@5 (rs'"e H5-@5 (rs
Pre)io%s in!%ce! a
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Iffy hypothesisIff y hypothesis
/heor( of refl%x* $enst%ral fl%i! thro the/heor( of refl%x* $enst%ral fl%i! thro thefertilise! o)%$ into the t%
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volutionvolution
/%
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/he pre"nanc( is %na
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In rare instances, a t%parietal peritone%$A, an! "i)es rise to aparietal peritone%$A, an! "i)es rise to a
)ia
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Pictures showing TUBAL
ABORTION
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!LINI!AL APP+OA!,!LINI!AL APP+OA!,
i"nosis can
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A!-T !TOPI! P+.NAN!/A!-T !TOPI! P+.NAN!/
Classical tria!Classical tria! is present in 597 of pt ithis present in 597 of pt ithr%pt%re ectopic.r%pt%re ectopic.
-- P'I2?-P'I2?- $ost constant feat%re in 457 pt$ost constant feat%re in 457 pt
- )aria
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O0O01#1# patient is restless in a"on(, loos
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!,+ONI! !TOPI! P+.NAN!/!,+ONI! !TOPI! P+.NAN!/
It can
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O01#O01# patient loo ill, )ar(in" !e"ree of pallor,patient loo ill, )ar(in" !e"ree of pallor,
sli"htl( raise! te$perat%re. Feat%res of shocsli"htl( raise! te$perat%re. Feat%res of shoc
are a
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-N+-PT-+" !TOPI!-N+-PT-+" !TOPI!
#i"h !e"ree of s%spicion & ectopic conscio%s#i"h !e"ree of s%spicion & ectopic conscio%s
clinician can !ia"nose.clinician can !ia"nose.
ia"nose! acci!entall( in 3aparoscop( oria"nose! acci!entall( in 3aparoscop( or3aparoto$(3aparoto$(
!0(!0( !ela(e! perio!, spottin" ith !isco$fort in !ela(e! perio!, spottin" ith !isco$fort in
loer a
P0AP0A ten!erness in loer a
P02P02 sho%l!
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DIAGNOSISDIAGNOSIS
**Pre#nancy in t%e fallopian tube is a blacPre#nancy in t%e fallopian tube is a blac
cat on a dar ni#%t+ It may mae itscat on a dar ni#%t+ It may mae its
presence felt in subtle ,ays and leap at you presence felt in subtle ,ays and leap at you
or it may slip past unobserved+ $lt%ou#% it isor it may slip past unobserved+ $lt%ou#% it isdifficult to distin#uis% from cats of ot%erdifficult to distin#uis% from cats of ot%er
colours in darness illumination clearlycolours in darness illumination clearly
identifies it+.identifies it+.
--/c+ Fadyen - 11--/c+ Fadyen - 11
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DIAGNOSISDIAGNOSIS
In recent (ears, inspite of an increase in theIn recent (ears, inspite of an increase in the
inci!ence of ectopic pre"nanc( there has
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I'G2OSISI'G2OSIS
Patient ith ac%te ectopic can
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;.;. C%l!ocentesisC%l!ocentesis?- >89-497A?- >89-497A
- Can
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'ndometrial cavity'ndometrial cavi ty
-$ trilaminar endometial pattern seen-$ trilaminar endometial pattern seen
-pseudo#estational sac-pseudo#estational sac
-decidual cyst may be seen-decidual cyst may be seen P2'342$C 5P2'342$C 5 'll pre"nancies in!%ce an en!o$etrial'll pre"nancies in!%ce an en!o$etrial
!eci!%al reaction, an! slo%"hin" of the !eci!%a can!eci!%al reaction, an! slo%"hin" of the !eci!%a can
create an intraca)itar( fl%i! collection calle! acreate an intraca)itar( fl%i! collection calle! a pseudosac pseudosac
'arly #estational sac 'arl y #estational sac Pseudosac Pseudosac locationlocation belo, t%e midline ec%o alon# t%ebelo, t%e midline ec%o alon# t%e
burried into endometium cavity line b, burried into endometium cavity line b,
endometrial layersendometrial layers
s%apes%ape usually round may c%an#eoviod usually round may c%an#eoviod
bordersborders double rin# sin#le layer double rin# sin#le layer
color flo,color flo, %i#% avascular %i#% avascular
pattern pattern perip%eral flo, perip%eral flo,
4'CI43$7 C82T4'CI43$7 C82T
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4'CI43$7 C82T 4'CI43$7 C82T
It is i!entifie! as an anechoic area l(in" ith in theIt is i!entifie! as an anechoic area l(in" ith in theen!o$etri%$
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-S. PI!T-+-S. PI!T-+
:.Ba"el si"n #(perechoic rin" aro%n! "estational:.Ba"el si"n #(perechoic rin" aro%n! "estational
sac in a!nexal re"ionsac in a!nexal re"ion
;. Blo
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#(perechoic rin" aro%n!#(perechoic rin" aro%n!"estational sac in a!nexal re"ion"estational sac in a!nexal re"ion
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Ring sign — a hyperechoic ringRing sign — a hyperechoic ring around an
extrauterine gestational sac.
