ECTOPIC

PREGNANCY

Definition:

Any pregnancy occurring outside the uterus

Incidence:

Increasing due to P.I.D./ infertility

1-2% of all births

9% after IVF-ET
Site of implantation:
Blastocyst normally implants in the endometrial
lining of uterine cavity. Implantation elsewhere is
considered ectopic.

SITES OF ECTOPIC PREGNANCY

Abdomen (< 2%)

Ampulla (>85%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Cervix (< 2%)
1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian
6)Cervical 7)Cornual-Rudimentary horn 8)Secondary
abdominal 9)Broad ligament 10)Primary abdominal

Risk Factors:
Any factor that leads, directly or indirectly, to a reduction in
tubal motility increases the risk for tubal pregnancy

Prior tubal damage from previous ectopic pregnancy or from

tubal surgey to rlieve infertility or for strerilization. HIGHEST
RISK
Pelvic inflammatory disease/ STI
Assisted conception { particularly IVF if tubes are patent and
damaged }
Smoking
Presence of an intra uterine device.
Failed contraception

Pathology of Ectopic
Pregnancy

TUBES LACKS A SUBMUCUSAL LAYER ->

Fertilized ovum borrows through the epithelium
Zygote reaches the muscular wall
Trophoblastic cells at zygote periphery proliferate, invade, and
erode adjacent muscularis
Maternal blood vessels disrupted leading to hemorrhage
Outcome: tubal abortion or rupture with hemorrhage

TUBAL RUPTURE

First few weeks- isthmic portion

1-2 weeks- interstitial portion

2 weeks or more- ampulla

Rupture may follow coitus or bimanual examination.

Tubal Pregnancy

Most common site of ectopic pregnancy

(99%)

The ampulla is the most frequent location of

implantation (64%)

Symptoms:

Ammenorhea

Abdominal pain

Vaginal bleeding
Signs:

Abdominal tenderness (91%)

1st trimester bleeding (79%)

Common associated findings:

Adnexal tenderness (54%) , Amenorrhea

Early pregnancy symptoms

Cullens sign (Periumbilical bruising)

Nausea, vomiting, diarrhea, dizziness

Other Signs:
Tachycardia, Low grade fever
Chadwicks sign (cervix and vaginal cyanosis)
Hegars sign (softened uterine isthmus)
Cervical Motion Tenderness
Enlarged uterus
Tender pelvic or adnexal mass
Cul-de-sac fullness
Signs suggestive of ruptured ectopic pregnancy:
Usually between 6 and 12 weeks gestation
Severe abdominal tenderness with rebound,
guarding
Orthostatic hypotension

Differential Diagnosis
Appendicitis
Threatened Abortion
Ruptured ovarian cyst
PID
Ovarian torsion
Intrauterine pregnancy
Alternative diagnoses:

Dysmenorrhea
Dysfunctional uterine bleed
Mesenteric lymphadenitis

Symptoms & Signs:

In a woman of child bearing age with a pelvic
/abdominal pain and/ or vaginal bleeding with
amennorhea ALWAYS.think

Pregnancy

Normal?
Ectopic

DIAGNOSIS

In recent years, inspite of an increase in

the incidence of ectopic pregnancy
there has been a fall in the case fatality
rate.
This is due to the widespread
introduction of diagnostic tests and an
increased awareness of the serious
nature of this disease.
This has resulted in early diagnosis and
effective treatment.

METHODS OF EARLY DIAGNOSIS

Immunoassay utilising monoclonal antibodies to

beta HCG.

Ultrasound scanning Abdominal & Vaginal

including Colour Doppler

Laparoscopy

Serum progesterone estimation

A combination of these
methods may have to be
employed.

Diagnostic modalities
1. Pregnancy test.
a) Urinary B-hCG sensitive, detects 25-50 ml I.U/ml.. Positive
before missing the next period
b) Serum B-hCG Mainly used for quantitative rather than
qualitative purposes
In 85% normal pregnancy B-hCG doubles every 2-3 days
In 85% ectopic pregnancy B-hCG 65% Increase every 2-3 days

2. Pelvic ultrasound scan

a) Abdominal. Sac at 5 wks
b) Transvaginal. A wk earlier than abdominal utz

METHODS OF EARLY DIAGNOSIS

At 4-5 weeks TVS

can visualise a gestational sac as

early as 4-5 weeks from LMP.
During this time the lowest serum beta
HCG is 2000 IU/Lt.
When beta HCG level is greater than this
and there is an empty uterine cavity on
TVS, ectopic pregnancy can be suspected.
In such a situation, when the value of beta
HCG does not double in 48 hours ectopic
pregnancy will be confirmed.

