ECTOPIC PREGNANCY

Dr Manal Behery
Professor OB&GYNE
Zagazig university 2014

Ectopic
:

(Ektopos) out of place

Definition
Ectopic pregnancy: fertilized embryo
implanted outside the uterine cavity

Classification of ectopic pregnancy

>95%

Mechanical factors

Congenital: long narrow tube, diverticulae and accessory

ostia.
Traumatic: operation on the tube as salpingoplasty and
tubal reversal following ligation.
Inflammatory: Chronic salpingitis
Neoplastic: Narrowing of the tube by a fibroid or a broad
ligament tumor.
Functional: As tubal spasm or antiperistaltic contractions.
endometriosis in the tube. encourages embedding of the
fertilized ovum.

RISK FACTORS

Hz of tubal surgery

Hx of STDs (such as chlamydia)

Hx of ART
Hx of ectopic (esp if conservatively managed
without surgery)
Smoking
IUD in place at time of conception

Prior history of PID (pelvic

inflammatory disease)

TUBAL SURGERY

Animation of intrauterine implantation

Pathology of Ectopic
Pregnancy

Outcomes
1.

Tubal abortion

2. Rupture of tubal pregnancy

Ruptured ectopic pregnancy

Extraperitoneal rupture (rupture through floor of the tube)

may lead to broad ligament hematoma with death of the
ovum, or intraligamentary pregnancy.

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3. Secondary abdominal pregnancy

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Symptoms & Signs:

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


Clinical
Finding: Undistrubed ectopic

Amenorrhoea
A dull aching pain is usually present in
one iliac fossa. It is due to distension of the
tube and stretching of its peritoneal coat.
Classic signs
adnexal or cervical motion
tenderness.

Signs:

Abdominal examination: Tenderness in one iliac

fossa.
Vaginal examination:

(cervical motion tenderness or jumping sign)

The cervix is soft and severe pain occurs
when it is moved from side to side
A mass may be felt to one side of the uterus. It
is very tender, soft and may be pulsating.

Subacute type:Symptoms:

Short period of amenorrhea in (25%) no history

of amenorrhea due to occurrence of post
conceptional bleeding that mistaken as a true
menstrual period

Pain: It is felt in one iliac fossa. It may be dull

aching or sharp stabbing or colicky
Fainting attacks or even shock
Vaginal bleeding occurs after pain

With ruptured ectopic pregnancy

abdominal guarding and rigidity,

shoulder pain
fainting attacks
and shock.

When a woman presents with an

early pregnancy

Ask
Askyourself
yourselftwo
twoquestions
questions

Where
Where isis this
this pregnancy?
pregnancy?
Is
Is itit viable?
viable?

Where is this pregnancy?

In a woman with an early pregnancy you
must determine if the pregnancy is
intrauterine or an ectopic, because her
life could depend on it!

How to you determine location of

the pregnancy?

First determine dating by LMP

Then perform ultrasound
If you can see location of the pregnancy, you
are done!
If you cannotit becomes more
complicated

-hCG discriminatory value (or zone)

It is the lower limit of hCG at which an

examiner can reliably visualize pregnancy
on ultrasound. It is 1000-2000 IU/L with
vaginal ultrasound and 5000-6000 IU/L
with abdominal ultrasound.

If -hCG levels above the

discriminatory value

The absence of uterine pregnancy

signifies an abnormal pregnancy; ectopic,
incomplete abortion

If -hCG levels are still below the

discriminatory value, serial -hCG and
ultrasound should be done.

Doubling sign:

In normal pregnancy a 66% or greater increase

in serum -hCG levels should be observed
every 48 hours (nearly doubles).

Inappropriately rising serum -hCG levels

suggest (but do not diagnose) an abnormal
pregnancy including ectopic, however, they do
not identify its location.

Tran abdominal US

Transvaginal ultrasound ( TVS):

Early pregnancy with unknown

location

Check a serum BHCG

If it is above the discriminatory zone (DZ)an
intrauterine pregnancy should be seen
Then do an ultrasound to see if you see the
pregnancy

LAPROSCOPY

Treatment of tubal pregnancy

If the patient is shocked: antishock measures.

If the patient is Rh negative and not sensitized
anti-D serum is given.
Medical therapy:
methotrexate (a folic acid antagonist).
IM methotrexate given as a single dose.

The best candidate is the woman who is

asymptomatic, compliant with follow-up, with
an initial serum value <5000 IU/L.
Contraindications:
Breastfeeding
Immunodeficiency / active infection
Chronic liver disease
Active pulmonary disease
Active peptic ulcer or colitis
Blood disorder
Hepatic, Renal or Haematological
dysfunction

Signs and Treatment failure and tubal

rupture:

Significantly worsening abdominal pain,

Haemodynamic instability

Level of HCG do not decline by at least 15%

between Day 4 & 7 post treatment

or plateauing HCG level after first week of

treatment

Follow-Up:

If the -hCG level does not decline (plateau or

increase), the patient may require either a
second dose of methotrexate or surgery.
Surgical management:

Laparoscopy approach salpingostomy

Laprotomy salpingostomy
salpingectomy

 Salpingostomy / Salpingotomy is only indicated

when:

1. The patient desires to conserve her fertility

2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 4Cm. In size
5. Contralateral tube is absent
or damaged

Segmental resection: removal of

a portion of the affected tube.

laparatomy (if the mass is greater than 3.5 cm in

diametar, internal bleeding, cardiovascular colapse)

Treatment:
-metotrexate (if the mass is less then 3.5 cm in diametar)

-laparascopy,or Laprotomy
SALPINGOSTOMY

SALPINGECTOMY
intrapertoneal blood then peritoneal toilet.

Removal of any pelvic hematomas or

Algorithm for the diagnosis of unruptured ectopic pregnancy

without laparoscopy.

Management of ectopic pregnancy

11- Positive pregnancy test

Lowe abdominal pain +

Minimal Vaginal bleeding

Asymptomatic with factors

for ectopic pregnancy

2. History + clinical examination

If sure of date of LMP and /or

Regular cycle, i.e.
>6 wks. gestation,
Arrange TV ultrasound

If unsure of date of LMP

and /or irregular cycle,
Measure serum hCG

If hCG <1000
(?early Intrauterine/
? Ectopic pregnancy

If Hcg >1000, use

protocol for
suspected
Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000
Meet criteria for
Methorexate treatment
Use methotrexate
protocol

Does not meet criteria

for methotrexate treatment
Laproscopic /salpingotomy/
Salpingectomy ?Proceed to
laparotomy OR Laparotomy if
haemodynamically unstable

Thank you

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