ectopic Pregnancy

Definition
 blastocyst implants anywhere other than endometrial lining of the uterine cavity.
Incidence
▪ 1/250 of reported pregnancies
▪ nowadays due to  STD (esp. chlamydial infections), IUD use + dt use of ovulatory drugs.
Sites
▪ The commonest site → fallopian tube (over 95%) : ampullary (70%), isthmic, fimbrial or interstitial.
▪ Ovarian. ▪ Cervical.
▪ Rudimentary horn.
▪ Primary and secondary abdominal pregnancy,
▪ Cesarean scar.
Tubal Pregnancy
Risk factors
1. tube
▪ Congenital  As long and narrow tube, diverticulae and accessory ostia.
▪ Traumatic  operations as salpingoplasty and tubal reversal following ligation.
▪ Inflammatory  Chronic salpingitis is the commonest cause of tubal pregnancy.
▪ Neoplastic  Narrowing of tube by a fibroid or a broad ligament tumor.
▪ Functional  As tubal spasm or antiperistaltic contractions.
2. Pelvic endometriosis.
3. Exogenous hormones. Induction of ovulation as clomid and gonadotrophins
4. Smoking →  tubal motility and cilia movements.
5. Progesterone only pills  tubal motility and cilia movements.
6. The intrauterine contraceptive device (IUD) :
Prevents intrauterine pregnancy but not tubal pregnancy leading to a relative increase in the rate of tubal pregnancy.
7. Advanced age and history of infertility are also risk factors.
Pathology
A. Ovaries
▪ One ovary contains the corpus luteum of pregnancy. ▪ Tubal pregnancy on the same side of corpus luteum in 80%
▪ presence of 2 corpora lutea → indicate associated intra- and extra uterine pregnancy "heterotopic pregnancy" or
bilateral ectopic pregnancy.
B. Tube
▪ ovum may be implanted in any part of the tube, however, the commonest site → ampulla.
▪ Because decidual reaction in the tube is poor, ovum penetrates deeply and becomes embedded in the muscle layer.
▪ chorionic villi erode blood vessels in the wall → hemorrhage around ovum followed by internal or external tubal rupture.
▪ some cases, spontaneous resolution may occur.
Tubal mole Tubal abortion
▪ blood coagulates in layers around ovum in ▪ When ovum reaches lumen →
lumen becomes expelled by tubal contractions through abdominal
forming a fleshy mass or mole. ostium
▪ may become absorbed or infected → pyosalpinx ▪ Abortion is complete when ovum reaches peritoneal cavity and
incomplete when it remains at the abdominal ostium
▪ Fate
 blood from site of rupture may be slight and collects around fimbrial end of tube forming a peritubal hematoma or
 it may be moderate and accumulates gradually into Douglas pouch forming a pelvic haematocele.
 Sometimes bleeding is excessive → severe intraperitoneal hemorrhage.
 Rarely secondary abdominal pregnancy
▪ External tubal rupture (lead to )
Intraperitoneal rupture Extraperitoneal rupture
(rupture through roof +sides of tubes) (rupture through floor of the tube)
▪ Paratubal hematoma : Blood collects along side of tube. broad ligament hematoma or intraligamentary pregnancy
▪ Pelvic haematocele.
▪ Severe intraperitoneal haemorrhage,
▪ Secondary abdominal pregnancy.
C. Uterus
▪ about 8 weeks pregnancy → slightly symmetrically enlarged and soft in consistency
▪ endometrium shows a decidual reaction.
changes are caused by the hormones of pregnancy estrogen and progesterone.
▪ Arias-Stella reaction
hypersecretory endometrium of pregnancy seen on histologic examination, occurs in ectopic + intrauterine pregnancies
therefore, is not useful in identifying an ectopic pregnancy.
But, the absence of chorionic villi on histologic examination is diagnostic.
▪ Drop in the level of human Chorionic Gonadotrophin (hCG)
leads to regression of corpus luteum with subsequent drop in level of estrogen and progesterone →
leads to separation of the decidua and vaginal bleeding.
▪ decidua comes out in small pieces or is expelled as an intact uterine cast "decidual cast", simulating spontaneous abortion
D. Fate of the ovum
ovum dies in great majority of cases or secondary abdominal pregnancy develops.
E. Fate of abdominal pregnancy
▪ great majority of cases (90%) → fetus dies because of poor blood supply.
▪ few cases → fetus grows till full term + risk of placental separation + intraperitoneal hemorrhage or death of the fetus.
▪ Such fetus is usually malformed (50%) due to poor blood supply.

