Ectopic Pregnancy Diagnosis & Management PDF

Dr. PRIYADHARSHINI M Definition Any pregnancy where the fertilized ovum gets implanted & develops in a site other than the normal endometrial cavity.  Serious hazard to a woman’s health and reproductive potential, requiring prompt recognition & early aggressive intervention Ovulation ovum p...

Dr. PRIYADHARSHINI M Definition Any pregnancy where the fertilized ovum gets implanted & develops in a site other than the normal endometrial cavity.  Serious hazard to a woman’s health and reproductive potential, requiring prompt recognition & early aggressive intervention Ovulation ovum picked up by fimbria swept by ciliary action towards ampulla fertilization. Zygote cleavage division in (3 -4 days)  morula (8-32 cell stage) embryo to uterine cavity for up to 72 hours D6 enters uterus implantation- uterine cavity in normal positioned pregnancy . hCG (trophoblast)mother’s serum 1 week after implantation, level doubles every 36-48 hours Delay or obstruction of the passage of fertilized egg down the fallopian tube to the uterus implantation in tube or ovary or peritoneal cavity ectopic pregnancy Eventually fails to develop hCG fails to raise dramatically  1-2 % of total pregnancy  Recurrence rate – 15% after 1st, 25% after 2 ectopics  Increasing incidence  4th leading cause of maternal mortality overall (4%)  MC cause of maternal mortality I trimester  Types: Tubal(95-98%) 2. Non tubal(2-5%) 3. Heterotropic(1/1000) 1. IMPLANTATION SITES UTERINE EXTRA (1.5) UTERINE CERVICAL <1% ANGULAR TUBAL OVARIAN ABDOMINAL (97%) (0.5) (0.1) AMPULLARY 70% ISTHMUS 12% CORNUAL CS SCAR <1% PRIMARY SECONDARY (rare) INFUNDIBULAR INTRAPERITONEAL EXTRAPERITONEAL 11% MC (broad lig) INTERSTITIAL 2%  Improved technology  The rising incidence of risk factors-  acute & chronic salpingitis  induced abortion  tubal ligation  tubal reconstructive surgery  ART  Conservative management of tubal pregnancy,  Congenital: long narrow tube, diverticulae , accessory      ostia. Traumatic: operation on the tube –salpingoplasty ,tubal reversal following ligation. Inflammatory: Chronic salpingitis Neoplastic: Narrowing of the tube by a fibroid or a broad ligament tumor. Functional: As tubal spasm or antiperistaltic contractions. Endometriosis in the tube. encourages embedding of the fertilized ovum. Separation of the gestational sac from the tubal wall Degeneration Fall of hCG level, Regression of the corpus luteum Drop in the oestrogen & progesterone level Separation of the uterine decidua with uterine bleeding Risk Factor Risk % High Risk PID * Tubal corrective surgery Tubal sterilization Previous EP In utero DES exposure IUD ** Documented tubal pathology 25 21.0 9.3 8.5 5.6 4.2-45 3.8-21 Moderate Risk Infertility Previous genital infection Multiple partners 2.5-21 Up to half of women with ectopic pregnancy will have no identifiable risk factors. Use of assisted reproductive technology (such as IVF and GIFT) 2.5-3.7 2.1 Slight risk Previous pelvic or abdominal surgery RISK FACTORS •7 fold risk after acute pelvic infection 0.93-3.8 Smoking 2.3-2.5 Douching 1.1-3.1 Intercourse before 18 years 1.6 ** 4 times risk- increased protection against IU pregnancy, increased incidence of PID Infections chlamydia, gonorrhoea Damage to ciliated surface of endosalpinx intratubal adhesions  partial tubal obstruction peritubal adhesions restricted tubal motility Alteration of tubal transport mechanisms slow the passage of egg time to implant itself in the tube 1- Tubal mole:  sac is surrounded by blood clot & retained  chronic ectopic pregnancy/ involution 2-Tubal abortion: ampullary  Separation of sac expulsion into peritoneal cavity through ostium.  Rarely, reimplantation of conceptus occurs in another abdominal structure secondary abdominal pregnancy. 3-Tubal rupture: isthmus  Rupture in anti-mesenteric border  profuse bleeding → intraperitoneal haemorrhage.  