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5454 66#,!. Assay##,!. Assay#
aA Sin"leaA Sin"le NN-#CG? little )al%e-#CG? little )al%e
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7474 Serum Pro)esteroneSerum Pro)esterone 88
- le)el ;5 n"$L$l is s%""esti)e of nor$al- le)el ;5 n"$L$l is s%""esti)e of nor$al
intra%terine pre"nanc(.intra%terine pre"nanc(.
- le)el D:5 n"$L$l is s%""esti)e of ectopic- le)el D:5 n"$L$l is s%""esti)e of ectopic
pre"nanc(.pre"nanc(.
- le)el D5 n"$L$l in!icates non)ia
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4 "ilatation & !uretta)e 84 "ilatation & !uretta)e 8
- Is reco$$en!e! in s%specte! case of- Is reco$$en!e! in s%specte! case of
inco$plete aPP:@A !ecrease in EP
- P'PP' >Pre"nanc( 'ssociate! Plas$a Protein 'A,- P'PP' >Pre"nanc( 'ssociate! Plas$a Protein 'A,
P'PPC >schan"erchaft protein :A has lo )al%eP'PPC >schan"erchaft protein :A has lo )al%ein EPin EP
- C'-:;5, Maternal ser%$ creatine inase,- C'-:;5, Maternal ser%$ creatine inase,Maternal ser%$ 'FP ele)ate! in ectopicMaternal ser%$ 'FP ele)ate! in ectopic
pre"nanc(.pre"nanc(.
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S-SP!T" !TOPI! P+.NAN!/S-SP!T" !TOPI! P+.NAN!/
1rine Pre"nanc( test positi)e1rine Pre"nanc( test positi)e
/rans)a"inal 1SG
I1 sac 2o I1 sac%antitati)e S-hCG
S pro"esterone
D 667 rise in @ hr orS pro"esterone D 5-:9 n"L$l
& C
=illi present =illi a
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"I((+NTIAL "IA.NOSIS"I((+NTIAL "IA.NOSIS
"0" of Acute ctopic"0" of Acute ctopic
:. 0%pt%re corp%s l%te%$ of pre"nanc(:. 0%pt%re corp%s l%te%$ of pre"nanc(
;. 0%pt%re of chocolate c(st;. 0%pt%re of chocolate c(st
H. /iste! o)arian c(stH. /iste! o)arian c(st
@. /orsion L !e"eneration of pe!%nc%late! fi
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"0" O( !,+ONI! $S-: A!-T' !TOPI!"0" O( !,+ONI! $S-: A!-T' !TOPI!