Diagnosis
 Undisturbed Tubal Pregnancy Subacute type Acute Type Chronic type with pelvic haematocele
▪ discovered accidentally ▪ The commonest type. ▪ dt sudden severe
chch

during routine examination ▪ caused by tubal mole,tubal abortion, intraperitoneal haemorrhage.

peritubal paratubal hematoma.
Symptoms Symptoms Symptoms Symptoms
▪ short period of amenorrhea ▪ short period of amenorrhea
for l or 2 months. for 1 or 2 months.
Sometimes (25%) → no history
due to occurrence of post conceptional bleeding
→ mistaken as true menstrual period.
▪ Symptoms of early pregnancy ▪ Symptoms of early pregnancy.
(NV) ▪ Pain ▪ Shoulder pain
▪ pain felt in one iliac fossa. felt on lying down
Diagnosis

dull aching in one iliac fossa. dull aching sharp stabbing colicky dt diaphragmatic irritation
Dt dt dt Dt by blood.
tubal contractions
distension of tube and distention erosion of ▪ abdominal pain ▪ lower abdominal pain
of tube wall of tube in case of tubal
stretching of its peritoneal coat. sudden severe Recurrent attacks
abortion.
after short period of amenorrhea ▪ fainting and vaginal bleeding
Disturbed ectopic pregnancy ▪ Fainting attacks or even shock, after a period of amenorrhea
▪ the commonest cause Dt pain and irritation of peritoneum (a history suggestive of disturbed
of acute abdominal pain by repeated attacks of bleeding. ectopic)
▪ in a sexually active woman ▪ Vaginal bleeding occurs after pain ▪ Pressure symptoms dt
▪ in child bearing period Dt separation of decidua. accumulation of blood
▪ even in absence of amenorrhea usually slight and dark brown in color, in Douglas pouch as
with decidual fragments. dysurea, dyschesia, and dyspareunia .
Signs Signs Signs Signs
General General General
▪ Varying degree of anemia Evidence of shock. as subacute type.
Abdominal depending upon amount of blood loss. Abdominal Abdominal
Tenderness in one iliac fossa. ▪ pulse → rapid, especially after attack of pain Tenderness and rigidity. pelvi -abdominal swelling may be felt
▪ Blood pressure falls may be shifting dullness. → fixed and ill defined.
Vaginal in proportion to amount of internal hemorrhage
▪ Local signs of pregnancy ▪ Temperature may be slightly  Vaginal Vaginal
(uterus is soft and slightly enlarged). dt absorption of blood from peritoneal cavity reveals little information mass
▪ cervix Abdominal dt  bulging through posterior fornix.
soft and severe pain occurs ▪ Tenderness and rigidity in one iliac fossa. marked tenderness and rigidity  fixed, tender
when it is moved from side to side ▪ Cullen sign may be present so pelvic organs cannot be felt.  soft, firm or hard if calcified and
(cervical motion tenderness or jumping sign) (bluish coloration around umbilicus due to this depends on its duration.
▪ mass the presence of blood in peritoneal cavity). DD  uterus is pushed forwards or upwards
may be felt to one side of uterus. Vaginal exam. : as before. by mass.
▪ Causes of internal hemorrhage
very tender, soft + may be pulsating ▪ Early pregnancy complications  slightly enlarged and soft.
as rupture corpus luteal cyst.
(threatened, incomplete, or missed abortion). ▪ Causes of acute abdominal pain
▪ Hemorrhagic corpus luteal cyst as acute appendicitis + renal calculi
Diagnostic procedures
1) Pregnancy test
Urinary Serum + quantitative beta-subunit of HCG in serum
▪ positive > 90% of cases of ectopic pregnancy. ▪ positive in all cases
▪ However a negative urinary test does not exclude ectopic pregnancy. ▪ very sensitive test
2) Pelvic ultrasonography (focus on evaluating the viability and location of the pregnancy) :
✓ Vaginal sonography (TVS) is more sensitive than abdominal sonography to diagnose ectopic pregnancy.
✓ In normal pregnancy :
Using TVS, a gestational sac is eccentrically + usually visible at about 4.5 weeks from the last menstrual period
fetal pole with cardiac activity is first detected at about 5.5 weeks.
