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Ectopic pregnancy
ECTOPIC PREGNANCY

In ectopic pregnancy, a fertilized ovum implants
in an area other-than the endometrial lining of
the uterus
 More than 95o/o of extrauterine Pregnancies-
occuri n the fallopian tube.
Isthmic     Ampullary
                       Interstitial and    12%         70%
                       cornual 2–3%



                                          Ovarian 3%
                                                        Fimbrial
               Cesarean scar                            11%
               <1



Abdominal 1%                      Cervical <1%




       Sites of ectopic pregnancie
incidence
 The incidence in the United Kingdom has changed
  little in the last decade with 9.6 ectopics per 1000
  pregnancies in 1991–1993 and 11.0 per 1000 pregnancies
  in 2000–2002
This may be due, at least in part, to a higher incidence
of salpingitis, an increase in ovularion induction
and assisted reproductive technology, and more
tubal sterilization
Increasing Ectopic Pregnancy
Rates
A number of reasons at least partially explain the increased
  rate of ectopic pregnancies in the United States and many
  European countries. Some of these include:
1. Increasing prevalence of sexually transmitted infections,
  especially those caused by Chlamydia trachomatis
2. Identification through earlier diagnosis of some ectopic
pregnancies otherwise destined to resorb spontaneously
3. Popularity of contraception that predisposes pregnancy
  failures to be ectopic
4. Tubal sterilization techniques that with contraceptive
  failure increase the likelihood of ectopic pregnancy
5. Assisted reproductive technology
6. Tubal surgery, including salpingotomy for tubal pregnancy
  and tuboplasty for infertility.
Mortality
 According to the World Health Organization (2007),
 ectopic pregnancy is responsible for almost 5 percent of
 maternal deaths in developed countries.
Risk factors for ectopic
pregnancy
   History of previous ectopic pregnancy
   (IUCD) or sterilization failure
   Pelvic inflammatory disease
   Chlamydia infection
   Early age of intercourse and multiple partners
   History of infertility
   Previous pelvic surgery
   Increased maternal age
   Cigarette smoking
   Strenuous physical exercise
   In utero DES exposure
TUBAL PREGNANCY
 The fertilized ovum may lodge in any portion of the
  oviduct, giving rise to ampullary, isthmic, and interstitial
  tubal pregnancies
In rare instances, the fertilized ovum may implant in the
  fimbriated extremity. The ampulla is the most frequent
  site, followed by the isthmus. Interstitial pregnancy
  accounts for only about 2 percent. From these primary
  types, secondary forms of tubo-abdominal, tubo-ovarian,
  and broadligament pregnancies occasionally develop.
Ectopic pregnancy
Clinical presentation
1-subacute clinical picture of
A. abdominal pain &vaginal bleeding in early pregnancy.
    Vaginal bleeding is usually dark red, indicative old blood
B- abdominal/ pelvic pain may be localized to the iliac fossa.
C- sholder tip pain indicative of free blood in the abdominal cavity
D- dizzeness (anaemia)
Bimanual examination can reveal tenderness in the fornices and there
  may be cervical excitation
2- Acute clinical presentation due to rupture ectopic pregnancy with
  massive intraperitoneal bleeding. They can present with signs of
  hypovolaemic shock & acute abdomen
Investigation
 The following are useful investigation for the diagnosis of
    ectopic pregnancy
   1- observations :Bp, pulse ,temperatuer
   2- laboratory investigations:
   Haemoglobin. blood group(prepare blood forr cross match) &
    B-HCG
   A B-HCG level of less than 5mIU/ml, is considered negative
    for pregnancy& any thing above 25 mIU/ml is considered
    positive for pregnancy
   In 85% of pregnancy the B-HCG levels almost double every 48
    hours in normally developing intrautrine pregnancy
In ectopic pregnancy the rise in B-HCG is suboptimal,. However
  multiple readings are required for comparison purposes.
Transvaginal ultrasound scan (TVS)
An intrauterine gestational sac should be visualized at 4.5 weeks
Gestation.the corresponding B-HCG at that gestation is around
  1500 mIU/ml.By the time a gestational sac with fetal heart
  pulsation is detcted (at around 5 weeks gestation)B-HCGlevel
  should be around 3000 mIU/ml
Thus , if there were discrepancy betwween B-HCG cocentration
  and that seen on ultrasound scan(e.g.a highB-HCG with no
  intruterine pregnancy on ultrasound scan), the differential
  diagnosis of an ectopic pregnancy must be made.
