Ectopic Pregnancy

 An ectopic pregnancy is a gestation that

implants outside of the endomitrial
cavity. It represents a serious hazard to
a woman’s health and reproductive
potential, requiring prompt recognition
and early aggressive intervention.
• More than 95% of ectopic pregnancies
implant in various anatomic segments of
the fallopian tube, including the
interstitial (1%), isthmic (9%), ampullary
(85%), and infundibular portions (5%).
Other less common sites of ectopic
implantation are the uterine cervix, ovary,
and the peritoneal cavity (Fig. 1).
Fig. 1. Possible locations of ectopic
pregnancy
 Epidemiology
 Since the early 1970s, the incidence of
ectopic pregnancy has tripled, and
currently this condition represents the
fourth leading cause of maternal mortality
overall (4%) and the most common cause
of maternal mortality in the first trimester.
Several factors have been implicated as
contributing to this increased incidence:
• Improved technology, which has allowed
for earlier and more complete diagnosis of
some patients whose condition went
undetected in the past.
• The rising incidence of acute and chronic
salpingitis, induced abortion, tubal ligation,
tubal reconstructive surgery, and
conservative management of tubal
pregnancy, all of which result in histologic
and structural damage to the tubes.
 The use of intrauterine contraceptive devices
(IUDs). Women with IUDs are four times
more likely to suffer from an ectopic
pregnancy. This effect is due to the better
protection afforded by IUDs against
intrauterine compared with extrauterine
pregnancy and the higher incidence of pelvic
inflammatory disease among IUD users.
 The overall incidence of
ectopic pregnancy is estimated
to be at least one in every 200
pregnancies.
 Etiology
 Probably as many as 50% of cases result from
alteration of tubal transport mechanisms
secondary to damage to the ciliated surface of
the endosalpinx caused by infections such as
Chlamydia and gonorrhea. Others are the
result of intrinsic abnormalities of the
fertilized ovum and possibly transmigration of
the oocyte to the contralateral tube, with
resulting delays in passage.
 Evolution
 Tubal pregnancies rapidly invade the
mucosa, feeding from the tubal vessels,
which become enlarged and engorged.
The segment of the affected tube is
distended as the pregnancy grows.
Possible outcomes of such abnormal
gestations are as follows:
 The pregnancy is unable to survive owing
to its poor blood supply, thus resulting in a
tubal abortion and resorption, or it is
expelled from the fimbriated end into the
abdominal cavity.
 The pregnancy continues to grow until the
overdistended tube ruptures, with resulting
profuse intraperitoneal bleeding.
 In rare instances, a tubal pregnancy will
be expelled from the tube and seed onto
sites in the abdominal cavity (e.g. the
omentum, the small or large bowel, or the
parietal peritoneum), and gives rise to a
viable abdominal pregnancy.
Symptoms and Clinical Diagnosis
 High risk factors can be
summarized as follows:
 A history of tubal infection (ectopic rate of 1
in 24, as opposed to 1 in 200 in noninfected
patients)
 Prior ectopic pregnancy (15% to 50%
increase in incidence of ectopic gestation in
subsequent pregnancies)
 History of tubal sterilization within the past
1 to 2 years (higher incidence if
cauterization was used)
 History of tubal reconstructive surgery
(tuboplasty or end-to-end reanastomosis
for sterilization reversal)
 Pregnancy with an IUD in place or a
history of IUD use.
 Infertility.
The classic symptom triad
amenorrhea,
vaginal bleeding,
abdominal pain.
 Abdominal pain, usually in the lower abdomen
in early cases, or generalized in ruptured
ectopics with a hemoperitoneum. Amenorrhea
or a history of an abnormal last menstrual
period is found in 75% to 90% of ectopic
pregnancies. Vaginal bleeding, from spotting
to the equivalent of a menstrual period, results
from a low human chorionic gonadotropin
(hCG) production by the ectopic trophoblast
and is seen in 50% to 80% of patients.
 Making the diagnosis of an acutely
ruptured ectopic pregnancy is fairly
straightforward. The patient presents with
symptoms of increasing abdominal pain,
abdominal distention, and hypovolemia.
The entire abdomen is acutely tender with
guarding and rebound tenderness.
 Differential Diagnosis

