Non tubal ectopic

NON TUBAL ECTOPIC PREGNANCY

M A G DY A B D E L R A H M A N M O H A M E DL E C T U R E R O F O B / GY N

2 0 1 5

ECTOPIC PREGNANCY• The implantation Of a fertilized ovum

outside the uterine cavity.

• 97 % are tubal.

ECTOPIC PREGNANCY• Ectopic implantation can also occur

outside of the fallopian tube, within the cervix, ovary, abdomen, uterine cornua, and cesarean scars.

• These extra tubal implantations may not be associated with tubal pathology or the expected preexisting risk factors for tubal ectopic implantation.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

INTERSTITIAL PREGNANCY

• The interstitial, or cornual, portion of the fallopian tube is tortuous, 0.7mm in diameter and 1-2 cm in length.

• This is a relatively thick segment of fallopian tube with a greater capacity to expand before rupture.

U/S• The identification of an echogenic line

between the gestational sac and the endometrial cavity, “the interstitial line sign,” and an empty uterine cavity with a gestational sac eccentrically located outside the endometrial cavity.

• Angular pregnancies are implanted in one of the lateral angles of the uterine cavity, medial to the uterotubal junction.

• Appearance of the bulge of an interstitial pregnancy is lateral to the round ligament, whereas the bulge of an angular pregnancy is medial to the round ligament, displacing the round ligament laterally

TREATMENTMethotrexate (systemic or local), in unruptured ectopic, 94% success rate.

Corneal resection.Embolization.Hysterectomy.

Future pregnancies.CS near term.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

CERVICAL PREGNANCY• Within the cervical canal below the

level of the internal cervical os.• The placenta and entire chorionic sac

containing the pregnancy must be below the internal cervical os and the cervical canal must be dilated and barrel shape.

Presentation.Painless vaginal bleeding.Open external os with fleshy endocervical mass.

Treatment:Methotrexate only.Methotrexate followed by

currettage.Uterine artery embolization.Cervical cerclage.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

OVARIAN PREGNANCY• The presenting signs and symptoms are

similar to other ectopic pregnancies.• Difficult pre-operative diagnosis.• Ultrasound finding suggesting ovarian

implantation is a walled cystic mass within or adjacent to an ovary, but this does not exclude a corpus luteum and a tubal implantation.

Speigelberg’s criteria:• The tube must be intact and distinctly

separate from the ovary.• The gestational sac must occupy the

normal anatomical location of the ovary.• The gestational sac must be connected to

the uterus by the utero-ovarian ligament.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

ABDOMINAL PREGNANCY• The pathogenesis of abdominal

implantation is controversial. • Many are the result of secondary

implantation within the peritoneal cavity after tubal abortion, tubal rupture, or uterine rupture.

• The most common abdominal implantation site is the posterior culde-sac, followed by the mesosalpinx, the omentum, the bowel and its mesentery, and the peritoneum of the pelvic and abdominal walls.

• Abdominal pregnancies frequently progress until late diagnosis, defined as greater than 20 weeks’ gestation, leading to a high maternal mortality rate, 0.5-18%.

• It should be terminated as soon as the diagnosis is confirmed, regardless of gestational age.

Management of placenta:Cut umblical cord short & placenta left insitu.

Postoperative methotrexate & selective embolization of feeding vessels are tried.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

CESAREAN SCAR ECTOPIC PREGNANCY

Incidence is increasing:• This increase is presumably due to

increased recognition and the increasing number of cesarean deliveries.

Need high suspicious for diagnosis.

• Cesarean scar implantation is a gestation completely surrounded by myometrium and the fibrous tissue of the scar and separated from the endometrial cavity or fallopian tube.

U/S:Empty uterine cavity.Empty endocervical canal.GS sac in anterior part of isthmus.Absence of healthy myometrium between the bladder and the gestational sac.

• The time interval after C.S. is important factor.

• Early diagnosis with ultrasound can offer treatment options capable of avoiding uterine rupture and hemorrhage and could preserve the uterus.

Treatment options:Direct methotrexate injection.Hysteroscopic resection.Abdominal resection (laparoscopic or open).

Hysterectomy.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

PREGNANCY IN A RUDIMENTARY HORN• 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.

NON TUBAL ECTOPIC• Interstitial pregnancy .• Cervical pregnancy.• Ovarian pregnancy.• Abdominal pregnancy.• Cesarean scar ectopic pregnancy.• Pregnancy in a rudimentary horn.• Ectopic after hysterectomy.

ECTOPIC AFTER HYSTERECTOMY

• Only 56 cases of ectopic pregnancy after hysterectomy have been reported.

• Over half of such pregnancies have been “early presentations,” this occurring because an unrecognized, preclinical pregnancy existed at the time of hysterectomy & mostly tubal.

• “Late presentation” ectopics have occurred after all types of hysterectomy occur with retention of one or both ovaries with the presence of a vaginal-tubal or vaginal peritoneal fistula.

• 72% follow vaginal hysterectomy.

NOVEL MARKERSProgesterone:• < 20 nmol/L …… 95 % predict pregnancy

failure.• > 60 nmol/L …… strongly associated with

viable pregnancy.

NOVEL MARKERS• VEGF.• Pregnancy associated plasma

protein-A.• Activin B.• Human placental lactogen.• Alpha fetoproteins.• Creatine kinase.