ADVANCES IN THE

MANAGEMENT OF ECTOPIC
PREGNANCY
 ECTOPIC PREGNANCY

DEFINITION

Any pregnancy where the fertilised ovum

gets implanted & develops in a site other
than normal uterine cavity.

07/12/08 23:28 Ectopic Pregnancy 2

 INCIDENCE
>1 in 100 pregnancies.
• Recent evidence indicates that the incidence of
ectopic pregnancy has been rising in many
countries.
– USA-5 fold
– UK-2 fold
– France 15/1000 pregnancies
– India-1in100 deliveries
• Recurrence rate - 15% after 1st, 25% after 2
ectopics

07/12/08 23:28 Ectopic Pregnancy 3

 HISTORY

• Ectopic pregnancy was first described in 963 Ad by

Albucasis.
• 1884 -- Robert Lawson Tait of Birmingham
performed the first successful Salpingectomy
operation
• 1953 -- Stromme – Conservative surgery of
Salpingostomy
• 1973 -- Shapiro & Adller – Laparoscopic
Salpingectomy
• 1991 -- Young et al – Laparoscopic Salpingotomy

07/12/08 23:28 Ectopic Pregnancy 4

 AETIOLOGY

• Any factor that causes delayed transport of

the fertilised ovum through the.
• Fallopian tube favours implantation in the
tubal mucosa itself thus giving rise to a tubal
ectopic pregnancy.
• These factors may be Congenital or Acquired.

07/12/08 23:28 Ectopic Pregnancy 5

 AETIOLOGY

• CONGENITAL - Tubal Hypoplasia , Tortuosity ,

Congenital diverticuli , Accessory ostia , Partial
stenosis
• ACQUIRED -
– Inflammatory: PID, Septic Abortion, Puerperal Sepsis,
MTP (lntraluminal adhesion)
– Surgical: Tubal reconstructive surgery, Recanalisation of
tubes
– Neoplastic: Broad ligament myoma, Ovarian tumour
– Miscellaneous Causes: IUCD , Endometriosis, ART (IVF
& & GIFT), Previous ectopic

07/12/08 23:28 Ectopic Pregnancy 6

 SITES OF ECTOPIC PREGNANCY

Ampulla (>85%) Abdomen (< 2%)

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
07/12/08 23:28 Ectopic Pregnancy 7
 CLINICAL PRESENTATION

• Ectopic Pregnancy remains asymptotic

until it ruptures when it can present in two
variations - Acute &. Chronic
• SYMPTOMS-
– Amenorrhea
– Abdominal Pain
– Syncope
– Vaginal Bleeding
– Pelvic Mass

07/12/08 23:28 Ectopic Pregnancy 8

 DIAGNOSIS

“Pregnancy in the fallopian tube is a black cat on

a dark night. It may make its presence felt in
subtle ways and leap at you or it may slip past
unobserved. Although it is difficult to
distinguish from cats of other colours in
darkness, illumination clearly identifies it.”

--Mc. Fadyen - 1981

07/12/08 23:28 Ectopic Pregnancy 9
 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.
• Now the rate of tubal rupture is as low as 20%.
07/12/08 23:28 Ectopic Pregnancy 10
 METHODS OF EARLY DIAGNOSIS

• Immunoassay utilising monoclonal antibodies to beta

HCG
• Ultrasound scanning – Abdominal & Vaginal including
Colour Doppler
• Laparoscopy
• Serum progesterone estimation not helpful

A combination of these methods may have to be

employed.
07/12/08 23:28 Ectopic Pregnancy 11
 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.

07/12/08 23:28 Ectopic Pregnancy 12

 METHODS OF EARLY DIAGNOSIS

The USG features of ectopic pregnancy after

5 weeks can be any of the following-

• Demonstration of the gestational sac with or

without a live embryo (Begel’s sign) - The GS
appears as an intact well defined tubal ring by
6 weeks when it measures 5 mm in diameter.
Afterwards it can be seen as a complete
sonolucent sac with the yolk sac and the
embryonic pole with or without heart activity
inside.
07/12/08 23:28 Ectopic Pregnancy 13
 METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5
weeks can be any of the following-

1. Poorly defined tubal ring possibly containing

echogenic structure and POD typically containing
fluid or blood.
2. Ruptured ectopic with fluid in the POD and an
empty uterus.
3. In Colour Doppler, the vascular colour in a
characteristic placental shape, the so-called fire
pattern, can be seen outside the uterine cavity while
the uterine cavity is cold in respect to blood flow
07/12/08 23:28 Ectopic Pregnancy 14
 MANAGEMENT

• Depends on the stage of the disease and

the condition of the patient at diagnosis.
• Options-
– Surgery – Laparoscopy / Laparotomy
– Medical – Administration of drugs at the
site / systemically
– Expectant – Observation
07/12/08 23:28 Ectopic Pregnancy 15
 MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY

• Hospitalisation
• Resuscitation -
– Treatment of shock
– Lie flat with the leg end raised
– Analgesics
– Blood transfusion

07/12/08 23:28 Ectopic Pregnancy 16

 MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY

Culdocentesis: -
• Most Helpful in Emergent Situations to
Confirm Diagnosis
• Highly Specific if performed and
Interpreted Correctly: - Presence of Free-
Flowing, NON-Clotting Blood
• Negative Tap Inconclusive
• Remains Controversial
07/12/08 23:28 Ectopic Pregnancy 17
 MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY

• Laparotomy should be done at the earliest.