rupture in mesenteric border broad ligament haematoma. OUTCOMES Tubal abortion Tubal Rupture •Extraperitoneal rupture (rupture through floor of the tube) broad ligament hematoma with death of intraligamentary pregnancy. the ovum, 16 The diagnosis often presents great difficulty Usually missed because it is NOT suspected. “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  Multimodality approach including  Proper history (cycle, pregnancy, PID,infertility, gynaecological surgery, contraception)  Clinical examination (Proper general, abdominal, vaginal and vital signs)  Judicious use of investigation  Wide spectrum of presentation from asymptomatic pt to others with acute abdomen and in shock  Early symptoms - either absent/ subtle.  7.2 weeks after LMP (range 5-8 weeks) ABDOMINAL PAIN Most common ECTOPIC AMENORRHOEA 75% ABNORMAL VAGINAL BLEEDING 70%  Apart from classical triad pt presents with  Features of shock  Danforth sign, cullen sign  P/A-Abdominal tenderness,guarding,BS decreased/absent  P/S-Minimal bleeding  P/V-Uterus bulky,fornix tender full,pod full,adnexal mass, cervical motion tenderness ”JUMPING SIGN”  Bimanual examination should be very gentle with facilities for immediate surgical intervention if needed  H/O-acute attack of pain from which she has     recovered O/E-ill looking without any features of shock P/A-irregular mass,tenderness P/S-vaginal mucosa pale P/V-uterus may be normal/bulky,ill defined mass may be felt through fornix  Difficult to diagnose and high degree of clinical suspiscion is needed,sometimes diagnosed accidentally during laparoscopy/laparotomy  C/F-Delayed periods,spotting with lower abdominal discomfort  P/A-tenderness in lower abdomen  P/V-Uterus normal size,small tender mass may be felt in the fornix DIFFERENTIAL DDX DIAGNOSIS (1) NON GYNECOLOGICAL Appendicitis (Perforated) Acute Pancreatities Myocardial Infarct Pelvic Abcess Splenic Rupture Perforated Gastric or Duodenal Ulcer (2) GYNAECOLOGICAL Septic Abortion Rupture of Follicle or Corpus Luteum Cyst Degenerating leiomyoma Threatened Abortion Acute pelvic inflammatory disease Retroverted Gravid Uterus Pyosalpinx Twisted Ovarian Cyst Pelvic Abcess •Accuracy of initial clinical evaluation < 50%. General investigations  Urine pregnancy test Culdocentesis Transvaginal ultrasonography Serum beta hcg Urine beta hcg Serum progesterone Uterine currettage Laparoscopy/laparotomy  Presence of free flowing nonclotting blood intraabdominal haemorrhage  serous fluid negative  Lack of fluid return/clotted blood non- diagnostic  Negative culdocentesis does not exclude chance of ectopic  UPT not always positive  Serum β-hCG (ELISA / RIA) detects very early pregnancy about 10 days after fertilization i.e. before the missed period. Discriminatory zone:  1000-2000 IU/L TVS; 5000-6000 IU/L TAS Absence of uterine pregnancy abnormal pregnancy( ectopic, incomplete abortion) β-hCG levels still below the discriminatory value, serial β-Hcg USG should be done. Doubling sign:  Normal : >66% increase levels every 48 hours (nearly 2X).  Inappropriately rising serum β-hCG levels suggest (but do not diagnose) abnormal pregnancy including ectopic Do not identify its location.  Specificity 94%,sensitivity 38%  TVS superior to TAS  Failure to see Gestational sac at 4-5 wks gestation and at beta hcg 1500iu/l i.e. the discriminatory zone  Observation of g.sac, embryo, cardiac activity outside the uterus  In some cases no sac is found either intrauterine/extrauterine  7-20% proved to be ectopic  25% of ectopic presents with PUL  Intrauterine pregnancy in which the sac is not developed, collapsed or aborted.  Ectopic too small to be detected Transvaginal USG Positive β-hCG test + empty uterus by sonar ± adnexal mass Ectopic pregnancy.  Endometrial cavity shows trilaminar echo pattern  Identification of double decidual sac sign(DDSS) is the best method to differentiate true sacs from pseudosacs Pseudogestational sac seen formed by the sloughing of decidua creating an intracavitary fluid collection.it differs from true g.sac in having only one layer and midline location where as true sac is usually eccentric  Decidual cast sometimes seen  Decidual cyst anechoic area at the endometriummyometrium border  Pouch of douglas may contain free fluid  Presence of corpus luteal cyst in ipsilateral ovaries is a     useful marker Appx 60%-seen as inhomogenous mass/blob sign adjacent to ovary, moving separetely from it Appx 20%-as adnexal