2. Dr.P.L.Kanani Pearl Woman’s Hospital
ECTOPIC PREGNANCY
Dr.P.L.Kanani
Pearl Woman’s Hospital

3. DEFINITION
“Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity”.
It represents a serious hazard to a woman’s health and reproductive potential, requiring prompt recognition and early aggressive intervention.

4. Is one in which fertilized ovum is implanted &
develops outside normal uterine cavity

5. IMPLANTATIONS SITES EXTRAUTERINE UTERINE -CERVICAL (1:18,000) -ANGULAR
-CORNUAL
-CAESAREAN
SCAR (<1)
TUBAL 95-96%
-Ampulla 70%
-Isthmus 12%
-Infundibulum 11%
-Interstitial &
cornual 2%
OVARIAN
(1:40,000)
ABDOMINAL
(1:10,000)
PRIMARY
SECONDARY
Intraperitoneal
Extraperitoneal
Broad Ligament
(rare)

7. INCIDENCE
Increased due to PID, use of IUCD, Tubal surgeries, and Assisted reproductive techniques (ART).
Ranges from 1:25 to 1:250
Average range is 1 in 100 normal pregnancies.
Late marriages and late child bearing -> 2%
ART -> 5%
Recurrence rate - 15% after 1st, 25% after 2 ectopics

8. ETIOLOGY:
Any factor that causes delayed transport of the fertilised ovum through the tube.
Fallopian tube favours implantation in the tubal mucosa itself thus giving rise to a tubal ectopic pregnancy.
These factors may be Congenital or Acquired.

9. ETIOLOGY CONGENITAL Tubal Hypoplasia Tortuosity Congenital diverticuli
Accessory ostia
Partial stenosis
Elongation

10. Pelvic Inflammatory disease (6-10 times)
ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
Contraceptive Faliure
CuT - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%

11. Tubal sterilization faliure -40%
Depends on sterilization technique and age of the patient
Bipolar Cauterisation -65%
Unipolar Cautery -17%
Silicon rubber band -29%
Interval Salpingectomy -43%
Postpartum Salpingectomy -20%
Reversal of sterilisation
- Depends on method of sterilization, Site of
tubal occlusion, residual tubal length.
- Reanastomosis of cauterised tube -15%
- Reversal of Pomeroy’s - < 3%

12. Tubal reconstructive surgery (4-5 times)
Assisted Reproductive technique
- Ovulation induction, IVF-ET
- Risk of heterotopic pregnancy(1%)
Previous Ectopic Pregnancy
- 7-15% chances of repeat ectopic pregnancy

13. Other Risk factors Age 35-45 yrs Previous induced abortion
Previous pelvic surgeries
Cigarette smoking
DES Exposure in Utero
Infertility
Salpingitis Isthmica Nodosa
Genital Tuberculosis
Fundal Fibroid & Adenomyosis of tube

14. Factors facilitating nidation of ovum in tube: - Premature degeneration of zona pellucida - Increased decidual reaction - Tubal endometriosis

15. Evolution
Tubal pregnancies rapidly invade the mucosa, feeding from the tubal vessels, which become enlarged and engorged. The segment of the affected tube is distended as the pregnancy grows. Possible outcomes of such abnormal gestations are as follows:

16. The pregnancy is unable to survive owing to its poor blood supply, thus resulting in a tubal abortion and resorption, or it is expelled from the fimbriated end into the abdominal cavity.
The pregnancy continues to grow until the overdistended tube ruptures, with resulting profuse intraperitoneal bleeding.
Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months
Abortion is common in ampullary pregnancies,whereas rupture is in isthmic.

17. In rare instances, a tubal pregnancy will be expelled from the tube and seed onto sites in the abdominal cavity (e.g. the omentum, the small or large bowel, or the parietal peritoneum), and gives rise to a viable abdominal pregnancy.

19. Pictures showing TUBAL ABORTION

20. CLINICAL APPROACH
Dignosis can be done by history, detail examination and judicious use of investigation.
Wide spectrum of clinical presentation from asymtomatic pt to others with acute abdomen and in shock.