With transabdominal sonography these structures are visualized slightly later.
✓ In ectopic pregnancy
Tube Uterus
▪ Hematosalpinx or peritubal hematoma. ▪ No intrauterine pregnancy.
▪ ring-like mass that may have yolk sac or embryonic pole ▪ Pseudogestational sac : may be detected.
with or without cardiac activity (sure sign). result of an intracavitary fluid collection
✓ Free fluid in peritoneum (internal haemorrhage). caused by sloughing of decidua situated in midline of uterus
✓ Color Doppler : ring of color (ring of fire)
may around extrauterine gestational sac and helps to locate it
3) Combining beta HCG and ultrasound
▪ β-hCG discriminatory value (or zone) ▪ absence of uterine pregnancy ▪ If β-hCG levels are still ▪ Doubling sign
lower limit of hCG at which with β-hCG levels below discriminatory value In normal pregnancy a 66% or
examiner can reliably visualize pregnancy on US . above discriminatory value → make greater  in serum β-hCG levels
vaginal ultrasound abdominal ultrasound → signifies abnormal pregnancy; serial β-hCG and US should be observed every 48 hours
1000-1500 IU/L 6000 IU/L ✓ ectopic, (nearly doubles).
✓ incomplete abortion, ▪ Inappropriately  serum β-hCG
✓ resolving completed abortion suggest (but do not diagnose)
abnormal pregnancy (ectopic)
however, they not identify its location.
4) Serum progesterone→ Predicts pregnancy viability not location.
≥ 25ng/ml or higher → healthy pregnancy. <5 ng/ml → nonviable pregnancy.
5) Complete blood count (CBC) →  level of haemoglobin, and haematocrit value indicates internal haemorrhage.
6) Urine analysis (excludes pyelonephritis and renal causes).
7) Uterine curettage → Examination of products from the uterus shows decidua cells but no chorionic villi.
8) Laparoscopy →
The most accurate technique of identifying an ectopic pregnancy (by direct visualization).
not done in presence of excessive intraperitoneal haemorrhage → as these need immediate laparotomy.
9) Magnetic resonance imaging → Very accurate to diagnose abdominal pregnancy.
Treatment
▪ patient is shocked → antishock measures ▪ patient is Rh negative and not sensitized anti-D serum is given
Medical therapy
▪ By systemic methotrexate (a folic acid antagonist).
▪ Intramuscular methotrexate given as a single dose.
Indications Contraindications
▪ Hemodynamically stable. Absolute Relative
▪ Initial serum hCG <3000 IU/L. ▪ Breastfeeding. ▪ Gestational sac > 3.5 cm.
▪ Adnexal mass <3.5 cm in diameter. ▪ Peptic ulcer disease ▪ Embryonic cardiac motion.
▪ No fetal cardiac activity. ▪ Immunodeficiency.
▪ The most common side effects include ▪ Liver disease.
nausea, vomiting, diarrhea, gastric distress, dizziness, and stomatitis. ▪ Leukopenia or thrombocytopenia.
▪ serum β-hCG level is determined before administering methotrexate ▪ Renal disease.
+ repeated on days 4 and 7 following injection. ▪ Known sensitivity to methotrexate.
▪ Comparison is then made between the day 4 and the day 7 serum values. .
▪ If there is decline by 15% or more ▪ If β-hCG level does not decline
(successful) → measure (plateau or increase),
weekly serum β-hCG levels Patient may require either a
until they are undetectable. second dose of methotrexate or
surgery.
Surgical treatment
▪ Through laparoscopy or laparotomy.
▪ Either conservative (linear salpingostomy or segmental resection) or definitive (salpingectomy) :
Linear salpingostomy Segmental resection Salpingectomy
▪ surgeon makes an in-cision on fallopian tube removal of portion of affected tube ▪ removal of entire tube
over site of implantation, ▪ indication
removes pregnancy + allows incision to heal by 2ry intention little or no normal tube remains.
▪ must be followed with ▪ Both tubes are inspected
serial quantitative β-hCG levels because bilateral tubal pregnancy may occur,
to monitor regression of pregnancy other tube may be diseased, absent or malformed.
▪ Removal of any pelvic hematomas or
intrapertoneal blood then peritoneal toilet