hyperechoic ring/bagel sign (fluid sacs with thick echogenic ring) Appx 13%-as obvious gestational sac with fetal pole/cardiac activity Doppler improve the accuracy & identify the placental shape ( ring of fire pattern) & blood flow outside the uterine cavity  Value >25ng/ml  normal intrauterine pregnancy  Value<5ng/ml nonviable intrauterine pregnancy/ extrauterine pregnancy  Most of ectopic pregnancy value ranges 10-25 ng/ml Diagnostic laparoscopy Gold standard for diagnosis of ectopic pregnancy Diagnosis & removal of ectopic mass can be done at the same time  Presence of villi excludes ectopic pregnancy not heterotopic pregnancy  Absence of villi and presence of Ariastella reaction suggests ectopic pregnancy  OTHERS- VEGF, CA125, creatine kinase, fetal fibronectin, placental protein, Estradiol, maternal AFP, relaxin Suspected ectopic UPT+ S/S STABLE UNSTABLE TVS ECTOPIC Non diagnostic Intrauterin e pregnancy ABORTION Serum beta HCG <1500 >1500 CURETTAGE VILLI ABORTION NO VILLI Repeat B HCG SURGICAL MANAGEMENT 1 2 3 4 • EXPECTANT MANAGEMENT • MEDICAL MANAGEMENT • SURGICAL MANAGEMENT • EMERGENCY MANAGEMENT 1 EXPECTANT MANAGEMENT Criteria for selection (RCOG-green top-21-guideline)  Asymptomatic pt  Hemodynamically stable  <100 ml fluid in the pouch of Douglas  Lower beta hcg value<1000 IU/ml  Adnexal mass <3cm without cardiac activity  Pregnancy of unknown location They must be fully compliant and must be willing to accept the potential risks of tubal rupture. • Success rate is 60% with decreasing beta hcg titre MONITORING  Initial follow up  twice weekly with serial Hcg measurements  weekly by TVS  By the first week  drop in HCG level  Adnexal mass size Otherwise reassess the options (Medical/Surgical)  If the fall of HCG & reduction in size of adnexal mass satisfatory  weekly hCG & TVS till HCG falls <20 IU  45–70% of PUL resolve spontaneously with expectant management  Ectopic pregnancy was subsequently diagnosed in 14–28% of PUL  Intervention(laparoscopic salpingostomy) has been shown to be required in 23–29% of cases MEDICAL 2 Minimal symptoms/ hemodynamically stable No signs or symptoms of active bleeding / haemoperitoneum. HCG<3000(RCOG) Normal CBC,RFT,LFT Size<4cm Absence of cardiac activity Persistent ectopic after conservative surgery Good compliance and follow up can be assured(RCOG) Women should be given clear information(preferably written)about the possible need for further Tt and adverse effects following Tt (RCOG) Exclusion criteria Selection criteria CRITERIA FOR MEDICAL MANAGEMENT Any hepatic dysfunction, thrombocytopenia (<100,000), blood dyscrasia(WBC <2000). Difficulty/unwillingness of patient for prolonged follow-up (avg follow-up 35days). Ectopic mass >4cm presence of cardiac activity Women on concurrent corticosteroid therapy SYSTEMIC ( IV, IM or orally ) • Methotrexate LOCALLY • • • • SALPHINGOCENTESIS (laparoscopic direct injection, retrograde salpingography) RU-486 PgF2 alpha, MTX KCl , hyperosmolar glucose Actinomycin D Other agents- not recommended because their safety & accuracy are not well documented Advantage:  Increased conc at local site  lesser systemic s/e  Increased fertility  Shorter hospital stay Follow up:  Beta hcg twice wkly till<10iu/l  TVS weekly till 4-6 wk  Hcg after 6 month Methotrexate : folic acid antagonist inhibits DHFR enzyme thus depleting the stores needed for DNA/RNA synthesis during trophoblast proliferation first used by Tanaka et al(1982)interstitial ectopic pregnancy Methotrexate-IM(buttock or lateral thigh) Prior tests- CBC,LFT,RFT,CXR repeated after 1 week 1.Multidose regimen – MTX 1mg/kg IM on 1,3,5,7 days Leucovorin 0.1mg/kg on 2,4,6,8 days Measure B-hCG levels on days 1,3,5,7 until 15% decrease between 2 measurement Once B-hCG level drops 15%, stop MTX & monitor B-hCG weekly until non pregnant level 2.Single dose regimen : MTX 50mg/m 2 on day 0 Measure B-hCG level on days 4 & 7 If level drops by 15%, monitor B-hCG weekly until non pregnant level. If levels do not drop by 15%, repeat dose of MTX & measure B-hCG on days 4 & 7 87% success rate Advantages: Increased pt compliance Simplified administration Safe & effective Less expensive Less monitoring 3.Two dose regimen:  MTX 50mg/m2 on days 0 & 4  Measure B-hCG levels on days 4 & 7  If levels drop by 15%, monitor B-hCG weekly until non pregnant level  If level do not drop by 15%, repeat dose of MTX on days 7 & 11 & measure B-hCG on days 7 & 11. If levels drop 15%, monitor B-hCG level weekly until non pregnant level UNTOWARD EFFECTS: Dose & frequency dependent (30-40%)  nausea, vomiting  Stomatitis,  abdominal pain  bone marrow suppression  Alopecia  dermatitis & pneumonitis.  