:. Pel)ic a
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MANA.MNTMANA.MNT
Expectant$ana"e$ent Me!ical$ana"e$ent S%r"ical$ana"e$ent
3ocal S(ste$ic>1SG or 3aparoscopicA
salpin"ocentesis
- Methotrexate- Potassi%$ chlori!e- Prosta"la!in>PGF;QA
- #(pers$olar "l%cose- 'ctino$(cin - Mifepristone
Methotrexate
0a!ical
Salpin"ecto$(
Conser)ati)e
-Salpin"osto$(
-Salpin"oto$(
- Se"$entalresection
-Milin" or fi$
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MANAGEMENT OF RUPTURED ECTOPICMANAGEMENT OF RUPTURED ECTOPIC
P0I2CIP3E?P0I2CIP3E? +esuscitation and Laparotomy+esuscitation and Laparotomy
ANTI S,O!; T+ATMNT1ANTI S,O!; T+ATMNT1
- I= line $a!e patent, cr(stalloi! is starte!- I= line $a!e patent, cr(stalloi! is starte!
- Bloo! sa$ple for #sent for #P st%!(A- Salpin"ecto$( is the !efiniti)e s%r"er( >sent for #P st%!(A
- Bloo! transf%sion to
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MANAGEMENT OF UNRUPTUREDMANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCYECTOPIC PREGNANCY
OP/IO2S? -OP/IO2S? -
S10GIC'3-S10GIC'3-
S10GIC'33Y 'MI2IS/E0ES10GIC'33Y 'MI2IS/E0E
MEIC'3 >S'MA /0E'/ME2/MEIC'3 >S'MA /0E'/ME2/
MEIC'3 /0E'/ME2/MEIC'3 /0E'/ME2/
EPEC/'2/ M'2'GEME2/EPEC/'2/ M'2'GEME2/
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7'#$/lostalo et al = 3>>7'# 11
:. /%
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EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
Spontaneo%s resol%tion occ%rs in 8;7,hile ;7 illSpontaneo%s resol%tion occ%rs in 8;7,hile ;7 illnee! laparoscopic salpin"osto$(nee! laparoscopic salpin"osto$(
In spontaneo%s resol%tion, it $a( tae @-68 !a(sIn spontaneo%s resol%tion, it $a( tae @-68 !a(s
>$ean ;9 !a(sA for the ser%$ #CG to ret%rn to non>$ean ;9 !a(sA for the ser%$ #CG to ret%rn to nonpre"nant le)el.pre"nant le)el.
/he percenta"e fall in ser%$ #CG
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M"I!AL MANA.MNTM"I!AL MANA.MNT
S%r"er( is the $ainsta( of /Lt orl!i!eS%r"er( is the $ainsta( of /Lt orl!i!e
Me!ical ML$ $a( M/A 1nr%pt%re! sac D H.5c$ itho%t car!iac acti)it(1nr%pt%re! sac D H.5c$ itho%t car!iac acti)it(
S-hCG D :9,999 I1L3S-hCG D :9,999 I1L3 Persistant Ectopic after conser)ati)e s%r"er(Persistant Ectopic after conser)ati)e s%r"er(
P#YSICI'2 C#ECR 3IS/P#YSICI'2 C#ECR 3IS/ CBC, 3F/, 0F/, S-hCGCBC, 3F/, 0F/, S-hCG /rans)a"inal 1SG ithin @ hrs/rans)a"inal 1SG ithin @ hrs O
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MEDICAL MANAGEMENTMEDICAL MANAGEMENT
ME/#O/0E'/E?ME/#O/0E'/E? It can
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!ontd??!ontd??
'!)anta"es '!)anta"es
Mini$al #ospitalisation.1s%all( o%t!oorMini$al #ospitalisation.1s%all( o%t!oor
treat$enttreat$ent
%ic reco)er(%ic reco)er(
497 s%ccess if cases are properl( selecte!497 s%ccess if cases are properl( selecte!
isa!)anta"es-isa!)anta"es-
Si!e effects lie GI & SinSi!e effects lie GI & Sin
Monitorin" is essential- /otal
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SURGICALLY ADMINISTERED MEDICAL TtSURGICALLY ADMINISTERED MEDICAL Tt
(SAM)(SAM)
Aim Aim- trophoRiss, :44HA
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Trophotoxic substances used-Methtrexate >Pans(, :44A
Potassi%$ Chlori!e >0o01 @6APGF;α >3i$
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INST+-!TION TO T, PATINTSINST+-!TION TO T, PATINTS
If /Lt on o%tpatient
Chance of t%
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S-+.I!AL MANA.MNT O( !TOPI!S-+.I!AL MANA.MNT O( !TOPI!