 Identification of an intruterine pregnancy(gestational sac, yolk
  sac, and fetal pole) on TVS effectively excludes the possibility
  of ectopic pregnancy in most patients except in those patients
  with rare hterotopic pregnancy.
 The presence of free fluid during TVSis suggestive of a
  ruptured cetopic pregnancy
 Lparoscopy:this can be used to diagnose and treat ectopic
  pregnancy
Culdocentesis
This simple technique was used commonly in the past to
 identify hemoperitoneum. The cervix is pulled toward the
 symphysis with a tenaculum, and a long 16- or 18-gauge
 needle is inserted through the posterior vaginal fornix into
 the cul-de-sac. If present, fluid can be aspirated, however,
 failure to do so is interpreted only as unsatisfactory entry into
 the cul-de-sac and does not exclude an ectopic pregnancy,
 either ruptured or unruptured. Fluid containing fragments of
 old clots, or bloody fluid that does not clot, is compatible
 with the diagnosis of hemoperitoneum resulting from an
 ectopic pregnancy. If the blood subsequently clots, it may
 have been obtained from an adjacent blood vessel rather
 than from a bleeding ectopic pregnancy.
Ectopic pregnancy
Ultrasound
 With the advent of diagnostic ultrasound and the
 increasing use of conservative treatment, the diagnosis
 of ectopic pregnancy is increasingly made without the
 help of surgery.

                                             Gestational sac
                                            with a live
                                   embryo
                                               and a yolk sac
                                   Uterus
In women with ectopic pregnancies bleeding within the
uterine cavity may resemble an early intrauterine
  pregnancy (‘pseudosac’).
 The presence of free fluid in the pouch of Douglas is a
frequent finding in women with normal intrauterine
  pregnancies and it should not be used to diagnose an
  ectopic. However, the presence of blood clots is
  important and is a common finding in ruptured
  ectopics
In women with intrauterine pregnancy on the scan a
possibility of heterotopic pregnancy should be excluded.
This is particularly the case in women who conceived
  after stimulation of ovulation orIVF (in vitro
  fertilization).
Serum Progesterone. A single progesterone measurement
can be used to establish with high reliability that there is a
  normally developing pregnancy. A value exceeding 25
  ng/mL excludes ectopic pregnancy with 92.5-percent
  sensitivity .
 Conversely, values below 5 ng/mL are found in only 0.3
  percent of normal pregnancies . Thus, values 5 ng/mL
  suggest either an intrauterine pregnancy with a dead fetus
  or an ectopic pregnancy. Because in most ectopic
  pregnancies, progesterone levels range between 10 and 25
  ng/mL, the clinical utility is limited
Novel Serum Markers. A number of
preliminary studies have
  been done to evaluate novel markers to detect ectopic
    pregnancy. These include vascular endothelial growth
    factor (VEGF), cancer antigen 125 (CA125), creatine
    kinase, fetal fibronectin, and mass spectrometry-based
    proteomics None of these are in current clinical use.
 Differential diagnosis
The diagnosis is from any other acute abdominal
catastrophe such as rupture of a viscus or acute
peritonitis. The clinical picture is so typical that in
most cases diagnosis presents no difficulty. Other
diagnoses which may confuse are:
• inevitable miscarriage;
• bleeding with an ovarian cyst;
• pelvic appendicitis;
• acute salpingitis.
Management
Expectant management
 Expectant management has important advantages over
   medical treatment as it follows the natural history of the
   disease and is free from serious side effects of
   methotrexate. Expectant management requires prolonged
   follow-up and it may cause anxiety to both women and
   their carers.
However, the main limiting factor in the use of expectant
management is the relatively high failure rate and
the inability to identify with accuracy the cases that are
likely to fail expectant management. To minimize the
risk of failure many authors have used very strict selection
criteria for expectant management such as the initial
hCG <250 IU
Surgery

Surgery has been traditionally used both for the
  diagnosis and treatment of ectopic pregnancy.
With recent advances in operative laparoscopy, the
  minimally invasive approach has also become accepted
  as the method of choice to treat most tubal ectopic
  pregnancies.