• Salpingectomy is the definitive treatment.
• No benefit from removing Ovary along with the
tube
• If blood is not available, auto-transfusion can
be done.

07/12/08 23:28 Ectopic Pregnancy 18

 MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
INVESTIGATIONS-
• Laboratory/Chemical test –
– Serial quantitative beta HCG level by RIA
– Serum progesterone level (<5 mg/ml in ectopic
pregnancy)
– Low levels of Trophoblastic proteins such as
SPI and PAPP-, Placental protein 14 & 12
• USG- usually haematocele is found
• Laparoscopy
07/12/08 23:28 Ectopic Pregnancy 19
 MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY

TREATMENT – ALWAYS SURGICAL

• Salpingectomy of the offending tube

• If pelvic haematocele is infected,
posterior. colpotomy is to be done to
drain the pelvic abscess
• Salpingo-oophorectomy

07/12/08 23:28 Ectopic Pregnancy 20

 MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY

OPTIONS: -
• SURGICAL-
• SURGICALLY ADMINISTERED
MEDICAL (SAM) TREATMENT
• MEDICAL TREATMENT
• EXPECTANT MANAGEMENT

07/12/08 23:28 Ectopic Pregnancy 21

 SURGICAL TREATMENT OF ECTOPIC
PREGNANCY

• Carried out either by Laparoscopy / Laparotomy.

• The procedures are: -
– Salpingectomy / Cornual resection / Excision
– Conservative surgery (in cases of Infertility & desire
for pregnancy)
• Linear salpingostomy
• Linear salpingotomy
• Segmental resection and anastomosis
• Milking of the tube
07/12/08 23:28 Ectopic Pregnancy 22
 SURGICAL TREATMENT OF
ECTOPIC PREGNANCY

The debate goes on

LAPAROTOMY?
VS.
LAPAROSCOPY?

SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?
07/12/08 23:28 Ectopic Pregnancy 23
 COMPARING LAPAROTOMY Vs LAPAROSCOPY

L’tomy L’scopy
Hospital cost More? Less?
Post operative adhesions More Less
Risk of future ectopic Same Same
Future fertility Same Same
Experience of Surgeon Trained Special
Instruments General Special

07/12/08 23:28 Ectopic Pregnancy 24

 SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
 All tubal pregnancies can be treated by partial
or total Salpingectomy
 Salpingostomy / Salpingotomy is only
indicated when:
1. The patient desires to conserve her fertility
2. Patient is hemodynamically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 5Cm. In size
5. Contralateral tube is absent or damaged
07/12/08 23:28 Ectopic Pregnancy 25
 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
patient’s previous gynaecological history and
the appearance of the pelvic organs, to decide
between salpingostomy / salpingotomy and
salpingectomy.
07/12/08 23:28 Ectopic Pregnancy 26
 SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
Fertility reducing factor Score
• Antecedent one Ectopic pregnancy 2
• Antecedent each further
Ectopic pregnancy 1
• Antecedent Adhesiolysis 1
• Antecedent Tubal micro surgery 2
• Antecedent Salpingitis 1
• Solitary tube 2
• Homolateral Adhesions 1
• Contralateral Adhesions 1

07/12/08 23:28 Ectopic Pregnancy 27

 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.
07/12/08 23:28 Ectopic Pregnancy 28
 LAPAROSCOPIC SALPINGECTOMY

• It is carried out by laparoscopic scissors

and diathermy or Endo-loop.
• After passing a loop of No.1 catgut over
the ectopic pregnancy the stitch is tightened
and then the tubal pregnancy is cut distal to
the loop stitch.
• The excised tissue is removed by piece
meal or in a tissue removal bag.
07/12/08 23:28 Ectopic Pregnancy 29
 LAPAROSCOPIC SALPINGOTOMY

• To reduce blood loss, first 10-40 IU of vasopressin

diluted in10 ml of normal saline is injected into the
mesosalpinx.
• Then the tube is opened through an antimesenteric
longitudinal incision over the tubal pregnancy by a
Co2 laser (Paulson, 1992)
– Argon laser (Keckstein et al; 1992)
– Laparoscopic scissors and ablating the bleeding points
with bipolar diathermy.
– Fine diathermy knife (Lundorff, 1992)
07/12/08 23:28 Ectopic Pregnancy 30
 LAPAROSCOPIC SALPINGOTOMY

• The tubal pregnancy is then evacuated by

suction irrigation.
• Hemostasis of the trophpblastic bed is
ensured.
• The tubal incision is left open.