21. ACUTE ECTOPIC PREGNANCY
Classical triad is present in 50% of pt with
rupture ectopic.
- PAIN:- most constant feature in 95% pt
- variable in severity and nature
- AMENORRHOEA: % of pt
- there may be delayed period or slight
spotting at the time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
Feeling of nausea,vomiting,fainting attack, syncope attack(10%) due to reflex vasomotor disturbance.

22. O/E:- patient is restless in agony, looks blanched,
pale, sweating with cold clammy skin.
Features of shock, tachycardia, hypotension.
P/A:- abdomen tense, tender mostly in lower
abdomen,shifting dullness, rigidity may be
present.
P/S:- minimal bleeding may be present
P/V:- uterus may be bulky, deviated to opposite
side, fornix is tender, excitation pain on
movement of cervix.
POD may be full, uterus floats as if in water.

23. CHRONIC ECTOPIC PREGNANCY
It can be diagnosed by high clinical suspicion.
Patient had previous attack of acute pain from which she has recovered.
She may have amenorrhoea, vaginal bleeding with dull pain in abdomen,and with bladder and bowel complaints like dysuria,frequency or retention of urine, rectal tenesmus.

24. O/E:- patient look ill, varying degree of pallor,
slightly raised temperature. Features of shock
are absent.
P/A:- Tenderness and muscle guard on the lower
abdomen.
A mass may be felt, irregular and tender.
P/V:- Vaginal mucosa pale, uterus may be normal
in size or bulky, ill defined boggy tender
mass may be felt in one of the fornix.

25. UNRUPTURED ECTOPIC
High degree of suspicion & ectopic conscious clinician can diagnose.
Diagnosed accidentally in Laparoscopy or Laparotomy
C/F – delayed period, spotting with discomfort in
lower abdomen.
P/A – tenderness in lower abdomen
P/V – should be done gently
uterus is normal size, firm
small tender mass may be felt in the fornix

28. DIAGNOSIS
In recent years, inspite of an increase in the incidence of ectopic pregnancy there has been a fall in the case fatality rate.
This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease.
This has resulted in early diagnosis and effective treatment.
Now the rate of tubal rupture is as low as 20%.

29. DIAGNOSIS Patient with acute ectopic can be diagnosed clinically.
Blood should be drawn for Hb gm%, blood grouping and cross matching, DC and TWBC, BT, CT.
Should be catheterized to know urine output.
Bed side test:-
1. Urine pregnancy test:- positive in 95% cases.
ELISA is sensitive to mlU/ml of β hCG and
can be detected on 24th day after LMP.

30. Other Investigations:-
1. Ultra Sonography-
a) Transvaginal Sonography (TVS):
- Is more sensitive
- It detect intrauterine gestational sac at
4-5wks and at S-β hCG level as low as 1500
IU/L .

31. -A trilaminar endometial pattern seen
Endometrial cavity
-A trilaminar endometial pattern seen
-pseudogestational sac
-decidual cyst may be seen
PSEUDOSAC – All pregnancies induce an endometrial decidual reaction, and sloughing of the decidua can create an intracavitary fluid collection called a pseudosac
Early gestational sac Pseudosac
location below the midline echo along the
burried into endometium cavity line b/w
endometrial layers
shape usually round may change,oviod
borders double ring single layer
color flow high avascular
pattern peripheral flow

32. DECIDUAL CYST
It is identified as an anechoic area lying with in the endometrium but remote from the canal and often at the endometrial-myometrial border.
Adenxa
% an extrauterine yolk sac or embryo seen in fallopian tubes confirms tubal pregnancy.
- A halo or tubal ring surrounded by a thin hypoechoic area caused by subserosal edema can be seen.
Rectouterine cul-de-sac
Free peritonial fluid with an adnexal mass
suggestive of ectopic pregnancy

33. b) Color Doppler Sonography(TV-CDS): - Improve the accuracy
b) Color Doppler Sonography(TV-CDS): - Improve the accuracy. -Identify the placental shape (ring- of-fire pattern) and blood flow outside the uterine cavity. c) Transabdominal Sonography: - can identify gestational sac at 5-6 wks - S-β hCG level at which intrauterine gestational sac is seen by TAS is 1800 IU/L.

34. USG PICTURE 1.‘Bagel’ sign – Hyperechoic ring around gestational sac in adnexal region 2. ‘Blob’ sign – Seen as small inconglomerate mass next to ovary with no evidence of sac or embryo. 3. Adnexal sac with fetal pole and cardiac activity is most specific. 4. Corpus luteum is useful guide when looking for EP as present in 85% cases in Ipsilateral ovary.