Deranged LFT Rest up to one hour after the injection. local reaction- anti-histamine/ steroid cream (v.rare) use reliable contraception for 3 months after MTX (barrier or hormonal) Avoid  sexual intercourse during treatment  exposure to sunlight.  alcohol , vitamin preparations containing folate until the hormone level is back to zero.  aspirin or drugs such as Ibuprofen for one week after treatment. FOLLOWED UP for signs of tubal rupture-( severe pain/unstable/falling Hct)- surgical intervention OUTCOME  90% successful treatment with single dose regime.  10 – 20%. Recurrent ectopic pregnancy rate  80%. Tubal patency rate  75% abdominal pain-separation pain.(D3-D7)  14 % of medical management 2nd dose of MTX  10% finally require surgical management Risk of subsequent ectopic 10% following either MTX(MD)/salpingostomy. similar reproductive outcomes Success rates(time to resolution ) correlates with initial serum B HCG  Medical management- cheap initially  but considering the cost of follow up & the loss of work time for patient & carers no cost saving was seen at serum hCG levels above 1500 iu/l 3 SURGICAL  Not a suitable candidate for medical therapy.  Failed Medical therapy.  heterotropic pregnancy with viable intrauterine pregnancy.  hemodynamically unstable & needs immediate treatment. Surgical approachlaparoscopy or laparotomy  hemodynamic stability  size & location of ectopic mass  surgeons expertise Quick in and Quick out - principle Conservative & extirpative • unruptured ampullary ectopic pregnancy(toc), • wishes to retain potential for future fertility • affected fallopian tube otherwise normal • Contralateral tube appears damaged CONTRAINDICATIONS iNDICATIONS Linear salpingostomy:  <2cm size, in distal third of tube  Antemesenteric border incised –heals by secondary intention  FOLLOW UP Ruptured tube use of extensive cautery to obtain hemostasis severely damaged tube recurrent ectopic pregnancy in same tube. Salpingotomy  Conservative surgical management  Incision – closed with vicryl7-0  ectopic has not ruptured  the tube appears normal Segmental resection and anastomosis: for unruptured isthmic pregnancy Milking /fimbrial expression: infundibular pregnancy, best reserved when products protrude out. 2X recurrence EXTIRPATIVE Salpingectomy (PARTIAL/TOTAL)  Salpingectomy (tubal removal) is the principle treatment especially where there is tubal rupture  wedge area of outer 3rd of interstitial portion of tube is also resected ,known as cornual resection to minimise occurence of pregnancy in tubal stump Total salpingectomy is the procedure of choice:  completed childbearing and no longer desires fertility  history of an ectopic pregnancy in the same tube.  severely damaged tubes  Cumulative inrauterine pregnancy rates and also incidence of recurrent ectopic – higher with salpingostomy Salpingectomy Salpingotomy • There may be a higher subsequent intrauterine pregnancy rate associated with salpingotomy but the magnitude of this benefit may be small • Trend towards higher subsequent ectopic pregnancy • small risk of tubal bleeding in the immediate postoperative period • potential need for further treatment for persistent trophoblast Salpingostomy Salpingectomy  Chance of intrauterine pregnancy- 73%  Chance of recurrent ectopic15% Laparoscopy Tubal patency: 80-90% Intrauterine preg: 55-75% Recurrent ectopic: 10-15%  57%  10% Laparotomy  80-90%  55-75%  10-15% Laparotomy  hemodynamically unstable and an expedited abdominal entry is required  patients with cornual , interstitial ectopics  Extensive pelvic/abdominal adhesive disease  surgeons inexperienced & patients where laparoscopic approach is difficult  An alternative to laparoscopy is the use of minilaparotomy incision.