1. Medical management (discussed later).
2. Conservative surgery by salpingostomy or laparoscopic aspiration.

1. Acquired causes:
   1. Pelvic inflammatory disease (PID).
   2. Surgical:
      • Surgical reconstruction of tube (Tuboplasty)
      • Spontaneous recanalization occurs after ligation
   3. Intrauterine contraceptive device (IUCD).
   4. Endometriosis.
   5. Broad ligament tumor and ovarian tumor—kinking of the tube.
   6. In vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT).
2. Congenital
   Hypoplasia, undue tortuosity of the tube and accessory lumina.

1. The patient has a short period of amenorrhea.
2. Symptoms of early pregnancy—nausea, breast tenderness.
3. Abdominal pain due to:
   • Distension of the tube
   • Choriodecidual hemorrhage
   • Escape of blood in the peritoneal cavity (associated with syncope).
     (Combination of abdominal pain and syncopal attack is the most important symptom of ectopic pregnancy).
     3
4. Vaginal bleeding—mild, following pain. This is uterine in origin due to separation of decidua.
5. Shoulder tip pain may occur in heavy peritoneal collection of blood and when the patient is lying down.
6. A large pelvic hematocele may cause retention of urine.

1. Pallor+, pulse rate (PR) is high, intermittent pyrexia.
2. Early pregnancy change of breast.
3. Tenderness and muscle guard over lower abdomen.
4. Intestinal distention by peritoneal fluid.
5. Hemoperitoneum of 2 to 3 weeks causes bruising around umbilicus (cullen's sign)—not so common.

1. Irregular tender mass on the affected side felt through the fornix.
2. Ill-defined tender semisolid swelling in pouch of douglas (POD).
3. Arterial pulsation through the fornix (occassionally).

1. Hemoglobin percent (Hb%)—lower, leukocyte count is high, pregnancy test is positive in 50 percent of cases.
2. Ultrasonography (USG)—Bagel sign—on endovaginal sonography (EVS) hyperechoic ring around the gestational sac in the adnexal region, but more often they are seen as a small inconglomerate mass near the ovary with no evidence of sac or embryo—blob sign. Hemoperitoneum may also be found. Transvaginal sonography (TVS) can diagnose 80 percent of ectopic pregnancy.
3. Laparoscopy—is helpful for diagnosis of ectopic pregnancy (EP).
4. Culdocentesis:
   • +ve inference—0.5 mL of unclotted blood
   • -ve inference—0.5 mL of serous blood
   • Indeterminate—no fluid.
5. Final diagnosis—by laparotomy.

1. Short period of amenorrhea.
2. Excruciating pain in the hypogastrium.
3. Features of shock (pallor, low blood pressure (BP), PR increased, cold clammy skin, oliguria).

1. Features of shock.
2. Presence of free fluid may cause dullness of lower abdomen.

1. Acute tenderness and pain due to movement of cervix by vaginal examination is the leading sign.
2. POD is often felt soft, fluctuant, full and tender due to pelvic hematocele.

1. Complete blood count (CBC), Hb%—low.
2. USG—empty cavity with fluid in POD/abdomen.
3. Culdocentesis—Aspiration contains blood.

1. Salpingostomy: A linear incision over ectopic pregnancy along the antimesosalpinx border provided the pregnancy is in ampullary part and size is less than 5 cm. It is not suitable in the isthmic pregnancy.
2. Segmental excision and end to end anastomosis for isthmic pregnancy.
3. Milking of the tube—in ampullary pregnancy, where pregnancy can be easily dislodged.
4. Salpingectomy: Removal of the affected tube is the usual procedure.
   (Portion of the tube should always be examined histologically and bacteriologically for tuberculosis [TB]).

1. By USG (EVS)—empty uterine cavity and adnexal mass.
2. β-hCG—in normal pregnancy, this hormone level doubles every 2 days; in abnormal gestation, the rate is much lower or absent.
3. Color flow dopplor—see USG in obstetrics.

1. Patient is of good health, hemodynamically stable and able to follow-up examination
2. Unruptured EP
3. No evidence of intrauterine pregnancy
4. Ectopic mass is less than 3.5 cm
5. hCG less than 10,000 IU/l
6. No yolk sac seen
7. No fetal heart tone.

1. Intrasac methotrexate by EVS guidance, where reduced dose is required.
2. Systemic injection of methotrexate is used, 50 mg/m² is administered on day 0. Up to 13 percent of cases required second dose if the hCG level does not reduce by 15 percent between 4 to 7 days.