35. Hyperechoic ring around
gestational sac in adnexal region

36. Ring sign — a hyperechoic ring around an extrauterine gestational sac.

37. 2. β-HCG Assay- a) Single β-HCG: little value b) Serial β-HCG: is required when result of initial USG is confusing. - When hCG level < 2000 IU/L doubling time help to predict viable Vs nonviable pregnancy. -Rise of β-HCG <66% in 48 hrs indicate ectopic pregnancy or nonviable intrauterine pregnancy . Biochemical pregnancy is applied to those women who have two β-HCG values >10 IU/L

38. 3. Serum Progesterone – - level >25 ngm/ml is suggestive of normal intrauterine pregnancy. - level <15 ngm/ml is suggestive of ectopic pregnancy. - level <5 ngm/ml indicates nonviable pregnancy, irrespective of its location. 4. Diagnostic Laparoscopy (Gold standard)– - Can be done only when patient is haemodynamically stable. -It confirms the diagnosis and removal of ectopic mass can be done at the same time.

39. 5. Other hormonal Tests – - Placenta protein (PP14) decrease in EP - PAPPA (Pregnancy Associated Plasma Protein A), PAPPC (schwangerchaft protein 1) has low value in EP - CA-125, Maternal serum creatine kinase, Maternal serum AFP elevated in ectopic pregnancy.

40. Laparoscopy Urine Pregnancy test positive Transvaginal USG IU sac
SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive
Transvaginal USG
IU sac
No IU sac
Quantitative S-hCG
+ S progesterone
< 66% rise in 48 hr or
S progesterone < 5-10 ng/ml
>66% rise in 48 hr or
S progesterone > 5-10 ng/ml
D & C
Repeat S-hCG in 48 hrs
till USG discrimination zone
Villi present
Villi absent
Laparoscopy
IU sac
Incomplete
abortion
No sac
Continue to monitor

41. DIFFERENTIAL DIAGNOSIS D/D of Acute Ectopic 1
DIFFERENTIAL DIAGNOSIS D/D of Acute Ectopic 1. Rupture corpus luteum of pregnancy 2. Rupture of chocolate cyst 3. Twisted ovarian cyst 4. Torsion / degeneration of pedunculated fibroid 5. Incomplete abortion 6. Acute Appendicitis 7. Perforated peptic ulcer 8. Renal colic 9. Splenic rupture

42. D/D OF CHRONIC (SUB ACUTE) ECTOPIC 1. Pelvic abscess 2. Pyosalpinx 3
D/D OF CHRONIC (SUB ACUTE) ECTOPIC 1. Pelvic abscess 2. Pyosalpinx 3. Subserous uterine fibroid 4. Salpingintis 5. Retroverted gravid uterus 6. Appendicular lump

43. MANAGEMENT
Expectant
management
Medical
management
Surgical
management
Radical
Conservative
Local
Systemic
(USG or Laparoscopic)
Salpingectomy
salpingocentesis
Methotrexate
Salpingostomy
Salpingotomy
- Segmental
resection
Milking or fimbrial
expression
Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
Actinomycin D
Mifepristone

44. MANAGEMENT OF RUPTURED ECTOPIC
PRINCIPLE: Resuscitation and Laparotomy
ANTI SHOCK TREATEMENT:
- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching, BT, CT
- Folley’s catheterization done
- Colloids for volume replacement
LAPAROTOMY:
Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given
- Autotransfusion only when donated blood not available.

46. MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY
OPTIONS: -
SURGICAL-
SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT
MEDICAL TREATMENT
EXPECTANT MANAGEMENT

47. EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA (Ylostalo et al , 1993)- : 1. Tubal ectopic pregnancies only 2. Haemodynamically stable 3. Haemoperitoneum < 50ml 4. Adnexal mass of < 3.5 cm without heart beat. 5. Initial β HCG <1000 IU/L and falling in titre SUCCESS RATE - Upto 60% PROTOCOL: - Hospitalization with strict monitoring of clinical symptom - Daily Hb estimation - Serum β HCG monitoring 3-4 days until it is <10 IU/L - TVS to be done twice a week.

