Ectopic pregnancy

The most likely site for ectopic pregnancy is the oviduct (95%), with eight times as many
implantations occurring in the distal ampulla than in the proximal isthmus. Cornual (2%) and
abdominal pregnancies (1%) are uncommon. Cervical and ovarian pregnancies are rare.
Risk factors.
Previous pelvic inflammatory diseases
Previous ectopic pregnancy
Previous tubal surgery
IUD
Prolonged infertility
Clinical findings are variable depending on how early the diagnosis is made, the location of
implantation, and whether rupture has occurred.
With an unruptured ectopic pregnancy, the classic symptom triad is delay of menses, vaginal
bleeding, and abdominal pain. The classic signs are adnexal or cervical motion tenderness.
With a ruptured ectopic pregnancy, findings parallel the degree of internal bleeding and
hypovolemia. Abdominal guarding rigidity is usually indicative of significant intraperitoneal
bleeding. BP (especially orthostatic) and pulse changes indicate substantial blood loss.
Differential diagnosis.
Reproductive tract causes: spontaneous abortion, molar pregnancy, ruptured corpus luteum,
acute PID, adnexal torsion (), degenerating leiomyoma.
Nonreproductive tract: acute appendicitis, pyelonephritis, pancreatitis, diverticulitis, ileitis,
ulcerative colitis.
Diagnosis.
-hCG test
Pelvic sonography
Laparoscopy
Culdocentesis (placing a needle through the posterior fornix into the cul-de-sac) reveals
bloody aspiration.
Management.
Treatment is based on whether the oviduct is ruptured, the patients desires regarding future
fertility, and the condition of the conralateral oviduct.
Laparotomy is indicated if the patient is hemodynamically unstable with a significant
hemoperitoneum. The bleeding must be rapidly stopped.
Laparoscopy is the procedure of choice in the stable patient.
The choice of tubal procedures is directed by the site of implantation, size of the mass, and
degree of tubal damage.
Linear salpingostomy is indicated for an ampullary ectopic pregnancy less than 5 cm in
size. The antimesenteric border is incised , the trophoblastic tissue is removed by finger or
tupfer. The incision is allowed to close secondarily or sutured above the plastic catheter by
different authors. Follow up with with serial -hCG titers is needed to rule out persistent
pregnancy.
Segmental resection is indicated for isthmic ectopic pregnancy in which tubal lumen
() is usually severely distorted. The tubal segment containing the ectopic mass is
resected. Reanastomosis of the tubal stumps ( ) can be performed.
Salpingoectomy is the procedure of choice when the normal tubal anatomy is clearly
destroyed or there is no desire for future fertility.
Methotrexate is being used successfully for the medical management of ectopic pregnancies
that are less than 6 weeks gestation, when the unruptured ectopic mass is less than 3 cm
diameter. The agent may be given parenterally or may be directly injected into the mass. Serial hCG titers are required at weekly intervals and repeated until the values return to nonpregnant

values. Additional courses of methotrexate may be required until a satisfactory -hCG response
is detected.
NB! Blood type and Rh determination should be made to identify if the patient is Rh0(D)
negative. Rh0(D) immune globulin is indicated to prevent isoimmunization if the atypical
antibody test is negative.