Ectopic Pregnancy by Dr Richa KAtiyar, IVF specialist. http://how-to-get-pregnant.in

1. Ectopic Pregnancy
Dr.Richa Katiyar
MBBS, MD (AIIMS), Fellowship ART (Germany)
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

2. Definition
“ Implantation of fertilised ovum
anywhere apart from the endometrial
cavity
“ Incidence – 19.7/ 1000 reported
pregnancies
“CDC and P, 1993
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

3. Incidence by Location
“ Natural conception
“ Tubal- 98.3%
“ Abdominal- 1.4%
“ Cervical- 0.15 %
“ Ovarian- 0.15%
“ Conception after
ART
“ Tubal- 82.2%
“ Cervical- 1.5%
“ Abdominal/ Ovarian-
4.6%
“ Heterotopic- 11.7%
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

4. Risk Factors
“ Tubal surgery
“ Genital infections
“ Infertility & treatment
“ Contraceptive use
“ Smoking
“ Prior abdominal surgery
“ Abortion
“ SIN
“ Endometriosis & leiomyoma
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

5. Diagnosis
“ History- menstrual, obstetric, current
contraceptive status, risk factors, symptoms
“ Symptoms- abd pain, abnormal uterine
bleeding, amenorrhoea, syncope,
dizziness,nausea, urge to defecate.
“ Signs- abd tenderness, peritoneal signs, Cx
excitation, adnexal mass, uterine size,
vomiting, shock
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

6. Evaluation
“RIA- gold standard
“ Urine pregnancy test- uses monoclonal
antibody against βHCG
“ βHCG- if less than 66% rise in 48 hrs-abnormal
pregnancy
“Serum Progesterone- if < 25ng/ml
“ Others- CA-125, MSAFP, CRP, Inhibin
A, Estradiol- nonspecific
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

7. Ultrasonography
pregnancy seen earliest with USG
TVS (weeks) TAUSG(weeks)
Gestational sac 4.3 4.3
Double decidual
4.4 5
outline
Yolk sac 4.6 5
Fetal pole 4.6 6
Fetal heart activity 4.6 6.5
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

8. TVS signs in ectopic
pregnancy
“ Empty uterus sign
“ Pseudogestational sac
“ Tubal or adnexal rings
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

9. β HCG and USG
Discriminatory Zone- that value
of β HCG at which all viable
pregnancies are identified
TA-USG > 6,500mIU/mL
TVS- 1,000-2,000mIU/mL
Color Doppler
Non Gravid uterus- Low peak
systolic, high resistance flow
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

10. Culdocentesis
“ For emergency situations when USG cannot be
done. Non clotting blood- ruptured ectopic
Diagnostic Laparoscopy- Gold Standard
“ Allows for diagnosis & treatment
“ For hemodynamically stable patients
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

11. Natural History of Disease
“ Tubal abortion- i.e. expulsion from
fimbria
“ Tubal rupture- occurs around 8 weeks
“Secondary abdominal pregnancy
“Secondary broad ligament pregnancy
“ Spontaneous involution
“ Chronic ectopic pregnancy (Histology-
Arias Stella reaction)
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

12. Management
Unruptured
Medical- Methotrexate
SAM - surgically
administered medical
M/M)- Mtx, KCL,
PGF2α, Glucose, NaCl,
RU 486
Surgical
Expectant
Ruptured
Hemodynamically
stable-
Laparoscopic or
laparotomy
Hemodynamically
unstable-laparotomy
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

13. Methotrexate
Is a folinic acid antagonist, inhibits syn of
purines & pyramidines
I/C- USG - dia < 4 cm,
βHCG < 15,000mIU/ml
Contra I/C- USG- dia > 4 cm,
- FHA +
“ Rupture
“ Pain > 24 hrs
“ Hepatic, renal, blood, peptic dysfunction
“ Poor pt. compliance
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

14. Single dose Mtx Protocol
“Day 0- βHCG , Blood inv
“Day 1- 50mg/ sqm i.m.
“Day 4- βHCG
“Day 7- βHCG, blood inv
“ If < 15% decline in βHCG b/w D4 and
D7, give 2nd dose MTX
“ If > 15% decline- follow with weekly
titers
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

15. Variable dose Mtx
“Mtx 1 mg/kg – i.m. on days 1,3, 5, 7
“ Leucovorin 0.1 mg/kg i.m. days 2, 4, 6, 8
“ Continue alternate day inj until βHCG
decrease >15% in 48 hrs or 4 inj of Mtx
“ Pt instructions- abstinence, no NSAIDS,
alcohol, folic acid, sunlight, TVS, PV
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

16. Surgical Treatment
“ Salpingostomy- linear incision on
antimesenteric border, ectopic flushed out,
wound healing by secondary intention
“ Salpingotomy- incision closed with 7-0 vicryl
“ Salpingectomy – if FT is diseased/
destroyed, uncontrolled bleeding, large
ectopic, complete family
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

17. Surgical M/M (2)
“Segmental resection and anastomosis
“ Milking – for fimbrial pregnancy
“ Follow up after surgery – weekly β HCG
titers till it falls very low
“ Non sensitized Rh–ve patients–give Anti D
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

18. Expectant M/M
“ For very early pregnancy with falling beta
HCG titres
“ Persistent ectopic – defined as requiring a
2nd course of therapy, when β HCG titres
increase
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com

19. Chronic Ectopic
“ When the ectopic does not completely resorb
“ Persistence of chorionic villi with bleeding into
the Tubal wall/ chronic bleeding from
fimbriated end of FT
“ Signs- amenorrhoea- 5-15 weeks, pain,
bleeding, pelvic mass, USG. β HCG levels-low
or absent
“ Tt- Surgical
Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in
Email: dr.richa.katiyar@gmail.com