07/12/08 23:28 Ectopic Pregnancy 31

 PERSISTENT ECTOPIC PREGNANCY
(PEP)

• This is a complication of salpingotomy /

Salpingostomy when residual trophoblast
continues to survive because of incomplete
evacuation of the ectopic pregnancy.
• Diagnosis is made because of a raised
postoperative serum HCG
• If untreated, can cause life threatening
haemorrhage

07/12/08 23:28 Ectopic Pregnancy 32

 PERSISTENT ECTOPIC PREGNANCY
(PEP)

• TREATMENT is by-
– Reoperation and further evacuation /
Salpingectomy
– Administration of IM / oral Methtrexate in a
single dose of 50 mg/m2 of body surface

07/12/08 23:28 Ectopic Pregnancy 33

 SAM TREATMENT

• Aim- trophoblastic destruction without systemic

side effects
• Technique- Injection of trophotoxic substance
into the ectopic pregnancy sac or into the affected
tube by-
– Laparoscopy or
– Ultrasonographically guided
• Transabdominal (Porreco, 1992)
• Transvaginal (Feichtingar, 1987)
– With Falloposcopic control (Kiss, 1993)
07/12/08 23:28 Ectopic Pregnancy 34
 SAM TREATMENT

• Trophotoxic substances used-

– Methtrexate (Pansky, 1989)
– Potassium Chloride (Robertson, 1987)
– Mifiprostone (RU 486)
– PGF2α (Limblom, 1987)
– Hyper osmolar glucose solution
– Actinomycin D

07/12/08 23:28 Ectopic Pregnancy 35

 MEDICAL TREATMENT WITH
METHOTREXATE

• Resolution of tubal pregnancy by systemic

administration of Methotrexate was first described by
Tanaka et al (1982)
• Mostly used for early resolution of placental tissue in
abdominal pregnancy. Can be used for tubal pregnancy
as well
• Mechanism of action- Interferes with the DNA
synthesis by inhibiting the synthesis of pyrimidines
leading to trophoblastic cell death. Auto enzymes and
maternal tissues then absorb the trophoblast.
07/12/08 23:28 Ectopic Pregnancy 36
 MEDICAL TREATMENT WITH
METHOTREXATE

• Ectopic pregnancy size should be < 3.5 cm.

• Can be given IV/IM/Oral, usually along with
Folinic acid
• Recent concept is to give Methtrexate IM in a
single dose of 50mg/m2 without Folinic acid.
• If serum HCG does not fall to 15% with in 4-7
days, then a second dose of Methtrexate is given
and resolution confirmed by HCG estimation
07/12/08 23:28 Ectopic Pregnancy 37
 MEDICAL TREATMENT WITH
METHOTREXATE

• Advantages –
– Minimal Hospitalisation.Usually outdoor treatment
– Quick recovery
– 90% success if cases are properly selected
• Disadvantages-
– Side effects like GI & Skin
– Monitoring is essential- Total blood count, LFT &
serum HCG once weekly till it becomes negative

07/12/08 23:28 Ectopic Pregnancy 38

 EXPECTANT TREATMENT

• Tubal Pregnancies are known to Abort / Resolve

• Befor the advent of salpingectomy in 1884,
ectopic pregnancies were being treated
expectantly with 70% mortality.
• Today only selected cases are managed
expectantly, screened and identified by high
resolution ultrasound scanner and monitored by
serial serum HCG assay
07/12/08 23:28 Ectopic Pregnancy 39
 EXPECTANT TREATMENT

• Identification criteria (Ylostalo et al , 1993)-

– Diameter of ectopic pregnancy <4 Cm.
– No sign of intrauterine pregnancy
– No sign of rupture by TVS
– No sign of acute bleeding by TVS
– Falling level of serum HCG at 2 day intervals
• If any deviation from the above criteria occurs,
then emergency treatment is necessary.
07/12/08 23:28 Ectopic Pregnancy 40
 EXPECTANT TREATMENT

• Spontaneous resolution occurs in 72%,while 28% will

need laparoscopic salpingostomy
• In spontaneous resolution, it may take 4-67 days (mean
20 days) for the serum HCG to return to non pregnant
level.
• The percentage fall in serum HCG by day 7 is a better
indicator than the percentage fall by day 2.
• Warning: - Tubal pregnancies have been known to
rupture even when Serum HCG levels are low.

07/12/08 23:28 Ectopic Pregnancy 41

 SUMMARY - KEY POINTS

• Incidence of ectopic pregnancy is rising while

maternal mortality from it is falling.
• Early diagnosis is the key to less invasive treatment.
• The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
• The trend is towards conservative treatment.
• Careful monitoring and proper counselling of patients
is mandatory.
• Ruptured ectopics should be unusual with compliant
patients and appropriate medical care.
07/12/08 23:28 Ectopic Pregnancy 42
07/12/08 23:28 Ectopic Pregnancy 43