48. EXPECTANT MANAGEMENT
Spontaneous resolution occurs in 72%,while 28% will need laparoscopic salpingostomy
In spontaneous resolution, it may take 4-67 days (mean 20 days) for the serum HCG to return to non pregnant level.
The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2.
Warning: - Tubal pregnancies have been known to rupture even when Serum HCG levels are low.

49. MEDICAL MANAGEMENT Surgery is the mainstay of T/t worldwide
Medical M/m may be tried in selected cases
CANDIDATES FOR METHOTREXATE (MTX)
Unruptured sac < 3.5cm without cardiac activity
S-hCG < 3-5,000 IU/L
Persistant Ectopic after conservative surgery
PHYSICIAN CHECK LIST
CBC, LFT, RFT, S-hCG
Transvaginal USG within 48 hrs
Obtain informed consent
Follow up frequently

50. MEDICAL MANAGEMENT METHOTREXATE:
It can be used as oral,intramuscular ,intravenous usually along with folinic acid.
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 also be used for tubal pregnancy.
Mechanism of action-Methotrexate is a folic acid antagonist that inactivates the enzyme dihydrofolate reductase.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.

52. Contd…… 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

53. SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
Aim- trophoblastic destruction without systemic side effects
Technique- Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by-
Laparoscopy or
Ultrasonographically guided
Transabdominal (Porreco, 1992)
Transvaginal (Feichtingar, 1987)
With Falloposcopic control (Kiss, 1993)

54. SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
Advantage of local MTX :
- Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up: - Serum β HCG twice weekly till < 10 IU/L
- TVS weekly for 4-6 weeks
- HCG after 6 months for tubal patency

55. INSTRUCTION TO THE PATIENTS
If T/t on outpatient basis rapid transportation should be available
Refrain from alcohol, sunlight, multivitamins with folic acid, and sexual intercourse until S-hCG is negative.
Report immediately when vaginal bleeding, abdominal pain, dizziness, syncope (mild pain is common called separation pain or resolution pain)
Failure of medical therapy require retreatment
Chance of tubal rupture in 5-10 % require emergency Laparotomy.

56. SURGICAL MANAGEMENT OF ECTOPIC
Conservative Surgery
Can be done Laparoscopically or by microsurgical laparotomy
INDICATION:
- Patient desires future fertility
- Contralateral tube is damaged or surgically removed
previously
CHOICE OF TECHNIQUE: depends on
- Location and size of gestational sac
- Condition of tubes
- Accessibility

57. VARIOUS CONSERVATIVE SURGERIES 1
VARIOUS CONSERVATIVE SURGERIES 1.Linear Salpingostomy: - Indicated in unruptured ectopic <2cm in ampullary region. - Linear incision given on antimesentric border over the site and product removed by fingers, scalpel handle or gentle suction and irrigation. - Incision line kept open (heals by secondary intention) 2. Linear Salpingotomy : - Incision line is closed in two layers with 7-0 interrupted vicryl sutures. 3. Segmental Resection & Anastomosis: - Indicated in unruptured isthmic pregnancy - End to end anastomosis is done immediately or at later date

58. 4. Milking or fimbrial Expression: - This is ideal in distal ampullary or infundibular pregnancy. - It has got increased risk of persistent ectopic pregnancy. ADVANTAGES OF LAPAROSCOPY - It helps in diagnosis, evaluation, and treatment . - Diagnose other causes of infertility. - Decreased hospitalization, operative time, recovery period, analgesic requirement. Follow up after conservative surgery - With weekly Serum β HCG titre till it is negative. - If titre increases methotrexate can be given.

59. DEBATABLE ISSUES. Salpingectomy Vs Salpingostomy
DEBATABLE ISSUES ? Salpingectomy Vs Salpingostomy ? Laparotomy Vs Laparoscopy ? Reproductive outcome ? Risk of Recurrent Ectopic

60. SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY
Salpingostomy / Salpingotomy is only indicated when:
The patient desires to conserve her fertility
Patient is haemodinamically stable
Tubal pregnancy is accessible
Unruptured and < 5Cm. In size
contralateral tube is absent or damaged
All tubal pregnancies can be treated by partial or total Salpingectomy