METHODS OF EARLY DIAGNOSIS

2.

3.
4.

Poorly defined tubal ring possibly

containing echogenic structure and POD
typically containing fluid or blood.
Ruptured ectopic with fluid in the POD and
an empty uterus.
In Colour Doppler, the vascular colour in a
characteristic placental shape, the socalled fire pattern, can be seen outside
the uterine cavity while the uterine cavity
is cold in respect to blood flow

Diagnostic modalities
If early pregnancy problems. Urine B-hCG + AScan
Intra-uterine pregnancy .GOOD
No Intra-uterine gestation Seen serum B-hCG + TVS.
with serum B-hCG of 1500-2000 ml I.U/ml Intra uterine gestation should be
seen using TVS otherwise suspect Ectopic pregnancy

3. Diagnostic Laparoscopy.

Early Pregnancy Assessment Clinic {EPAC}:

Diagnostic modalities
Early Pregnancy Assessment Clinic {EPAC}:
With Advance in diagnosis and improvement in patient awareness
ectopic pregnancy is more and more being diagnosed in its early
stages. So, to reduce the incidence of maternal mortality and serious
morbidity this dedicated clinic is a must in regional hospitals.
Patients with early pregnancy problems to report to

Facilities to perform urine and serum P.T. onsite

Facilities and expertise in performing TVS
Access to operating theatre and blood bank

MANAGEMENT
Depending on the presentation:
Acute with ruptured ectopic and intra-abdominal bleeding.
ABC,,, + surgical approach.
Early stages, with intact ectopic:
1. Expectant decreasing B-hCG . Tubal abortion
2. Medical Depending on size of ectopic and level of B-hCG..
Use methotrexate.. Not common approach
3. Surgical

SURGICAL TREATMENT OF
ECTOPIC PREGNANCY
The debate goes on
LAPAROTOMY?
VS.
LAPAROSCOPY?
SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?

SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY

Salpingostomy / Salpingotomy is only

indicated when:
1.
2.
3.
4.
5.

The patient desires to conserve her fertility

Patient is haemodinmically stable
Tubal pregnancy is accessible
Unruptured and < 5Cm. In size
Contralateral tube is absent or damaged

SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY

The choice of surgical treatment does not

influence the post treatment fertility, but prior
history of infertility is associated with a marked
reduction in fertility after treatment
Making the choice Chapron et al (1993) have
described a scoring system, based on the
patients previous gynaecological history and
the appearance of the pelvic organs, to decide
between salpingostomy / salpingotomy and
salpingectomy.

SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY

Fertility reducing factor

Antecedent one Ectopic pregnancy
Antecedent each further
Ectopic pregnancy
1
Antecedent Adhesiolysis
1
Antecedent Tubal micro surgery
Antecedent Salpingitis
1
Solitary tube
2
Homolateral Adhesions
1
Contralateral Adhesions
1

Score
2

SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY

The rationale behind the scoring system

is to decide the risk of recurrent ectopic
pregnancy.
Conservative surgery is indicated with a
score of 1-4 only, while radical treatment
is to be performed if the score is 5 or
more.

 Fertility post ectopic surgery

The overall subsequent conception rate in women with ectopic
pregnancies is about 60%
less than half of these pregnancies result in another ectopic
or spontaneous abortion, so only about one third of women
with ectopic pregnancies have subsequent live births
. The subsequent fertility rate is significantly higher in parous
women younger than 30 years. If the ectopic pregnancy is a
women's first pregnancy, her subsequent conception rate is
only about 35%. On the other hand, women with high parity
(more than three pregnancies) who develop an ectopic
pregnancy have a relatively high rate of conception (80%).
The subsequent conception rate is lower in women who have a
history of salpingitis and in those who have gross evidence of
damage to the opposite oviduct as a result of previous
salpingitis. Future fertility is significantly higher in women who
have unruptured tubal pregnancies than in those who have
ruptured ectopic pregnancies; hence, early diagnosis with
serial hCG and ultrasound is desirable.

Repeat Ectopic Pregnancy

The rate of repeat ectopic pregnancy

after a single ectopic pregnancy ranges
from 8% to 20%, with a mean of 15%.
Only about one of three nulliparous
women who have an ectopic pregnancy
ever conceives again (35%), and about
one third have another ectopic
pregnancy (13%). After two ectopic
pregnancies, infertility rates as high as
90% have been reported

REMEMBER

Ectopic pregnancy is a life threatening condition & on the

increase
Not all cases present with a classical picture
ALWAYS suspect ectopic pregnancy in a woman of a childbearing age c/o pain and/or p.v. bleeding
Tailor your management on the patient presentation.+/_ F.up