1. The EP sac must be less than 4 cm in diameter
2. It is easily approachable.

1. Ectopic pregnancy due to widespread pelvic adhesion.
2. Uterus is diseased.
3. When the patient is in a good condition.
4. Interstitial pregnancy.

1. Patient does not wish for further pregnancy—Total abdominal hysterectomy (TAH).
   7
2. If patient wishes for further pregnancy—partial hysterosalpingectomy, but there is a risk of rupture of the uterus in future pregnancy.

1. The tube on the affected side must be intact.
2. The fetal sac must occupy the position of ovary.
3. The ovary and the sac must be connected with the uterus by ovarian ligament.
4. Definite ovarian tissue must be present in the wall of the sac.

1. Remove the rudimentary horn.
2. If the pedicle is short and attachment is wide, hysterectomy is the treatment of choice.

1. X-ray of abdomen:
   • Absence of uterine outline and placental shadow
   • Intermingling of maternal gas shadow with the fetal parts (Bishop's sign)
   • An abnormal high position of fetus
   • Fetal parts overlapping maternal spine in the lateral view (Weinberg's sign).
2. USG of abdomen.

1. As soon as diagnosis is made laparotomy should be done as the delay may lead to spontaneous intraperitoneal hemorrhage.
2. • Removal of the placenta, if it is not adherent to any vital organ.
   • If adherent to broad ligament and uterus, go for hysterectomy.
   • If placenta is adherent to bowel then cut the cord, close to the placenta and leave it. It usually gets absorbed or occasionally forms abscess.
   • The place of methotrexate is doubtful in this case.

1. Therapeutic abortion previously
2. Previous cesarean section
3. Asherman's syndrome
4. IUI and IVF.

1. The distended cervix is smaller on P/V examination
2. On curettage, no evidence of trophoblastic tissue
3. The product of conception is confined within the cervix
4. The internal os is closed.

1. Ballooning of cervical canal
2. Gestational sac is within the endocervix
3. Internal os is closed
4. No evidence of intrauterine pregnancy.

1. There must be cervical gland opposite to placental attachment
2. The placental attachment to the cervix must be intimate
3. The whole or a portion of the placenta must be situated below the entrance of uterine vessels or below the peritoneal reflection of the anterior and posterior surface of the uterus
4. No fetal element should be present in the corpus uteri.

1. Hysterectomy is the only treatment of choice
2. Other surgical alternatives less radical to hysterectomy are sometime helpful
   1. D and C operation
   2. To control bleeding
      1. Packing of the uterus and cervix
      2. Intracervical 30 mL Foley's catheter
      3. Deep lateral cervical stitches or placement of cervical circlage
      4. In some cases bilateral internal iliac artery ligation.
3. Medical—Some patients may be treated with methotrexate either intraamniotically or systematically. Therapeutic success has been reported with the use of etoposide or combination chemotherapy.

 

1. Congenital maldevelopment of uterus—rupture commonest at mid trimester.
2. Spontaneous rupture at last trimester
   10
   

   Figure 1.2: Rupture of uterus (Subtotal hysterectomy done)
   • Previous operation (myomectomy or classical cesarean section [CS])—common
   • Old perforation (MTP).

1. Acute abdominal pain with features of shock
2. Contracted uterus is felt as a suprapubic mass
3. Easily palpable fetus.
4. Fetal heart sounds (FHS)—absent.

1. Obstructed labor—malpresentation, malposition, cephalopelvic disproportion (CPD), hydrocephalus.
2. Multiparity—causes more fibrous tissue and malnutrition produces certain changes in myometrium and susceptible to rupture.
3. The cesarean or hysterotomy scar rupture (very common).
4. Injudicious use of oxytocics.

1. Internal version.
2. Extraction of fetus through the incomplete dilated cervix
3. Operative delivery like difficult forceps, craniotomy, decapitation.

1. Complete: When all the coats of the uterus are involved including peritoneum.
   11
2. Incomplete: When peritoneum is not involved.
   • Spontaneous rupture is more often complete than incomplete
   • Traumatic rupture is more often incomplete than complete.

1. Dextrorotation of the uterus expose lateral wall to increased stress of labor.
2. Passive venous congestion in the left broad ligament due to left ovarian vein draining into the left renal vein at right angle.

1. Defective healing of classical scar due to contraction and relaxation in uterine involution.
2. Difficulty in approximation of edges.
3. Incomplete hemostasis and infection.
4. Placenta on the scar makes the scar tissue weak.

1. Signs of prolonged and difficult labor.
2. Acute pain on lower abdomen.
3. Previous labor pain stops when rupture occurs.
4. Shock appears due to intraabdominal hemorrhage.
5. The uterine outline is completely lost and fetus is felt most superficially when palpating the patient's tender abdomen.
6. FHS is absent.

