2. ECTOPIC PREGNANCY DEFINITION Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity. 05/09/2015 14:22Ectopic Pregnancy 1

3. INCIDENCE >1 in 100 pregnancies.  Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries.  USA-5 fold  UK-2 fold  France 15/1000 pregnancies  India-1in100 deliveries  Recurrence rate - 15% after 1 st, 25% after 2 ectopics 05/09/2015 14:22Ectopic Pregnancy 2

4. HISTORY  Ectopic pregnancy was first described in 963 Ad by Albucasis.  1884 -- Robert Lawson Tait of Birmingham prformed the first successful Salpingectomy operation  1953 -- Stromme – Conservative surgery of Salpingostomy  1973 -- Shapiro & Adller – Laparoscopic Salpingectomy  1991 -- Young et al – Laparoscopic Salpingotomy 05/09/2015 14:22Ectopic Pregnancy 3

5. AETIOLOGY  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. 05/09/2015 14:22Ectopic Pregnancy 4

6. AETIOLOGY  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 05/09/2015 14:22Ectopic Pregnancy 5

7. 05/09/2015 14:22Ectopic Pregnancy 6 SITES OF ECTOPIC PREGNANCY 1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal Ampulla (>85%) Isthmus (8%) Cornual (< 2%) Ovary (< 2%) Abdomen (< 2%) Cervix (< 2%)

8. CLINICAL PRESENTATION  Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations - Acute &. Chronic  SYMPTOMS-  Amenorrhea  Abdominal Pain  Syncope  Vaginal Bleeding  Pelvic Mass 05/09/2015 14:22Ectopic Pregnancy 7

9. DIAGNOSIS “Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it.” --Mc. Fadyen - 1981 05/09/2015 14:22Ectopic Pregnancy 8

10. 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%. 05/09/2015 14:22Ectopic Pregnancy 9

11. METHODS OF EARLY DIAGNOSIS  Immunoassay utilising monoclonal antibodies to beta HCG  Ultrasound scanning – Abdominal & Vaginal including Colour Doppler  Laparoscopy  Serum progesterone estimation not helpful 05/09/2015 14:22Ectopic Pregnancy 10 A combination of these methods may have to be employed.

12. METHODS OF EARLY DIAGNOSIS  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. 05/09/2015 14:22Ectopic Pregnancy 11 At 4-5 weeks -

13. METHODS OF EARLY DIAGNOSIS The USG features of ectopic pregnancy after 5 weeks can be any of the following- 05/09/2015 14:22Ectopic Pregnancy 12 1. Demonstration of the gestational sac with or without a live embryo (Begel’s sign) - The GS appears as an intact well defined tubal ring by 6 weeks when it measures 5 mm in diameter. Afterwards it can be seen as a complete sonolucent sac with the yolk sac and the embryonic pole with or without heart activity inside.

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15. METHODS OF EARLY DIAGNOSIS 2. Poorly defined tubal ring possibly containing echogenic structure and POD typically containing fluid or blood. 3. Ruptured ectopic with fluid in the POD and an empty uterus. 4. In Colour Doppler, the vascular colour in a characteristic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow 05/09/2015 14:22Ectopic Pregnancy 14 The USG features of ectopic pregnancy after 5 weeks can be any of the following-

16. MANAGEMENT  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 05/09/2015 14:22Ectopic Pregnancy 15

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19. MANAGEMENT OF ACUTE ECTOPIC PREGNANCY  Hospitalisation  Resuscitation -  Treatment of shock  Lie flat with the leg end raised  Analgesics  Blood transfusion 05/09/2015 14:22Ectopic Pregnancy 18

20. MANAGEMENT OF ACUTE ECTOPIC PREGNANCY 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 05/09/2015 14:22Ectopic Pregnancy 19

21. MANAGEMENT OF ACUTE ECTOPIC PREGNANCY  Laparotomy should be done at the earliest.  Salpingectomy is the definitive treatment.  No benefit from removing Ovary along with the tube  If blood is not available, auto-transfusion can be done. 05/09/2015 14:22Ectopic Pregnancy 20

22. MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY INVESTIGATIONS-  Laboratory/Chemical test –  Serial quantitative beta HCG level by RIA  Serum progesterone level (<5 mg/ml in ectopic pregnancy)  Low levels of Trophoblastic proteins such as SPI and PAPP-, Placental protein 14 & 12  USG- usually haematocele is found  Laparoscopy 05/09/2015 14:22Ectopic Pregnancy 21

23. MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY 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 05/09/2015 14:22Ectopic Pregnancy 22

24. MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY  SURGICAL-  SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT  MEDICAL TREATMENT  EXPECTANT MANAGEMENT 05/09/2015 14:22Ectopic Pregnancy 23 OPTIONS: -

25. SURGICAL TREATMENT OF ECTOPIC PREGNANCY  Carried out 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 05/09/2015 14:22Ectopic Pregnancy 24

26. SURGICAL TREATMENT OF ECTOPIC PREGNANCY 05/09/2015 14:22Ectopic Pregnancy 25 LAPAROTOMY? VS. LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY? The debate goes on

27. 05/09/2015 14:22Ectopic Pregnancy 26 COMPARING LAPAROTOMY Vs LAPAROSCOPY L’tomyL’scopy Hospital costMore?Less? Post operative adhesionsMoreLess Risk of future ectopicSame Same Future fertilitySame Same Experience of SurgeonTrainedSpecial Instruments GeneralSpecial

28. 05/09/2015 14:22Ectopic Pregnancy 27 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

29. 05/09/2015 14:22Ectopic Pregnancy 28  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. SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY

30. 05/09/2015 14:22Ectopic Pregnancy 29 Fertility reducing factor Score Antecedent one Ectopic pregnancy2 Antecedent each further Ectopic pregnancy1 Antecedent Adhesiolysis1 Antecedent Tubal micro surgery2 Antecedent Salpingitis1 Solitary tube2 Homolateral Adhesions1 Contralateral Adhesions1 SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY

31. 05/09/2015 14:22Ectopic Pregnancy 30 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. SALPINGECTOMY VS SALPINGOSTOMY / SALPINGOTOMY

32. 05/09/2015 14:22Ectopic Pregnancy 31  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. LAPAROSCOPIC SALPINGECTOMY

33. 05/09/2015 14:22Ectopic Pregnancy 32  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 – Co 2 laser (Paulson, 1992) – Argon laser (Keckstein et al; 1992) – Laparoscopic scissors and ablating the bleeding points with bipolar diathermy. – Fine diathermy knife (Lundorff, 1992) LAPAROSCOPIC SALPINGOTOMY

34. 05/09/2015 14:22Ectopic Pregnancy 33  The tubal pregnancy is then evacuated by suction irrigation.  Hemostasis of the trophpblastic bed is ensured.  The tubal incision is left open. LAPAROSCOPIC SALPINGOTOMY

35. PERSISTENT ECTOPIC PREGNANCY (PEP)  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 serum HCG  If untreated, can cause life threatening hemorrhage 05/09/2015 14:22Ectopic Pregnancy 34

36. PERSISTENT ECTOPIC PREGNANCY (PEP)  TREATMENT is by-  Reoperation and further evacuation / Salpingectomy  Administration of IM / oral Methtrexate in a single dose of 50 mg/m2 of body surface 05/09/2015 14:22Ectopic Pregnancy 35

37. SAM TREATMENT  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) 05/09/2015 14:22Ectopic Pregnancy 36

38. SAM TREATMENT  Trophotoxic substances used-  Methtrexate (Pansky, 1989)  Potassium Chloride (Robertson, 1987)  Mifiprostone (RU 486)  PGF2  (Limblom, 1987)  Hyper osmolar glucose solution  Actinomycin D 05/09/2015 14:22Ectopic Pregnancy 37

39. MEDICAL TREATMENT WITH METHOTREXATE  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. 05/09/2015 14:22Ectopic Pregnancy 38

40. MEDICAL TREATMENT WITH METHOTREXATE  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 05/09/2015 14:22Ectopic Pregnancy 39

41. MEDICAL TREATMENT WITH METHOTREXATE  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 05/09/2015 14:22Ectopic Pregnancy 40

42. EXPECTANT TREATMENT  Tubal Pregnancies are known to Abort / Resolve  Befor the advent of salpingectomy in 1884, ectopic pregnancies were being treated expectantly with 70% mortality.  Today only selected cases are managed expectantly, screened and identified by high resolution ultrasound scanner and monitored by serial serum HCG assay 05/09/2015 14:22Ectopic Pregnancy 41

43. EXPECTANT TREATMENT  Identification criteria (Ylostalo et al, 1993)-  Diameter of ectopic pregnancy <4 Cm.  No sign of intrauterine pregnancy  No sign of rupture by TVS  No sign of acute bleeding by TVS  Falling level of serum HCG at 2 day intervals  If any deviation from the above criteria occurs, then emergency treatment is necessary. 05/09/2015 14:22Ectopic Pregnancy 42

44. EXPECTANT TREATMENT  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. 05/09/2015 14:22Ectopic Pregnancy 43

45. SUMMARY  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. 05/09/2015 14:22Ectopic Pregnancy 44

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