There are important advantages of laparoscopic over
  open surgery which include less post-operative pain,
  shorter hospital stay and faster resumption of social
  activity
Laporatomy
In a case of severe haemorrhage in ruptured ectopic
  pregnancy , the patient must be taken immediately to
  the operating theatre. Little time should be wasted in
  attempting resuscitation which can prove useless and
  may only increase bleeding. An intravenous drip
  should be set up and a blood transfusion given as soon
  as possible.
 Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic
  pregnancy unless the woman is hemodynamically unstable
 Tubal surgery is considered
*conservative when there is tubal salvage. Examples
  include salpingostomy, salpingotomy, and fimbrial
  expression of the ectopic pregnancy.
 *Radical surgery is defined by salpingectomy.
Laparoscopy techniques exist to:
• kill the embryo with a direct injection of
methotrexate or mifepristone allowing absorption
so requiring no surgery on the tube;
• incise the swollen tube over the ectopic pregnancy,
aspirate the embryo, and achieve
haemostasis (salpingostomy).
Salpingostomy. This procedure is used to remove a small
  pregnancy that is usually less than 2 cm in length and
  located in the distal third of the fallopian tube . A 10- to
  15- mm linear incision is made with unipolar needle
  cautery on the antimesenteric border over the pregnancy.
  The products usually will extrude from the incision and
  can be carefully removed or flushed out using high-
  pressure irrigation that more thoroughly
removes the trophoblastic tissue
Linear salpingostomy for ectopic
pregnancy
 Salpingotomy. Seldom performed today, salpingotomy
 is essentially the same procedure as salpingostomy except
 that the incision is closed with delayed-absorbable suture..
 Salpingectomy. Tubal resection may be used for
 both ruptured and unruptured ectopic pregnancies.
 When removing the oviduct, it is advisable to excise a
 wedge of the outer third (or less) of the interstitial portion
 of the tube. This so-called cornual resection is done in an
 effort to minimize the rare recurrence of pregnancy in the
 tubal stump. Even with cornual resection, however, a
 subsequent interstitial pregnancy is not always prevented .
Persistent Trophoblast. Incomplete removal of
 trophoblast
may result in persistent ectopic pregnancy. Because of this,
 administered a “prophylactic” 1 mg/m2 dose of
 methotrexate postoperatively. Persistent trophoblast
 complicates 5 to 20 percent of salpingostomies and can be
 identified by persistent or rising hCG levels. Usually -
hCG levels fall quickly and are at about 10 percent of
 preoperative values by day 12 . Also, if the postoperative
 day 1 serum - hCG value is less than 50 percent of the
 preoperative value, then persistent trophoblast rarely is a
 problem
Medical Management with Methotrexate
This folic acid antagonist is highly effective against rapidly
 proliferating trophoblast, and it has been used for more
 than 40 years to treat gestational trophoblastic disease
Selection criteria for conservative management of ectopic
  pregnancy
1. Minimal clinical symptoms
2. Certain ultrasound diagnosis of ectopic
3. No evidence of embryonic cardiac activity
4. Size <5 cm
5. No evidence of haematoperitoneum on ultrasound scan
6. Low serum hCG (methotrexate <3000 IU/l; expectant
7. <1500 IU/l)
 The followin are resonable indications for
    methotrexate use
   1-cornual pregnancy
   2-Prsistant trophoblastic disorders
   3- patient with one fallopian tubeand fertility desired .
   4-patient who refuse surgery or whome surgery is risky
   5-treatment of ectopic pregnancy where trophoblast is
    adherent to bowel or blood vessel
Contrindications of medical
treatment
 1- chronic liver, renal or haematological disordes
 2- active infection
 3-immunodeficency
 4- breast feeding
Side effect of methotrexate
nausea.vomiting ,stomatitis, cojuctivitis, GI upset,
  photosensitive skin reaction Abdominal pain
Advise the women to take contraception for three months
  after methotreate. It is also important to avoid alcohol &
  exposure to sunlight during treatment
 Non-tubal ectopics
Interstitial ectopics
The implantation of the conceptus in the proximal portion
of the Fallopian tube, which is within the muscularwall
of the uterus, is called an interstitial pregnancy. The
  incidence of interstitial ectopic is 1 in 2500–5000 live
  births and it accounts for2–6% of all ectopic pregnancies
Ruptured interstitial pregnancy usually presents
  dramatically with severe intra-abdominal bleeding, which
requires urgent surgery. Haemostasis can usually be
achieved by removing the pregnancy tissue and suturing
the rupture site. However, in cases of extreme bleeding a
cornual resection or in rare cases a hysterectomy may be
necessary to arrest the bleeding.