1. Hemorrhage through the cervical orifice (os).
2. The presenting part often goes up.
3. Hematuria on catheterization if bladder is involved.
4. Cervix hangs like a curtain.

1. General condition is satisfactory.
2. The uterine outline is intact if rupture is incomplete.
3. Tenderness and fullness in suprapubic and iliac region.
4. The FHS is absent or irregular.
5. An unexplained collapse during the late first and early second stage of labor with tender inert uterus with slight bleeding should suggest rupture of uterus and not accidental hemorrhage.
6. When a patient collapse after difficult vaginal delivery, it is advisable to explore the uterus after manual removal of placenta (MRP).

1. Stop oxytocin, if running.
2. Start IV fluid (NS/RL).
3. Blood transfusion in severe hemorrhage.
4. Continuous maternal monitoring.
5. Emergency laparotomy with rapid operative delivery.

1. If the tear is small.
2. There must be strong reason to preserve the uterine function.
3. Clean wound and edges are not ragged as in rupture of LSCS scar.
4. If patient does not want issue perform tubal ligation with repair.

• When the tear is irregular, irreparable and edges are friable.
• In colporrhexis.
• Lateral tears with broad ligament hematoma.
• When the uterus is infected.
  If bladder is involved—repair of bladder in two layers followed by hysterectomy and Foley's catheter is kept in bladder for 10 days.

 

1. Trophoblastic proliferation of cytotrophoblast and syncytiotrophoblast.
2. Hydropic changes in the stroma with cistern formation.
3. Absence of fetal blood vessels.

1. Hydatidiform mole (Complete and partial)
2. Invasive mole (chorioadenoma destruens)
3. Chorio-carcinoma
4. Placental site trophoblastic tumor.

1. Maternal age greater than 40 years.
2. Teen age less than 19 years.
3. Asian woman.
4. Malnutrition.
5. Immunologic and genetic factors are also responsible.

1. Primary death of fetus results in failure in villus circulation and consequence edema and liquefaction of stroma.
2. Primary error in the development of the vessels in the core causing villus to become overloaded with fluid and food staffs, the later then provide epithelial cells with excessive growth stimulus for proliferation.
3. Anoxia causes active fluid secretion into the core of the villus, as well as cellular hyperplasia.

1. Period of amenorrhea—8 to 12 weeks or more.
2. Vaginal bleeding.
3. Pain abdomen.
4. Passage of grape-like vesicles.
5. Excessive vomiting, hypertension.
6. Fetal movement is absent if gestational age (GA) greater than 20 weeks.

1. History
2. General survey—anemia, BP (may increase), hyperthyroidism in 1 percent case.

1. Uterine size is enlarged than period of amenorrhea in 50 percent of cases, in some cases size correspond or even less, due to discharge of moles per vagina.
   15
   

   Figure 1.6: USG—H mole
2. Doughy feeling, i.e. no fetal part felt.
3. FHS—absent.

1. Os—closed, internal ballottement is absent.
2. Bilateral cystic enlarged ovary in 25% to 50% of cases (Lutein cyst).
3. Bloody discharge.
4. Discharge of vesicles (50%).

1. β-hCG level is very high, both in urine and blood—urinary hCG level, of 3,50,000 to 5 million IU/L above 100 days, is strongly indicative. Biweekly rising titer is helpful.
2. Sonography—‘snow storm appearance’
   • Sonolucent area due to blood clot
   • Absence of gestational sac at 5 to 7 weeks
   • Repeat scan a week later.
     (D/D of snowstorm appearance—missed abortion, degenerated fibroid).
3. Others—Renal, hepatic and thyroid function test, chest radiography.

1. Hemorrhage
2. Shock
3. Sepsis
4. Perforation
5. Malignant change (5%).

16

1. Complete mole
2. Bilateral theca lutein cyst (& 6 cm)
3. Age above 40 years
4. Serum hCG—1 million U/L before starting treatment.

1. Start IV drip with RL oxytocin is administered only after dilatation of cervix and partial evacuation to aid hemostasis.
2. Grouping and cross matching for blood
3. Antibiotic by IV route
4. Early evaluation
5. Partial expulsion:
   • Os open—suction evacuation by cannula with 10 units of syntocinon
   • Os closed—Slow dilatation by—laminaria tent and cerviprime (intracervical) gel or misoprostol per vagina and then suction curettage.
   At the end of first week, repeat curettage for complete evacuation of uterus and sending the material for histopathological (H/P) examination is not mandatory. It is done only in presence of persisting trophoblast in the uterine cavity. Repeated evacuation may cause high chance of requiring chemotherapy and may increase rate of complications.