!onservative Sur)ery!onservative Sur)ery
Can
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2A+IO-S !ONS+2ATI2 S-+.+IS2A+IO-S !ONS+2ATI2 S-+.+IS
34Linear Salpin)ostomy34Linear Salpin)ostomy??
- In!icate! in %nr%pt%re! ectopic D;c$ in a$p%llar( re"ion.- In!icate! in %nr%pt%re! ectopic D;c$ in a$p%llar( re"ion.
- 3inear incision "i)en on anti$esentric
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%4 Milin) or fim*rial Bpression1%4 Milin) or fim*rial Bpression1
-- /his is i!eal in !istal a$p%llar( or inf%n!i
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":ATA:L ISS-S":ATA:L ISS-S
CC Salpin"ecto$( =s Salpin"osto$(Salpin"ecto$( =s Salpin"osto$(
CC 3aparoto$( =s 3aparoscop(3aparoto$( =s 3aparoscop(
CC 0epro!%cti)e o%tco$e 0epro!%cti)e o%tco$e
CC 0is of 0ec%rrent Ectopic 0is of 0ec%rrent Ectopic
SALPIN.!TOM/SALPIN.!TOM/
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2S2S
SALPIN.OSTOM/ 0 SALPIN.OTOM/SALPIN.OSTOM/ 0 SALPIN.OTOM/
'll t%
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CONTD……CONTD……
/he choice of s%r"ical treat$ent !oes not infl%ence the/he choice of s%r"ical treat$ent !oes not infl%ence the
post treat$ent fertilit(, :44HA ha)e
!escri
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(ertility reducin) factor(ertility reducin) factor ScoreScore 'ntece!ent one Ectopic pre"nanc('ntece!ent one Ectopic pre"nanc( ; ; 'ntece!ent each f%rther'ntece!ent each f%rther
Ectopic pre"nanc(Ectopic pre"nanc( : : 'ntece!ent '!hesiol(sis'ntece!ent '!hesiol(sis : : 'ntece!ent /%
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Laparotomy 2s LaparoscopyLaparotomy 2s Laparoscopy
- 3aparoscop( is reser)e! for pt ho are- 3aparoscop( is reser)e! for pt ho are
he$o!(na$icall( sta
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LAPAROSCOPIC SALPINGECTOMYLAPAROSCOPIC SALPINGECTOMY It is carrie! o%t Recstein et al :44;A'r"on laser >Recstein et al :44;A– 3aparoscopic scissors an! a
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P+SISTNT !TOPI! P+.NANA!/P+SISTNT !TOPI! P+.NANA!/ /his is a co$plication of salpin"oto$( L salpin"osto$(/his is a co$plication of salpin"oto$( L salpin"osto$(
hen resi!%al trophoD 6 s a$enorrhoeaA
;. S$aller si+e D ; c$ >Inco$plete re$o)alA;. S$aller si+e D ; c$ >Inco$plete re$o)alA
H. Preoperati)e hi"h ser%$H. Preoperati)e hi"h ser%$ NN #CG > H,999 I1L3A an!#CG > H,999 I1L3A an!
postoperati)e a(: titre is D 597 of preoperati)e le)el, ispostoperati)e a(: titre is D 597 of preoperati)e le)el, is
pre!ictor of persistent EP.pre!ictor of persistent EP.
@. I$plantation $e!ial to the salpin"osto$( site.@. I$plantation $e!ial to the salpin"osto$( site.
TreatmentTreatment
s%r"er(
/otal or partial
salpin"ecto$(
Me!ical>selecte! 's($pto$atic ptA
M/ 3e%o)orin
O2A+IAN !TOPI! P+.NAN!/O2A+IAN !TOPI! P+.NAN!/
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Incidence1Incidence1 :?@9,999:?@9,999
+is factor1 #+is factor1 # I1CI1C
- En!o$etriosis on s%rface of o)ar(- En!o$etriosis on s%rface of o)ar(
!ourse1!ourse1
CLF are sa$e as t%
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A:"OMINAL P+.NAN!/A:"OMINAL P+.NAN!/Incidence1Incidence1 0arest0arest
MM+ 1MM+ 1 8- ti$es t%O0 1O0 1 - '
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"ia)nosis1"ia)nosis1 Confir$e!