-success rate similar Laparoscopy Laparotomy • Less intraoperative blood loss • Shorter operation time • Shorter hospital stay • Lower analgesic requirement • Future intrauterine pregnancy rate same • Lower repeat ectopic pregnancy rate • Future intrauterine pregnancy rate same • Preferable in the haemodynamically unstable patient LAPROSCOPY  Tubal patency, future intrauterine pregnancy, future ectopic rates - no differences in laparoscopic salpingotomy and salpingostomy (recent cochrane review)  COMPARING systemic methotrexate with tube- sparing laparoscopic surgery, randomized trials have shown no difference in overall tubal preservation, tubal patency, repeat ectopic pregnancy, or future pregnancies(ACOG 2008) Algorithm for the diagnosis of unruptured ectopic pregnancy without laparoscopy EMERGENCY RUPTURED ECTOPIC PRINCIPLE: Quick Resuscitation and simulataneous arrangement for laparotomy definitive surgery ANTI SHOCK TREATMENT: ABC of resuscitation  give facial oxygen  Site two IV lines (at least 16g), commence IV fluids (crystalloid)  Send blood for CBC, Clotting screen and cross-match at least 4 units of blood.  - Folleys catheterization done  - colloids for volume replacement whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive monitoring of haemodynamic state LAPAROTOMY  - Rapid exploration of abdominal cavity done - Salpingectomy (definitive surgery) peritoneal toileting record operative findings including the state of the remaining tube/pelvis  Blood transfusion done  Anti D Ig (250 IU)given to Rh negative women RCOG Guideline factors affecting future pregnancy:  prior h/o of infertility (the most important)  treatment choice history ( whether surgical or nonsurgical)  For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.  Rate of fertility may be better following salpingostomy than salpingectomy.  Resorption/ tubal abortion- obviates need for further or medical management  Falling HCG(caution: tubal rupture can occur even with falling levels)  Low BHCG(<200mU/ml) 88%  Follow up with beta HCG  Complication of salpingotomy / salpingostomy(4-15%) when residual trophoblast continues to survive because of incomplete evacuation of ectopic pregnancy.  Mostly ruptures in post op  So serial monitoring of beta hcg.(D1, every 3-7 days thereafter till undetectable)  Risks are small size<2cm, early preg<6wk, preop high Bhcg>3000iu/l  Diagnosis : raised postoperative serum HCG  If untreated, can cause life threatening hemorrhage  TREATMENT  IM / oral Methorexate single dose of 50 mg/m2 -TOC  Reoperation and further evacuation / Salpingectomy  Pregnancy does not completely resolve after expectant     mgt Persistence of chorionic villi with bleeding into tubal wall slow distension , no rupture Amenorrhoea, symptomatic pelvic mass, BHCGlow/absent, bowel/ureteral obstructive symptoms DIAGNOSIS: USG TREATMENT: Removal of affected tube, ovary removed Non tubal pregnancy –types  Cervical(0.1-1%)  Ovarian(0.5-2%)  Abdominal(0.3-0.5%)  Interstitial(2-3%)  Angular  Cornual(1:1lakh)  Heterotropic  Multiple ectopic pregnancy  Ectopic in caesarean scar<1%)  Pregnancy after hysterectomy Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus. As such a horn is capable of some hypertrophy and distension, rupture usually does not occur before 16-20 weeks. Management affected cornual pregnancy is removed hysteroscopic resection, hysterectomy  Thick section of tube- expands max capacity before rupture(7-16w)  2.4% of all ectopics  Late presentation rate  Most dangerous –torrential haemorrhage(dual supply) mgt:  MTX – stable  Laparoscopic cornuostomy -unstable .  