The sac is completely surrounded by a myometrial
 mantle, which is typical of
 interstitial pregnancy.
Pregnancies located below the internal os –cervical
and Caesarean scar ectopics
Cervical pregnancy is defined as the implantation of the
 conceptus within the cervix, below the level of the
 internal os. Caesarean scar pregnancy is a novel entity,
 which refers to a pregnancy implanted into a deficient
 uterine scar following previous lower segment
 Caesarean section
 An attempt to remove cervical or Caesarean section
pregnancy is likely to cause severe vaginal bleeding and
hysterectomy rates of 40% have been described when
a D&C was attempted without pre-operative diagnosis
of cervical pregnancy
 Ovarian pregnancy
Ovarian pregnancy is defined as the implantation of the
conceptus on the surface of the ovary or inside the ovary,
away from the fallopian tubes
. The diagnosis of ovarian pregnancy is rarely achieved
pre-operatively; hence most women are treated
   surgically as the diagnosis is reached only at operation
Abdominal pregnancy
Abdominal pregnancy is a rarity that only a few
gynaecologists will encounter during their professional
career. Most abdominal pregnancies are the result of
  reimplantation of ruptured undiagnosed tubal ectopic
  pregnancies.
With the increasing accuracy of first-trimester
transvaginal scanning it is likely the prevalence of
advanced abdominal pregnancy will decrease even further
in the future.
The clinical and ultrasound features
of an early abdominal pregnancy are very similar to
tubal ectopic pregnancies. However, viable abdominal
pregnancies, which progress beyond the first trimester,
are typically missed on routine transabdominal scanning.
Abdominal pregnancy should be suspected in women
with persistent abdominal pain later in pregnancy and
in those who complain of painful fetal movements.
Treatment of abdominal pregnancy is surgical. In
  advanced abdominal pregnancies
  accompanied by normal fetal development diagnosed
  in the late second trimester termination of pregnancy
  may be delayed for a few weeks until the fetus reaches
  viability.
At surgery the gestational sac should be opened carefully
avoiding disruption of the placenta. The fetus should be
removed, the cord cut short and the placenta should be
  left in situ .
Any attempt to remove the placenta may result
in massive uncontrollable haemorrhage. Adjuvant
  treatment with methotrexate is not necessary and the
  residual placental tissue will absorb slowly over a
  period of many months, sometimes a few years. The
  placental tissue left in situ may become infected
  leading to the formation of a pelvic abscess, which may
  require drainage.

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Ectopic pregnancy

  • 2. ECTOPIC PREGNANCY In ectopic pregnancy, a fertilized ovum implants in an area other-than the endometrial lining of the uterus More than 95o/o of extrauterine Pregnancies- occuri n the fallopian tube.
  • 3. Isthmic Ampullary Interstitial and 12% 70% cornual 2–3% Ovarian 3% Fimbrial Cesarean scar 11% <1 Abdominal 1% Cervical <1% Sites of ectopic pregnancie
  • 4. incidence  The incidence in the United Kingdom has changed little in the last decade with 9.6 ectopics per 1000 pregnancies in 1991–1993 and 11.0 per 1000 pregnancies in 2000–2002 This may be due, at least in part, to a higher incidence of salpingitis, an increase in ovularion induction and assisted reproductive technology, and more tubal sterilization
  • 5. Increasing Ectopic Pregnancy Rates A number of reasons at least partially explain the increased rate of ectopic pregnancies in the United States and many European countries. Some of these include: 1. Increasing prevalence of sexually transmitted infections, especially those caused by Chlamydia trachomatis 2. Identification through earlier diagnosis of some ectopic pregnancies otherwise destined to resorb spontaneously
  • 6. 3. Popularity of contraception that predisposes pregnancy failures to be ectopic 4. Tubal sterilization techniques that with contraceptive failure increase the likelihood of ectopic pregnancy 5. Assisted reproductive technology 6. Tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty for infertility.
  • 7. Mortality  According to the World Health Organization (2007), ectopic pregnancy is responsible for almost 5 percent of maternal deaths in developed countries.