61. The choice of surgical treatment does not influence the post treatment fertility, but prior history of infertility is associated with a marked reduction in fertility after treatment.
Making the choice – Chapron et al (1993) have described a scoring system, based on the patient’s previous gynaecological history and the appearance of the pelvic organs, to decide between salpingostomy / salpingotomy and salpingectomy.
CONTD……

62. Fertility reducing factor Score
Antecedent one Ectopic pregnancy
Antecedent each further
Ectopic pregnancy
Antecedent Adhesiolysis
Antecedent Tubal micro surgery
Antecedent Salpingitis
Solitary tube
Homolateral Adhesions
Contralateral Adhesions
The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy.
Conservative surgery is indicated with a score of 1-4 only, while radical treatment is to be performed if the score is 5 or more.

63. Laparotomy Vs Laparoscopy - Laparoscopy is reserved for pt who are hemodynamically stable. - Ruptured Ectopic does not necessarily require Laparotomy, but if large clots are present Laparotomy should be considered. Reproductive outcome Is similar in pt treated with either Laparoscopy or Laparotomy. Identical rates of 40% of IUP, around 12% risk of recurrent pregnancy with either radical or conservative pregnancy.

64. LAPAROSCOPIC SALPINGECTOMY
It is carried out by laparoscopic scissors & 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 tissue removal bag
LAPAROSCOPIC SALPINGOTOMY
To reduce blood loss, first 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)
The tubal pregnancy is then evacuated by suction irrigation.

65. PERSISTENT ECTOPIC PREGNANACY
This is a complication of salpingotomy / salpingostomy when residual trophoblast continues to survive because of incomplete evacuation of the ectopic pregnancy.
Diagnosis is made because of a raised postoperative β HCG
If untreated, can cause life threatening hemorrhage
Risk Factor: (seifer 1997)
1. Early ectopic pregnancy (< 6 wks amenorrhoea)
2. Smaller size < 2 cm (Incomplete removal)
3. Preoperative high serum β HCG (> 3,000 IU/L) and
postoperative Day1 titre is < 50% of preoperative level, is predictor of persistent EP.
4. Implantation medial to the salpingostomy site.
Treatment
surgery
Medical
(selected Asymptomatic pt)
Total or partial
salpingectomy
MTX + Leukovorin

66. OVARIAN ECTOPIC PREGNANCY
Incidence: 1:40,000
Risk factor: - IUCD
- Endometriosis on surface of ovary
Course:
C/F are same as tubal pregnancy
ruptures within 2-3 wks
Diagnosis: On Laparotomy
Spiegelberg’s Criteria
1. Ipsilateral tube is intact and separate from sac
2. Sac occupies the position of the ovary
3. Connected to uterus by ovarian ligament
4. Ovarian tissue found on its wall on HP study
M/M
Unruptured
Ruptured
Ovarian wedge resection
Laparotomy
Ovarian Cystectomy
Oophorectomy

67. ABDOMINAL PREGNANCY Incidence: Rarest
MMR : 7-8 times > tubal ectopic
90 times > Intrauterine pregnancy
H/O : - Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation,
diarrhoea, abdominal pain.
- Fetal movement may be painful and high in
the abdomen
O/E : - Abnormal fetal position, easy in palpating
fetal parts.
- uterus palpated separate from sac
- no uterine contraction after oxytocin
infusion

68. Diagnosis: Confirmed by USG, CT scan, MRI, Radiography TYPE
Primary
Secondary
Studiford’s criteria
Conceptus escapes out
through a rent from
primary site
Both tubes and ovaries normal
Absence of Uteroperitonal fistula
Pregnancy related to Peritoneal
surface & young enough to rule
out possibility of secondary
implantation
Intraperitoneal
Extraperitoneal
Broad ligament

69. FATE OF SECONDARY ABDOMINAL PREGNANCY : 1
FATE OF SECONDARY ABDOMINAL PREGNANCY : 1. Death of ovum – complete absorption 2. Placental separation – massive intraperitoneal haemorrhage 3. Infection – fistulous communication with intestine, bladder, vagina, or umbilicus 4. Fetus dies (majority) – mummification, adipocere formation, or calcified to lithopaedion 5. Rarely – continue to term (malformation) M/M: - Urgent Laparatomy irrespective of period of gestation - Ideal to remove entire sac fetus, placenta, membrane - Placenta may be left if attached to vital organs, get absorbed by aseptic autolysis