Hysteroscopic resection with selective arterial embolisation, Inj kcl  Hysterectomy(rupture) Rubin1911 (following hysterectomy) Paalman McElin 1959 (Before hysterctomy) • Uterus smaller than the surrounding distended cervix • External os may be open • Visible cervical lesion often blue or purple in colour • Profuse bleeding on manipulation of cervix • Amenorrhoea  painless bleeding • Softened enlarged cervix to the size of uterine corpus • Products of conception entirely confined & firmly attached to endocervix • Closed internal os and partially open external os  Gestatational sac /placental tissue visualizd within      cervix Cardiac motion noted below the level of internal os No intrauterine pregnancy’ Hourglass uterine shape with ballooned cervial canal No movement of sac with pressure from transvaginal probe(no sliding sign) Closed internal os Diagnosis  Clinical- painless vaginal bleeding/crampy pain 1/3massive harmorrhage Very rarely>20 weeks  Imaging- USG: true cervical pregnancy vs ongoing spontaneous abortion: no sliding sign  MRI pelvis D/D:  Carcinoma, cervical/prolapsed submucosal leiomyoma  Trophoblastic tumor  Placenta praevia Medical treatment with MTX,KCL surgical dilation & curettage fetal cardiac activity- Cervical pregnancy-Management Multidose MTX+KCL injection Evacuation and cervical packing with haemostatic agent as fibrin glue and gauze. Lateral cervical suture placement Cervical cerclage Angiographic Arterial embolization Laparotomy-uterine artery& internal iliac artery ligation If bleeding continues or extensive rupture occurs hysterectomy is needed. MC type of non tubal ectopic Aetiology: * Pelvic adhesions. * Favourable ovarian surface for implantation as in ovarian endometriosis. Pathogenesis: * Fertilization of the ovum inside the ovary or, * implantation of the fertilized ovum in the ovary. Spiegelberg criteria(1878) * The gestational sac located in the region of the ovary, * the ectopic 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.  Misdiagnosis very common(Ruptured corpus luteal cyst75%)  Laparotomy ovarian cystectomy/wedge resection for unruptured and oophorectomy for ruptured.  Treatment with MTX and prostaglandin injection has also been reported • Studifords criteria for diagnosis primary abdominal pregnancy Secondary • Presence of normal tubes & ovaries with no evidence of recent or past pregnancy • No e/o uteroplacental fistula • presence of a pregnancy related exclusively to the peritoneal surface & early enough to eliminate the possibility of secondary implantation after primary tubal nidation • usually after tubal rupture or abortion • conceptus escapes out through a rent from primary site – Intraperitoneal or Extraperitoneal broad ligament • type of abdominal but extraperitoneal pregnancy. It develops between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the myometrium) pregnancy. Intraligamentous pregnancy Diagnosis: History: amenorrhoea  an attack of lower abdominal pain & slight vaginal bleeding which subsided spontaneously., painful FM Abdominal examination:  Unusual transverse or oblique lie.  Foetal parts are felt very superficial with no uterine muscle wall around. Vaginal examination:  The uterus is soft, about 8 weeks and separate from the foetus.  Displaced uterine cervix  No presenting part in the pelvis. Special investigations: Plain X-ray: shows abnormal lie. In lateral view, the foetus overshadows the maternal spines . Ultrasound: diagnoses only 40%,shows no uterine wall around the foetus (MRI): has a particular importance in preoperative detection of placental anatomic relationships. If pregnancy continues to term Perinatal mortality& morbidity is also increased(IUGR, congenital anomalies, fetal pulmonary hypoplasia, pressure deformities) maternal morbidity& mortality highly increased(7-8X, 50X)  laparotomy with removal of sac,fetus,placenta,membranes  placenta if attached to vital structures -left in situ after ligating base  Placental involution serial USG, BHCG  MTX treatment contraindicated -high rate of complications due to rapid tissue necrosis ANGULAR PREGNANCY Implantation at lateral angle of uterine cavity just medial to uterotubal junction In true sense not variety of ectopic pregnancy Confused with interstitial pregnancyround ligament lies medial to it.  intrauterine+ extrauterine       pregnancy coexist 1:1001:30000 ART patients Delayed diagnosis Serial B HCG NOT useful Surgical treatment of ectopic & intrauterine if desired Continue Spontaneous abortion high Newly highlighted Prior CS csar, outside normal uterine cavity Completely surrounded by myometrium & fibrous I: 1:800-1:2200 Imaging: sac well perfused(i/c/t avascular aborting GS) USG criteria:  Trophoblast