  • 8. Risk factors for ectopic pregnancy  History of previous ectopic pregnancy  (IUCD) or sterilization failure  Pelvic inflammatory disease  Chlamydia infection  Early age of intercourse and multiple partners  History of infertility  Previous pelvic surgery  Increased maternal age  Cigarette smoking  Strenuous physical exercise  In utero DES exposure
  • 9. TUBAL PREGNANCY  The fertilized ovum may lodge in any portion of the oviduct, giving rise to ampullary, isthmic, and interstitial tubal pregnancies In rare instances, the fertilized ovum may implant in the fimbriated extremity. The ampulla is the most frequent site, followed by the isthmus. Interstitial pregnancy accounts for only about 2 percent. From these primary types, secondary forms of tubo-abdominal, tubo-ovarian, and broadligament pregnancies occasionally develop.
  • 11. Clinical presentation 1-subacute clinical picture of A. abdominal pain &vaginal bleeding in early pregnancy. Vaginal bleeding is usually dark red, indicative old blood B- abdominal/ pelvic pain may be localized to the iliac fossa. C- sholder tip pain indicative of free blood in the abdominal cavity D- dizzeness (anaemia) Bimanual examination can reveal tenderness in the fornices and there may be cervical excitation 2- Acute clinical presentation due to rupture ectopic pregnancy with massive intraperitoneal bleeding. They can present with signs of hypovolaemic shock & acute abdomen
  • 12. Investigation  The following are useful investigation for the diagnosis of ectopic pregnancy  1- observations :Bp, pulse ,temperatuer  2- laboratory investigations:  Haemoglobin. blood group(prepare blood forr cross match) & B-HCG  A B-HCG level of less than 5mIU/ml, is considered negative for pregnancy& any thing above 25 mIU/ml is considered positive for pregnancy  In 85% of pregnancy the B-HCG levels almost double every 48 hours in normally developing intrautrine pregnancy
  • 13. In ectopic pregnancy the rise in B-HCG is suboptimal,. However multiple readings are required for comparison purposes. Transvaginal ultrasound scan (TVS) An intrauterine gestational sac should be visualized at 4.5 weeks Gestation.the corresponding B-HCG at that gestation is around 1500 mIU/ml.By the time a gestational sac with fetal heart pulsation is detcted (at around 5 weeks gestation)B-HCGlevel should be around 3000 mIU/ml Thus , if there were discrepancy betwween B-HCG cocentration and that seen on ultrasound scan(e.g.a highB-HCG with no intruterine pregnancy on ultrasound scan), the differential diagnosis of an ectopic pregnancy must be made.
  • 14.  Identification of an intruterine pregnancy(gestational sac, yolk sac, and fetal pole) on TVS effectively excludes the possibility of ectopic pregnancy in most patients except in those patients with rare hterotopic pregnancy.  The presence of free fluid during TVSis suggestive of a ruptured cetopic pregnancy  Lparoscopy:this can be used to diagnose and treat ectopic pregnancy
  • 15. Culdocentesis This simple technique was used commonly in the past to identify hemoperitoneum. The cervix is pulled toward the symphysis with a tenaculum, and a long 16- or 18-gauge needle is inserted through the posterior vaginal fornix into the cul-de-sac. If present, fluid can be aspirated, however, failure to do so is interpreted only as unsatisfactory entry into the cul-de-sac and does not exclude an ectopic pregnancy, either ruptured or unruptured. Fluid containing fragments of old clots, or bloody fluid that does not clot, is compatible with the diagnosis of hemoperitoneum resulting from an ectopic pregnancy. If the blood subsequently clots, it may have been obtained from an adjacent blood vessel rather than from a bleeding ectopic pregnancy.
  • 17. Ultrasound  With the advent of diagnostic ultrasound and the increasing use of conservative treatment, the diagnosis of ectopic pregnancy is increasingly made without the help of surgery. Gestational sac with a live embryo and a yolk sac Uterus
  • 18. In women with ectopic pregnancies bleeding within the uterine cavity may resemble an early intrauterine pregnancy (‘pseudosac’). The presence of free fluid in the pouch of Douglas is a frequent finding in women with normal intrauterine pregnancies and it should not be used to diagnose an ectopic. However, the presence of blood clots is important and is a common finding in ruptured ectopics
  • 19. In women with intrauterine pregnancy on the scan a possibility of heterotopic pregnancy should be excluded. This is particularly the case in women who conceived after stimulation of ovulation orIVF (in vitro fertilization).