.
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 Abdominal (Peritoneal) Pregnancy
Primary Secondary
Implantation occurs in the peritoneal cavity from start. Secondary to tubal, uterine or ovarian pregnancy.
Incidence : About 1 : 15,000 pregnancies.
Survival of the fetus occurs in only 10% to 20% of cases; up to one-half of those surviving have significant deformity.
Diagnosis
1- History
▪ history of recurrent attacks of lower abdominal pain, fainting and vaginal bleeding after a period of amenorrhea
(a history suggestive of disturbed ectopic in secondary type).
2- Examination :
▪ General : Signs of pregnancy.
▪ Abdominal exam
lie of the fetus is usually abnormal, e.g. a high transverse lie.
fetal parts are easily felt.
Uterine contractions cannot be detected over the mass.
▪ Vaginal exam : The uterus is felt separate from the mass. It is slightly enlarged.
3- Investigations
Sonography Studdiford's criteria of 1ry type (at laparotomy) :
▪ Abnormal fetal lie and attitude; ▪ No uteroperitoneal fistula.
▪ Fetus is seen separate from uterus; ▪ Both ovaries and tubes are healthy.
▪ Placenta is seen outside the uterus. ▪ sac is small enough to exclude 2ry implantation.
▪ No uterine wall is seen between fetus and urinary bladder;
Magnetic resonance imaging → Very accurate for diagnosis.
Differential Diagnosis : Some cases of rupture of uterus.
Treatment of advanced abdominal pregnancy :
▪ Once the condition is diagnosed
laparotomy is performed because fetus is malformed in 50% of cases + risk of infection or rupture and hemorrhage.
➔ fetus and placenta are removed.
If placenta is attached to important structures as intestines or large blood vessels if the placenta is attached to a removable structure → omentum, i
→ dangerous to remove it, so t can be removed with it.
✓ cord is cut short, ligated with silk + placenta is left and give methotrexate
If woman is Rh negative and not sensitized anti-D serum is given.
 Ovarian Pregnancy Cervical Pregnancy Heterotropic Pregnancy
▪ very rare ▪ Ovum is implanted in cervical canal. ▪ Heterotopic pregnancy
(1 :25,000 pregnancies). ▪ risk factor unique (coincident or combined pregnancy)
 risk factors and clinical picture history of dilation and curettage. is coexistence of ectopic + intrauterine pregnancy
chch

as tubal pregnancy. ▪ Cervix → enlarged and soft ▪ incidence → 1 in 30,000 pregnancies.

. with products of conception in cervical canal. ▪ result of assisted reproduction,
▪ Bleeding may be severe however, the rate of heterotopic regnancies
Because cervix is non-retractile. has increased to 1 in 100 pregnancies.
1. Ultrasound
classical sonographic description of gestational sac
on or within ovary.
Diagnosis

2. At operation: criteria of ovarian pregnancy

(Spiegelberg criteria) are
▪ pregnancy sac occupies position of ovary;
▪ wall of sac must contain ovarian tissue
▪ connected to uterus by ovarian, ligament
▪ Both tubes must be normal
woman is Rh negative + not sensitized Medical : Medical
▪ anti-D serum Medical management can be used if the ▪ potassium chloride can be injected
previously into pregnancy sac.
described ▪ Methotrexate is contraindicated
criteria are met. Dt
potential detrimental effects on normal pregnancy
By laparotomy and removal of affected ovary Surgical
TTT

Indication ▪ Suction evacuation of products of Surgical management of ectopic pregnancy

▪ mass alone cannot be removed. conception + curettage. while attempting to not disturb intrauterine pregnancy
To bleeding haemostatic cervical sutures
are placed at 3 and 9 o' clock before procedure,
followed by insertion of a Foley catheter
Into cervical canal to compress bleeding area
▪ Hysterectomy if severe bleeding
cannot be controlled

Cornual (Interstitial) Pregnancy Pregnancy In Rudimentary Horn

Def pregnancy in the interstitial part of the tube, which traverses the uterine wall. Rupture occurs at 16 to 20 Weeks or later
chch ▪ Swelling lateral to the insertion of the round ligament is the characteristic anatomic finding. due to the presence of myometrium.
▪ Tends to present several weeks later in pregnancy, as muscular cornu of uterus is better able to
expand and accommodate an enlarging pregnancy
(rupture typically occurs between the eighth and sixteenth gestational weeks).
TTT wedge resection or hysterectomy (as it is often associated with massive hemorrhage). excision of the horn