located b/w blader and anterior abdominal wall  Fetal pole absent in uterine cavity  Sagittal view through amniotic sac no myometrium b/w GS and bladder  Lack of continuity of anterior uterine wall Management: no role of expectant mgt –risk- uterine rupture  MTX, Hysteroscopic resection, uterus preserving wedge resection, hysterectomy     Pregnancy after hysterectomy Multiple ectopic pregnancy  Supracervical  Twin/multiple ectopic hysterectomy provides cervical canal intraperitoneal access  Pregnancy in periop period with implantation of already fertilized ovum in tube  After TAH secondary to vaginal mucosal defect that allows sperm into abdominal cavity pregnancies- less frequent  Variety of locations and combinations  ART  Treatment: similar to others consensus and expert opinion (Level C): limited or inconsistent evidence (Level B): good and consistent evidence (Level A): • If the initial hCG level is less than 200 mU/mL, 88% of patients experience spontaneous resolution. • An increase in serum hCG of < 53% in 48 hr confirms an abnormal pregnancy. • With an hCG level of > 5,000 mIU/mL, multiple doses MTX may be appropriate. • MTX can be considered in those women with a confirmed, or high clinical suspicion of, ectopic pregnancy who are hemodynamically stable with an unruptured mass. • Failure of the hCG level to decrease by at least 15% from day 4 to day 7 after MTX administration  treatment failure requiring therapy with either additional MTX / surgical intervention. • Post-treatment hCG levels monitored until a nonpregnancy level is reached • In comparing systemic methotrexate with tube-sparing laparoscopic surgery, randomized trials have shown no difference in overall tubal preservation, tubal patency, repeat ectopic pregnancy, or future pregnancies Surgical management of tubal pregnancy  laparoscopic approach to the surgical management of tubal pregnancy, in the haemodynamically stable patient, is preferable to an open approach.( A: evidence Ia)  Management of tubal pregnancy in the presence of haemodynamic instability should be by the most expedient method. In most cases this will be laparotomy.( C:evidenceIV)  In the presence of a healthy contralateral tube there is no clear evidence that salpingotomy should be used in preference to salpingectomy(B:EvidenceIIa).  Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contralateral tubal disease and the desire for future fertility. (B:EvidenceIIa). Medical management of tubal pregnancy  Medical therapy should be offered to suitable women, and units should have treatment and follow-up protocols for the use of methotrexate in the treatment of ectopic pregnancy(B:EvidenceIIa)..  If medical therapy is offered, women should be given clear information (preferably written) about the possible need for further treatment and adverse effects following treatment. Women should be able to return easily for assessment at any time during follow-up. (B:EvidenceIIa).  Women most suitable for methotrexate therapy are those with a serum hCG below 3000 iu/l, and minimal symptoms. (B:EvidenceIIa).  Outpatient medical therapy with single-dose methotrexate is associated with a saving in treatment (A: evidenceIb) Expectant management of pregnancy of unknown location  Expectant management is an option for clinically stable women with minimal symptoms and a pregnancy of unknown location. (C:EvidenceIII)  Expectant management is an option for clinically stable asymptomatic women with an ultrasound diagnosis of ectopic pregnancy and a decreasing serum hCG, initially less than serum 1000 iu/l. (C:EvidenceIII) Persistent trophoblast When salpingotomy is used for the management of tubal pregnancy, protocols should be in place for the identification and treatment of women with persistent trophoblast.( EvidenceIV) Anti-D immunoglobulin  Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin. .( EvidenceIV) Patient involvement  Women should be carefully advised, whenever possible, of the advantages and disadvantages associated with each approach used for the treatment of ectopic pregnancy. They should participate fully in the selection of the most appropriate treatment. .( EvidenceIV) THANK YOU