Submitted by : Sunita

1. Five percent Pregnant Patients in UK are offered invasive Prenatal Diagnostic tests
2. Additional risk of miscarriage following amniocentesis 1 percent
3. Ultrasound guidance reduces blood stained tap from 2.4 to 0.8 percent
4. Competency should be maintained by carrying out at least 30 ultrasound guided invasive procedures per annum
5. Audit should occur when Pregnancy losses exceed 4 per 100 consecutive amniocentesis or 8/100 CVS
6. Second insertion acceptable in 7 per 100 consecutive amniocentesis
7. Pregnancy loss rate in Midtrimester Amniocentesis 1 in 56 or 1.8 percent
8. Cell culture failure rate at 3rd trimester 9.7percent
9. Rate of transmission in HIV during amniocentesis with no treatment 25 percent and with mono or double therapy 6.1 percent
10. Risk of severe sepsis following invasive procedures less than 1 in 1000 procedures.

Submitted by : Surbhi Gupta 

✓ Incidence of Ectopic Pregnancy : 11/1000 pregnancies

✓ Estimate of 11000 EP diagnosed each year.

✓ Incidence of EP in females attending early pregnancy units: 2-3%

✓ Maternal mortality due to EP : 0.2/1000

✓ About 2/3 of these deaths due to substandard care.

✓ About 1/3 females with EP will have no known rik factor.

✓ Use of TVS for diagnosis of EP : Sensitivity : 87-99%
Specificity 94-99.9%

✓ False negative rate of laparoscopies for diagnosis of EP : 3-4.5%

Findings on TVS in Ectopic Pregnancy :

  • Most common finding – inhomogenous or non cystic adnexal mass – 50-60%
  • Gestational sac with yolk sac/embryonic pole ± cardiac activity – 15-20%
  • Pseudosac in endometrial cavity – 20%
  • Echogenic fluid in POD – 28-56%

Incidence of :

  • Cervical Pregnancy : <1%
  • Caesarean scar pregnancy : 1 in 2000 (0.05%)
  • Interstitial pregnancy : 1-6.3%
  •  Cornual Pregnancy : 1 in 76000 (Rarest form)
  • Abdominal pregnancy : 1% (1 in 2200 to 1 in 10000)

✓ Mortality rates in abdominal pregnancy is 7.7 times higher than tubal pregnancy and 89.8 times higher than intrauterine pregnancy ( TOG 2014)

✓ 13% of reported cases of caesarean scar pregnancy – misdiagnosed as intrauterine or cervical pregnancy at presentation.
✓ Interstitial line sign for diagnosis of interstitial pregnancy :
Sensitivity : 80%
Specificity : 98%

✓ Persistent trophoblast rates after salpingotomy – 3.9-11%
✓ Success rates of single dose methotrexate – 65-95%;
✓ 8-27% require second dose.
✓ Success rates with methotrexate is
81-98% when initial b-hCG is <1000 mIU/ml 38% when b-hCG is > 5000mIU/ml
88-100% when b-hCG decreases from day 1 to day 4
42-62% when b-hCG increases from day 1 to day 4

  • Success rates of expectant management – 57-100%
  • 30% of tubal EP can be managed expectantly.
  • Efficacy of systemic methotrexate in treatment of cervical pregnancy – 91%
  • Alloimmunization in EP – 25% of cases of ruptured EP have significant number of fetal cells in maternal circulation.
  • Rate of recurrent EP- 18.5%
  • About 1 in 5 females may need further treatment having salpingotomy.
Submitted by : Dr Anshika

Ectopic pregnancy

✓ Any pregnancy implanted outside endometrial cavity
Incidence-
• 11/1000 pregnancies in UK
• 2-3 % of women attending early pregnancy unit
Risk factors-
Tubal damage due to surgery/ infection
Smoking
IVF pregnancy

Tubal pregnancy

Majority of ectopic pregnancies
Diagnosis
TVS diagnostic tool of choice which positively identifies adnexal mass that moves separately from ovary .
It is 87-99% sensitive and 94-99.9% specific.
IX
Serum progesterone not useful
Serum Beta HCG to plan and prognosticate management
Laparoscopy no longer gold standard. 3-4.5% negative laparoscopies reported when procedure performed too early during development of ectopic pregnancy
MANAGEMENT
Expectant-
Option for clinically stable women with decreasing Beta hcg levels initially less than 1500 IU/L

Medical/ Pharmacological management-

Systemic Methotrexate maybe offered to suitable women with ectopic pregnancy
Generally 50 mg/m2 given as single dose but multiple doses also described
Overall success rate of methotrexate 65-95% with 3-27% requiring second dose