1. If patient's age greater than 35 years
2. Elderly with completed family
3. Perforating mole and placental site trophoblastic tumor
4. Patient not responding to chemotherapy.

1. In high-risk groups (as mentioned above)
2. When the patient cannot be followed up properly
3. High level of hCG persisting for 2 months after evacuation
4. Any detectable hCG in the serum after 6 weeks
5. Persistent uterine bleeding, even if trophoblastic tissues are not available by curettage. This is the indication of myometrial invasion
6. Evidence of metastasis in brain and lungs.

1. Irregular bleeding P/V
2. Central nervous system (CNS) disturbances like headache, vomiting
3. Hemoptysis and breathlessness.

1. Vaginal secondaries
2. Subinvolution of uterus
3. Theca lutein cyst.

1. Pregnancy
2. Choriocarcinoma
3. Enlarged ovary.

1. Irregular bleeding P/V
2. The uterus does not involutes satisfactorily
3. If β—hCG level is still positive, 6 weeks after evacuation.

• Patient should not be allowed to become pregnant for 1 year
• IUCD—no, for irregular bleeding
• Condom—preferable
• Low-dose oral contraceptive pill (OCP)—use, after β—hCG level becomes normal.

1. Non-metastatic: No evidence of disease outside the uterus. (Treatment: Single agent chemotherapy—methotrexate—0.4 mg/kg day IV or intramuscularly [IM] for 5 days course and repeat the same dose after 7 to 10 days). [Day 1, 3, 5, 7 with methotrexate Injection with folinic acid 0.1 mg/kg per day on 2, 4, 6, 8th day]
2. Metastatic: Any disease outside the uterus.

1. Short duration less than 4 months.
2. Urinary hCG less than 1,00,000 IU/24 hours or serum β-hCG less than 40,000 IU/mL.
3. No metastasis to brain or liver.
4. No significant prior chemotherapy.

1. Long duration greater than 4 months.
2. Urinary hCG greater than 1,00,000 IU/24 hours or serum β-hCG greater than 40,000 IU/mL.
3. Metastasis to brain and liver.
4. Unsuccessful prior chemotherapy.
5. Gestational trophoblastic tumor following term pregnancy.

1. Methotrexate—10 to 15 mg/day IV or IM
   Dactinomycin—10 to 12 µg/kg/day IV
   Chlorambucil—8 to 10 mg/day per mouth or Cyclophosphamide—3 to 5 mg/kg/day IV
   1. Give the course for 5 days
   2. Repeat the cycle with minimum interval of 10 to 14 days as toxicity allows.
2. 1. Continue repetitive chemotherapy three courses after negative serum β-hCG titer.
      19
   2. Remission is defined as three consecutive normal weekly β—hCG titer.

1. Titer rise (10 fold or more)
2. The plateau after two courses of MAC regime
3. New metastasis appear

1. Villus structure is present. Trophoblastic invasion of uterine wall and not the blood vessels.
2. Locally malignant and does not kill the patient by distant metastasis.

1. Correction of anemia, multiparity—total hysterectomy
2. Conservative chemotherapy till the lesion regresses and pulmonary deposit disappear spontaneously
3. Vaginal deposits removed and pulmonary deposit disappears spontaneously.

1. Development of pre-eclampsia (severe, not managed by medical treatment)
2. Intractable vaginal bleeding
3. Severe hyperemesis gravidarum
4. Hyperthyroidism
5. Evidence of trophoblastic embolism.

1. It may be benign with a capacity for spontaneous regression.
2. It may be highly malignant with resistance to cytotoxic drugs.

 

1. Maternal surface—spongy, 15 to 20 lobes or cotyledons, which are limited by fissures. Each fissure is occupied by decidual septum. Only the decidua basalis and the blood in the intervillus space are of maternal origin.
2. Fetal surface is glistened with the umbilical cord attached near the center. At term, 4/5th of placenta is of fetal origin.

1. Amniotic membrane
2. Chorionic plate
3. Choriodecidual space—contains stem villi with their branches, the space is filled with maternal blood.
4. Basal plate—from outside inward
   1. Part of compact and spongy layer of deciduas basalis
   2. Nitabuch's layer of fibrinoid degeneration of the outer syncytiotrophoblast at the junction of cytotrophoblastic shells and deciduas
   3. Cytotrophoblastic shell
   4. Syncytiotrophoblast.