  • 20. Serum Progesterone. A single progesterone measurement can be used to establish with high reliability that there is a normally developing pregnancy. A value exceeding 25 ng/mL excludes ectopic pregnancy with 92.5-percent sensitivity .  Conversely, values below 5 ng/mL are found in only 0.3 percent of normal pregnancies . Thus, values 5 ng/mL suggest either an intrauterine pregnancy with a dead fetus or an ectopic pregnancy. Because in most ectopic pregnancies, progesterone levels range between 10 and 25 ng/mL, the clinical utility is limited
  • 21. Novel Serum Markers. A number of preliminary studies have been done to evaluate novel markers to detect ectopic pregnancy. These include vascular endothelial growth factor (VEGF), cancer antigen 125 (CA125), creatine kinase, fetal fibronectin, and mass spectrometry-based proteomics None of these are in current clinical use.
  • 22.  Differential diagnosis The diagnosis is from any other acute abdominal catastrophe such as rupture of a viscus or acute peritonitis. The clinical picture is so typical that in most cases diagnosis presents no difficulty. Other diagnoses which may confuse are: • inevitable miscarriage; • bleeding with an ovarian cyst; • pelvic appendicitis; • acute salpingitis.
  • 24. Expectant management  Expectant management has important advantages over medical treatment as it follows the natural history of the disease and is free from serious side effects of methotrexate. Expectant management requires prolonged follow-up and it may cause anxiety to both women and their carers. However, the main limiting factor in the use of expectant management is the relatively high failure rate and the inability to identify with accuracy the cases that are likely to fail expectant management. To minimize the risk of failure many authors have used very strict selection criteria for expectant management such as the initial hCG <250 IU
  • 25. Surgery Surgery has been traditionally used both for the diagnosis and treatment of ectopic pregnancy. With recent advances in operative laparoscopy, the minimally invasive approach has also become accepted as the method of choice to treat most tubal ectopic pregnancies. There are important advantages of laparoscopic over open surgery which include less post-operative pain, shorter hospital stay and faster resumption of social activity
  • 26. Laporatomy In a case of severe haemorrhage in ruptured ectopic pregnancy , the patient must be taken immediately to the operating theatre. Little time should be wasted in attempting resuscitation which can prove useless and may only increase bleeding. An intravenous drip should be set up and a blood transfusion given as soon as possible.
  • 27.  Surgical Management Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless the woman is hemodynamically unstable  Tubal surgery is considered *conservative when there is tubal salvage. Examples include salpingostomy, salpingotomy, and fimbrial expression of the ectopic pregnancy.  *Radical surgery is defined by salpingectomy.
  • 28. Laparoscopy techniques exist to: • kill the embryo with a direct injection of methotrexate or mifepristone allowing absorption so requiring no surgery on the tube; • incise the swollen tube over the ectopic pregnancy, aspirate the embryo, and achieve haemostasis (salpingostomy).
  • 29. Salpingostomy. This procedure is used to remove a small pregnancy that is usually less than 2 cm in length and located in the distal third of the fallopian tube . A 10- to 15- mm linear incision is made with unipolar needle cautery on the antimesenteric border over the pregnancy. The products usually will extrude from the incision and can be carefully removed or flushed out using high- pressure irrigation that more thoroughly removes the trophoblastic tissue
  • 30. Linear salpingostomy for ectopic pregnancy
  • 31.  Salpingotomy. Seldom performed today, salpingotomy is essentially the same procedure as salpingostomy except that the incision is closed with delayed-absorbable suture..
  • 32.  Salpingectomy. Tubal resection may be used for both ruptured and unruptured ectopic pregnancies. When removing the oviduct, it is advisable to excise a wedge of the outer third (or less) of the interstitial portion of the tube. This so-called cornual resection is done in an effort to minimize the rare recurrence of pregnancy in the tubal stump. Even with cornual resection, however, a subsequent interstitial pregnancy is not always prevented .