 Many gynecologic and

nongynecologic disorders have
symptoms in common with ectopic
pregnancy. Gynecologic disorders to
be considered include:
 Threatened or incomplete abortion (also
presenting with pain, bleeding, and a positive
pregnancy test)
 A ruptured corpus luteum cyst (abdominal
pain, moderate to severe, at times coexisting
with a history of amenorrhea, vaginal
spotting, and presence or absence of
pregnancy, and evidence of hemoperitoneum)
 Acute pelvic inflammatory disease with
fever, abdominal pain, leukocytosis, and,
at times, adnexal masses.
 Adnexal torsion

 Degenerating leiomyoma (common in

pregnancy)
 The key to the successful management of
ectopic pregnancy is early diagnosis. Although
the number of new cases has increased
threefold, fewer are arriving at the hospital
ruptured, with the patient already in
hemorrhagic shock. This decrease is evidence
that a high index of suspicion and vigorous
efforts at early diagnosis are effective.
 β-hCG testing
 Human chorionic gonadotropin is consisting of
two linked subunits, α andβ. β-hCG is secreted
by both the cytotrophoblast and the
syncytiotrophoblast and has the sole function
of supporting the corpus luteum. Abnormal β-
hCG can not provide information on the
location of the pregnancy. Ultrasonography
must be used to locate the gestation.
 Ultrasonography
 This field has shown rapid technological
improvements in recent years, and its
application to the diagnosis of ectopic
pregnancy, alone and in combination with
hCG testing, is now the standard of care.
Transvaginal ultrasonography has allowed the
detection of an intrauterine gestational sac at
as early as 5 weeks of amenorrhea (2 mm
diameter).
 If the sac is not visualized at the uterine
cavity, special attention is needed to
differentiate between a true sac and a
pseudosac, which is a ring-like structure
produced on ultrasound by a prominent
decidual echo. Evidence of hemoperitoneum
may be inferred by the sonographic
description of “free fluid in the cul-de-sac.”
 Culdocentesis
 Culdocentesis is the technique by which a needle,
attached to a syringe, is inserted transvaginally
through the posterior vaginal fornix into the pouch of
Douglas to detect any fluid within the peritoneal
cavity (Fig. 2). Although the procedure is simple,
inexpensive, and rapid, it is quite uncomfortable for
the patient and is of limited use in an unruptured
ectopic pregnancy. It is unnecessary when the
diagnosis is obvious and has a high false-negative
rate.
Fig. 2. Technique for culdocentesis
 Management
 Emergency treatment
 Surgical treatment
Laparotomy
laparoscopy
 Medical treatment
 Expectant management
 Emergency treatment
 Immediate surgery is indicated when the
diagnosis of ectopic pregnancy with
hemorrhage is made. Transfusion with
whole blood or an appropriate blood
component therapy as soon as possible is
indicated when the patient is in shock.
 Surgical treatment
 Rapid entry into the abdomen should be
accomplished, as control of hemorrhage can be
lifesaving. Careful, fast exploration of the
abdominal cavity should be done at once.
Remove products of conception, clots, and
free blood. At operation the damaged tube is
usually removed. This procedure is the most
common for ectopic pregnancy.
 The type of procedure performed by either
laparoscopy or laparotomy will be dictated
by local findings at the time of surgery and
the desire of the woman for future fertility. In
patients who with to conserve fertility, a
linear salpingostomy is the treatment of
choice in unruptured ampullary pregnancies.
In ampullary pregnancies that have already
ruptured, a segmantal resection or partial
salpingectomy can be offered, which implies
the removal of only the affected segment of
tube, leaving the rest intact.
 Medical treatment
Unruptured ectopic pregnancy can be
treated with Methotrexate (MTX).
Block in folate metabolism
 Indications
• no contraidications to MTX
• type of unruptured or abortion
• unruptued mass <3 cm at its greastest
dimension
• β-hCG level <2000mIU/ml
• without signs of hemoperitoneum
 Expectant management
 As many as 80% of ectopic
pregnancies with hCG levels of
1000mIU/ml or less will not ruture
spontaneously or bleed profusely but
will undergo spontaneous resolution.
Expectant management is generally
reserved for reliable, relatively
asymptomatic patients in whom the
hCG titers are <200mIU/ml and delining.