Predictors of success

# Initial beta hcg level
81-98% when initial serum Beta hcg level is less than 1000 iu/l and 38% if more than 5000 iu/l
# USG-
Presence of yolk sac, fetal pole, cardiac activity predict more chances of failure
More chance of success if no gestational sac identified
# Smaller initial increase in beta hcg prior to administration on repeat 48 hour sample
# D1-D4 level changes-
More success if levels fall as opposed to if they temporarily rise

Adverse effects-

1. Marrow suppression
2. Pulmonary fibrosis
3. Nonspecific pneumonitis
4. Liver cirrhosis
5. Renal failure
6. Gastric ulceration common

Common side effects

1. Excess flatulence or bloating
2. Stomatitis
3. Mild increase in liver enzymes

Good candidate

Haemodynamic stability
Intrauterine pregnancy positively ruled out on TVS
Ideally beta hcg less than 1500 but can be upto 5000
No fetal cardiac activity
Willingness to attend followup
No known sensitivity to Methotrexate

NICE recommends Methotrexate as first line if

1. No significant pain
2. Unruptured mass less than 35 mm
3. No cardiac activity
4. 1500-5000 iu/l initial beta hcg levels
5. No intrauterine pregancy
It should not be given at first visit , unless diagnosis of ectopic is absolutely clear and viable intrauterine pregnancy has been excluded

Support and counseling

• Advantages and disadvantages of all methods to be discussed and active participation of women in selection of most appropriate treatment to be encouraged
• Women should be informed of routes to access to ectopic pregnancy trusts and local bereavement counseling
• Muscle relaxation techniques to be offered to those on Methotrexate
WAIT AT LEAST 3 MONTHS BEFORE CONCEIVING AGAIN- but no indication of termination if inadvertently pregnant in this period
• 7 day EPU access for women referred by GP or A&E services with availability of TVS, Beta hcg levels, diagnostic/ therapeutic algorithms
• Referral pathways if facilities not available locally

Training required for

Surgical and laparoscopic surgery
TVS and USG for diagnosing ectopic
Medical management with USG guided needle techniques
If surgeon is not having full range of skills, then adequate backup and support to be made available

Surgical-
• Laparoscopy preferable to open approach
• If contralateral tube is healthy then salpingectomy preferable to salpingotomy
• In c/o previous ectopic, previous PID, contralateral tubal damage, abdominal surgeries and other fertility reducing factors, salpingotomy to be considerd over salpingectomy
• Women undergoing salpingotomy to be fully informed of risk of persistent trophoblast with need for further f/up with serum Beta hcg , possibility of further treatment with systemic methotrexate or later salpingectomy
• NICE recommends followup with beta hcg after 7 days of salpingotomy and then weekly till Beta hcg less than 15IU/L
TUBAL ECTOPIC

 FUTURE FERTILITY

✓ In absence of h/o subfertility or tubal pathology, women maybe advised that there is no difference in rate of fertility, risk of future tubal ectopic or patency between different management methods
✓  In h/o subfertility , women should be advised that treatment of tubal ectopic pregnancy with expectant or medical management is associated with improved reproductive outcomes over radical surgery
✓  When used in doses for management of tubal ectopic pregnancy, methotrexate has no effect on a woman’s ovarian reserve

Anti D

Offer anti D prophylaxis who
Have surgical removal of ectopic
Where bleeding is repeated, heavy
Abdominal pain

NON TUBAL ECTOPIC PREGNANCIES

Cervical pregnancy
INCIDENCE – less than 1% of ectopic gestations
DIAGNOSIS ON USG-
1. Empty uterus
2. Barrel shaped cervix
3. Gestational sac present below level of internal cervical os
4. Absence of” sliding sign”
5. Blood flow around gestational sac using colour doppler
IX- Single serum beta hcg
DD –miscarriage
Management-
-Medical Rx with Methotrexate chances of success increased with intraamniotic instillation
Success of Methotrexate depends on early, accurate diagnosis and higher rate of success in-
-Gestational age less than 9 weeks although Rx maybe considered till 12+6 weeks
-Absence of fetal cardiac activity
-CRL< 10 mm -Initial beta HCG < 10000 -Surgical methods are associated with higher failure rate and are reserved for those with life threatening haemorrhage . Uterine artery ligation/ embolisation described but associated with complications like infection, uterine infarction, sciatic nerve injury, necrosis of bladder/ rectum. When no alternative available then D and C considered with measures to decrease bleeding but high rates of hysterectomy CERVICAL ECTOPIC

Caesarean scar pregnancy
INCIDENCE– 1 in 2000 pregnancies
DIAGNOSIS
By USG- TVS supplemented by TAS
MRI- when diagnosis unsure and expertise available
1. Empty uterine cavity
2. Gestational sac or solid mass of trophoblast located anteriorly at level of internal os embedded at site of previous lower uterine segment caesarean section
3. Thin/ absent layer of myometrium between gestational sac and bladder
4. Prominent trophoblastic/ placental circulation on Doppler
5. Thin/ absent layer of myometrium between gest sac and bladder
6. Empty endocervical canal
D/D- 13% caesarean scar ectopic were misreported as intrauterine/ cervical pregnancies