  • 33. Persistent Trophoblast. Incomplete removal of trophoblast may result in persistent ectopic pregnancy. Because of this, administered a “prophylactic” 1 mg/m2 dose of methotrexate postoperatively. Persistent trophoblast complicates 5 to 20 percent of salpingostomies and can be identified by persistent or rising hCG levels. Usually - hCG levels fall quickly and are at about 10 percent of preoperative values by day 12 . Also, if the postoperative day 1 serum - hCG value is less than 50 percent of the preoperative value, then persistent trophoblast rarely is a problem
  • 34. Medical Management with Methotrexate This folic acid antagonist is highly effective against rapidly proliferating trophoblast, and it has been used for more than 40 years to treat gestational trophoblastic disease
  • 35. Selection criteria for conservative management of ectopic pregnancy 1. Minimal clinical symptoms 2. Certain ultrasound diagnosis of ectopic 3. No evidence of embryonic cardiac activity 4. Size <5 cm 5. No evidence of haematoperitoneum on ultrasound scan 6. Low serum hCG (methotrexate <3000 IU/l; expectant 7. <1500 IU/l)
  • 36.  The followin are resonable indications for methotrexate use  1-cornual pregnancy  2-Prsistant trophoblastic disorders  3- patient with one fallopian tubeand fertility desired .  4-patient who refuse surgery or whome surgery is risky  5-treatment of ectopic pregnancy where trophoblast is adherent to bowel or blood vessel
  • 37. Contrindications of medical treatment  1- chronic liver, renal or haematological disordes  2- active infection  3-immunodeficency  4- breast feeding Side effect of methotrexate nausea.vomiting ,stomatitis, cojuctivitis, GI upset, photosensitive skin reaction Abdominal pain Advise the women to take contraception for three months after methotreate. It is also important to avoid alcohol & exposure to sunlight during treatment
  • 38.  Non-tubal ectopics Interstitial ectopics The implantation of the conceptus in the proximal portion of the Fallopian tube, which is within the muscularwall of the uterus, is called an interstitial pregnancy. The incidence of interstitial ectopic is 1 in 2500–5000 live births and it accounts for2–6% of all ectopic pregnancies
  • 39. Ruptured interstitial pregnancy usually presents dramatically with severe intra-abdominal bleeding, which requires urgent surgery. Haemostasis can usually be achieved by removing the pregnancy tissue and suturing the rupture site. However, in cases of extreme bleeding a cornual resection or in rare cases a hysterectomy may be necessary to arrest the bleeding.
  • 40. The sac is completely surrounded by a myometrial mantle, which is typical of interstitial pregnancy.
  • 41. Pregnancies located below the internal os –cervical and Caesarean scar ectopics Cervical pregnancy is defined as the implantation of the conceptus within the cervix, below the level of the internal os. Caesarean scar pregnancy is a novel entity, which refers to a pregnancy implanted into a deficient uterine scar following previous lower segment Caesarean section
  • 42.  An attempt to remove cervical or Caesarean section pregnancy is likely to cause severe vaginal bleeding and hysterectomy rates of 40% have been described when a D&C was attempted without pre-operative diagnosis of cervical pregnancy
  • 43.  Ovarian pregnancy Ovarian pregnancy is defined as the implantation of the conceptus on the surface of the ovary or inside the ovary, away from the fallopian tubes . The diagnosis of ovarian pregnancy is rarely achieved pre-operatively; hence most women are treated surgically as the diagnosis is reached only at operation
  • 44. Abdominal pregnancy Abdominal pregnancy is a rarity that only a few gynaecologists will encounter during their professional career. Most abdominal pregnancies are the result of reimplantation of ruptured undiagnosed tubal ectopic pregnancies. With the increasing accuracy of first-trimester transvaginal scanning it is likely the prevalence of advanced abdominal pregnancy will decrease even further in the future.
  • 45. The clinical and ultrasound features of an early abdominal pregnancy are very similar to tubal ectopic pregnancies. However, viable abdominal pregnancies, which progress beyond the first trimester, are typically missed on routine transabdominal scanning. Abdominal pregnancy should be suspected in women with persistent abdominal pain later in pregnancy and in those who complain of painful fetal movements.
  • 46. Treatment of abdominal pregnancy is surgical. In advanced abdominal pregnancies accompanied by normal fetal development diagnosed in the late second trimester termination of pregnancy may be delayed for a few weeks until the fetus reaches viability. At surgery the gestational sac should be opened carefully avoiding disruption of the placenta. The fetus should be removed, the cord cut short and the placenta should be left in situ .
  • 47. Any attempt to remove the placenta may result in massive uncontrollable haemorrhage. Adjuvant treatment with methotrexate is not necessary and the residual placental tissue will absorb slowly over a period of many months, sometimes a few years. The placental tissue left in situ may become infected leading to the formation of a pelvic abscess, which may require drainage.