70. CERVICAL PREGNANCY
Implantation occurs in cervical canal at or below internal Os.
Incidence: 1 in 18,000
RISK FACTORS :
- Previous induced abortion
- Previous caesarean delivery
- Asherman’s syndrome
- IVF
- DES exposure
- Leiomyoma

71. Diagnosis: CLINICAL CRITERIA: Paulman & McEllin 1
Diagnosis: CLINICAL CRITERIA: Paulman & McEllin 1. Uterine bleeding, no cramping, following amenorrhoea 2. Cervix distended,thin walled,soft consistency 3. Enlarged uterine fundus may be palpated. 4. Internal Os is closed 5. External Os is partially opened USG CRITERIA: American Journal of O&G 1. Echo-free uterine cavity/ pseudo-gestational sac 2. Decidual reaction 3. Hourglass uterus with ballooned cervical canal 4. Gestational sac in endocervix 5. Closed internal Os 6. Placental tissue in Cx canal

72. HISTOPATHOLOGIC CRITERIA: Rubin’s
1. Cervical glands present opposite to placenta
2. Placental attachment to the cervix must be
below the entrance of uterine vessels .
3. Fetal element absent from corpus uteri.
D/d :
- Carcinoma Cx
- Cervical submucous fibroid
- Trophoblastic tumour
- Placenta previa

73. MANAGEMENT Medical Surgical Conservative Radical surgery D & C
Recently proposed
Mainstay therapy in past
Single or Combination OR
Adjunct to surgery
Conservative
Radical
surgery
D & C
(risk of torrential bleeding)
Methotrexate
Actinomycin
KCl
Etoposide
Hysterectomy
Cerclage Bernstein ≈ Mc Donald’s
Wharton ≈ Shirodkar’s
Transvaginal ligation of Cx branch of
uterine artery
- Angiographic uterine A embolisation
Intracervical vasopressin inj
Foley’s catheter as tamponade

74. CORNUAL PREGNANCY
SITE: Implantation occurs in rudimentary horn of Bicornuate
uterus
COURSE :Rupture of horn occurs by
12-20 wks
D/D :
1. Interstitial tubal pregnancy
2. Painful leiomyoma along with
pregnancy
3. Ovarian tumor with pregnancy
4. Asymmetrical enlargement of uterus.
Implantation into cornu of normal uterus is sometime
called Angular pregnancy .
TREATEMENT:
- Affected cornu with pregnancy is removed
- Hysterectomy
- Hysteroscopically guided suction curettage if
communication with Cx is patent

75. Co-existing intrauterine and extra uterine pregnancies
HETEROTYPIC PREGNANCY
Co-existing intrauterine and extra uterine pregnancies
Incidence: 1 : 30,000
With ART – 1:7000
With ovulation induction – 1:900
More likely:
a) Ass. reproductive technique
b) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomy
M/M :
Depends on the site. Ectopic site may be removed
with continuation of IU pregnancy
(Rh Immunoglobulin: dose of 50 μ gm is sufficient to
prevent sensitization.)

76. INTERSTITAL PREGNANCY (2%) It ruptures late at 3-4 months gestation
INTERSTITAL PREGNANCY (2%) It ruptures late at 3-4 months gestation. Fatal rupture – severe bleeding as both uterine & ovarian artery supply. Early & Unruptured – Local or IM MTX with followup Cornual resection by Laparotomy may be done. There is high risk of uterine rupture in subsequent pregnancy. Rupture – Hysterectomy is indicated

77. UNRUPTURED ISTHAMIC EP

78. RUPTURED FIMBRIAL ECTOPIC PREGNANACY

79. OVARIAN ECTOPIC PREGNANCY

80. CORNUAL ECTOPIC PREGNANCY

81. CORNUAL ECTOPIC PREGNANCY

82. RUPTURED AMPULLARY ECTOPIC PREGNANCY

83. UNREUPTURED AMPULLARY ECTOPIC PREGNANCY

84. RUPTURED ISTHAMIC ECTOPIC PREGNACY

85. CORNUAL ECTOPIC PREGNANCY

86. HETEROTROPIC ECTOPIC PREGNANCY

87. SCAR ECTOPIC PREGNANCY