1. Outer syncytiotrophoblast
2. Cytotrophoblast
3. Basement membrane
4. Central stroma contains fetal capillaries, primitive mesenchymal cells and hofbauer (phagocytic cells)) from outside inward).

1. Syncytiotrophoblast
2. Cytotrophoblast
3. Basal membrane
4. Stromal tissue
5. Endothelium of fetal capillaries with basement membrane.

1. Transport:
   1. Oxygen is transported by diffusion
   2. Water, glucose, sodium ions (Na+), potassium ions (K+), calcium ions (Ca2+) and phosphorus pass from maternal to fetal side by passive diffusion
   3. Amino acid is transported by active process
   4. Iron and water soluble vitamin are transported by active mechanism to the fetus.
2. Synthesis:
   1. Enzyme—heat stable alkaline phosphatase, cysteine aminopeptidase (CAP)
   2. Protein hormone—hCG and human placental lactogen (HPL)
   3. Steroid hormone—estrogen and progesterone
      25
   4. Pregnancy-associated placental protein—pregnency associated plasma protein A (PAPP-A), pregnancy associated plasma protein-B (PAPP-B), etc.
3. Respiratory
4. Nutritive
5. Excretory
6. Barrier and immunological function

1. Placenta succenturiate
   An accessory lobe, which remains at a distance from main placenta and is connected to the main placenta by membrane containing umbilical blood vessels.
   Significance: It causes postpartum hemorrhage (PPH), shock, sepsis and placental polyp.
   

   Figure 1.9A: Placenta succenturiata
2. Placenta bipartia or tripartia
   Placenta is divided incompletely at the periphery into two or three lobes and this has no obstetrical significance.
   

   Figure 1.9B: Placenta bipartia
3. Placenta duplex or triplex
   Here, the placenta is completely divided into two or more lobules. The small lobules are attached with the main placenta by membrane or blood vessels. 26Significance: Antepartum hemorrhage (APH), PPH, retained bits.
   

   Figure 1.9C: Placenta duplex
4. Placenta membranacea—large, 15 inch in diameter. Here, the placenta develops from chorion laeve and from chorion frondosum.
   

   Figure 1.9D: Placenta circumvallate
5. Placenta circumvallate: Partial or complete ring divide the fetal surface into the distinct central and peripheral portion. The rim is raised yellowish-white in color and ½ inch broad and is composed of double layer of chorion, which undergoes infraction when the ring coincide with the placental margin. The condition is called placenta marginata.
   

   Figure 1.9E: Circumvallate placenta (Schematic diagram)
   Central zone is slightly depressed and normal appearance, but peripheral zone may be 5 to 7.5 cm in breadth. Placental 27tissue is thicker over peripheral zone. Vessels radiate from the cord up to the ring and then disappear.
   The probable explanation is that during early development, the chorionic frondosum is too restricted for nutrition of the fetus, to compensate for this the peripheral villi grow outwards splitting the deciduas basalis into two layers.
   Significance: Abortion, APH, Preterm labor, intrauterine growth restriction (IUGR), intrauterine fetal death (IUFD).
6. Battledore placenta:
   Cord is attached to the margin of the placenta.
   Significance: Cord presentation and cord prolapse.
   

   Figure 1.9F: Battledore placenta
7. Velamentous insertion of the cord
   Cord is inserted in the membrane and cord vessels traverse some distance along the membrane to reach the placent.
   Significance: Vasa previa is associated with placenta previa. (Here, the fetal blood loss is significant). Here intrapartum bleeding is common rather than antipartum bleeding.
   

   Figure 1.9G: Velamentous insertion of the cord

1. Lobules of the placenta
2. The lobules should fit together
3. he margins should be regular
4. If there is missing of lobules, they do not fit together.
   28

1. Attachment to umbilical cord to placenta
2. The umbilical vessels passing from the cord and fades into the margin
3. Look for free ending vessels, which may indicate succenturiate lobe has been left behind in uterus.

1. The chorion is the layer in contact with the uterus—rough and thick.
2. The amnion is the inner layer—thin and shiny.
3. The amnion can be peeled up to the insertion of the cord.
4. If the membrane is ragged, place them together and ascertain their completeness.

1. Amnion
2. Wharton's jelly
3. Umbilical artery (2) and umbilical vein (1). [A²V]

1. Malpresentation (breech)
2. Temporary arrest of descent
3. Separation of placenta
4. Inversion of uterus
5. Fetoplacental hematoma
6. Tearing of the cord.

1. Fetal heart anomaly
2. CNS defect
3. Kidney problem
4. Chromosomal anomalies like trisomy 13 and 18.