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(AT O( S!ON"A+/ A:"OMINAL P+.NAN!/ 1(AT O( S!ON"A+/ A:"OMINAL P+.NAN!/ 1
:.:. eath of o)%$ co$plete a$alfor$ationA
M0M1M0M1
## 1r"ent 3aparato$( irrespecti)e of perio! of "estation1r"ent 3aparato$( irrespecti)e of perio! of "estation
- I!eal to re$o)e entire sac fet%s, placenta, $e$
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!+2I!AL P+.NAN!/!+2I!AL P+.NAN!/
I$plantation occ%rs in cer)ical canal at or
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"ia)nosis1"ia)nosis1
C3I2IC'3 C0I/E0I'C3I2IC'3 C0I/E0I'?? Paulman @ /c'llinPaulman @ /c'llin
:. 1terine
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,ISTOPAT,OLO.I! !+IT+IA1 "ubin s
:. Cer)ical "lan!s present opposite to placenta:. Cer)ical "lan!s present opposite to placenta
;. Placental attach$ent to the cer)ix $%st
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MANA.MNTMANA.MNT
S%r"icalMainsta( therap( in past
0a!icals%r"er(
#(sterecto$(
Conser)ati)e
& C>ris of torrential
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SIT1SIT1 I$plantation occ%rs in r%!i$entar( horn of Bicorn%ateI$plantation occ%rs in r%!i$entar( horn of Bicorn%ate
%ter%s%ter%s
!O-+S 1!O-+S 10%pt%re of horn occ%rs
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,T+OT/PI! P+.NAN!/
Co-existin" intra%terine an! extra %terine pre"nanciesCo-existin" intra%terine an! extra %terine pre"nancies
Incidence1Incidence1 : ? H9,999: ? H9,999 ith '0/ :?8999ith '0/ :?8999
ith o)%lation in!%ction :?499ith o)%lation in!%ction :?499
More liely1More liely1
aA 'ss. repro!%cti)e techni%eaA 'ss. repro!%cti)e techni%e
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INT+STITAL P+.NAN!/ $5F'INT+STITAL P+.NAN!/ $5F'
It r%pt%res late at H-@ $onths "estation.It r%pt%res late at H-@ $onths "estation.
(atal rupture(atal rupture se)ere
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!ASA+AN S!A+ !TOPI! P+.NAN!/!ASA+AN S!A+ !TOPI! P+.NAN!/
0ecentl( reporte!0ecentl( reporte! 1SG slos on e$pt( %terine ca)it( an! "estational1SG slos on e$pt( %terine ca)it( an! "estational
sac attache! lo to the loer se"$ent caesareansac attache! lo to the loer se"$ent caesareanscar.scar.
!0(!0( 11 si$ilar to threatene! or ine)ita
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O S
:. M%ltiple Ectopic pre"nanc(:. M%ltiple Ectopic pre"nanc(
;. Pre"nanc( after h(sterecto$(;. Pre"nanc( after h(sterecto$(
H. Pri$ar( splenic pre"nanc(H. Pri$ar( splenic pre"nanc(
@. Pri$ar( hepatic pre"nanc(@. Pri$ar( hepatic pre"nanc(
5. 0ectroperitoneal pre"nanc(5. 0ectroperitoneal pre"nanc( 6. iaphra"$atic pre"nanc(6. iaphra"$atic pre"nanc(
MO0/'3I/Y ? In "eneral pop%lation is :9-:57 $ainl(MO0/'3I/Y ? In "eneral pop%lation is :9-:57 $ainl(
!%e to hae$orrha"e.!%e to hae$orrha"e.
SUMMARY - KEY POITS SUMMARY - KEY POITS
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Inci!ence of ectopic pre"nanc( is risin" hile $aternalInci!ence of ectopic pre"nanc( is risin" hile $aternal$ortalit( fro$ it is fallin".$ortalit( fro$ it is fallin".
Ectopic pre"nanc( can
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