REFER TO REGIONAL CENTRE TO CONFIRM DIAGNOSIS

Ix- no biochemical investigation
MANAGEMENT
Medical and surgical interventions with/ without additional haemostatic measures with first trimester pregnancy
Literature supports surgical over medical management
Patient to be counselled about severe maternal morbidity/ mortality.
TYPES-
1. Grows inwards may reach viability but massive haemorrhage from implantation site
2. Grows outwards with early uterine rupture / haemorrhage
CAESAREAN SCAR ECTOPIC

Interstitial pregnancy

INCIDENCE– 1% to 6.3% of ectopic gestations
DIAGNOSIS-
USG-
1. Empty uterine cavity
2. POCs/ gestational sac located laterally in interstitial/ intramural part of tube surrounded by less than 5 mm myometrium in imaging planes
3. 3. Presence of ” interstitial line sign”
3D USG maybe used for confirmation
MRI
D/D– early angular implantation of intrauterine pregnancy
IX– single Beta hcg to decide management sometimes repeated to ascertain diagnosis
MANAGEMENT-
Nonsurgical management- acceptable option for haemodynamically stable patient
Expectant management suitable only for women with low or significantly falling Beta hcg levels
Pharmacological management with Methotrexate acceptable however insufficient evidence for local versus systemic approach
Surgical- laparoscopic or open corneal resection/ laparoscopic salpingotomy
Hysteroscopic resection under laparoscopic or USG guidance
Prognosis depends on clinical presentation, size , fetal activity, serum beta hcg
INTERSTITIAL ECTOPIC

Cornual ectopic
INCIDENCE- 1 IN 76000 pregnancies- rarest
USG-
1. Visualization of single interstitial portion of fallopian tube in main uterine body
2. Gestational sac/ products of conception are mobile and separate from uterus and completely surrounded by myometrium
3. Vascular pedicle adjoining gestational sac to unicornuate uterus
IX-
Single beta hcg repeat after 48 hours maybe reuired
MANAGEMENT-
Surgical – excision of rudimentary horn by laparoscopy or Laparotomy
Sometimes anatomical aberrations of urinary tract may coexist
PROGNOSIS-
clinical presentation, size of corneal pregnancy, serum beta hcg level
CORNUAL ECTOPIC

 Ovarian ectopic

No specified USG criteria
Colour Doppler maybe helpful if fetal cardiac activity identified in ovary
IX-
Single Beta hcg at diagnosis and repeat after 48 hours maybe useful in deciding further management
Diagnosis generally difficult and generally during surgery or after histopathology

D/D-
Corpus luteal cysts
Tubal ectopic adherent to ovary
Ovarian germ cell tumors

MANAGEMENT
Definitive surgical treatment is preferred if laparoscopy required to make diagnosis of ovarian ectopic—wedge resection/ enucleation at times oophorectomy maybe required. Haemostasis maybe by electrocautery or suturing
Systemic methotrexate can be used to treat ovarian ectopic pregnancy when risk of surgery is high or postoperatively in presence of persistent residual trophoblast or persistently raised Beta hcg after surgery

OVARIAN ECTOPIC

Abdominal Ectopic
Defined USG criteria
1. Absence of intrauterine gestational sac
2. Absence of dilated tube and complex adnexal mass
3. Gestational cavity surrounded by loops of bowel and separated by peritoneum
4. Wide mobility similar to fluctuation of sac evident with pressure of TVS probe towards posterior cul de sac
MRI useful adjunct to plan surgical approach- identify placental implantation and prepare surgical team, arrange blood, bowel preparation, insertion of ureteral catheters, preoperative angiographic embolization
Helps avoid placental site during incision

High index of suspicion
Generally diagnosed by laparoscopy when investigating increased beta hcg levels

MANAGEMENT-
Laparoscopy- early pregnancy
Advanced- Laparotomy
Possible alternative treatment methods with systemic Methotrexate with USG guided feticide

ABDOMINAL PREGNANCY

HETEROTOPIC PREGNANCY
USG demonstrates intrauterine pregnancy and coexisting ectopic
To be considered in IVF pregnancies
Beta hcg of limited value
Management
Intrauterine pregnancy to be considered in management plan
Methotrexate only if intrauterine pregnancy is nonviable or woman doesn’t wish to continue pregnancy—–Abortion acts will apply
Clinically stable women may opt for local injection of KCl or hyperosmolar glucose with aspiration of sac contents
Surgical removal of ectopic is method of choice in haemodynamically stable and option in stable women
Expectant management is an option where USG indicates nonviable pregnancy

HETEROTOPIC PREGNANCY