CASE DISCUSSION:

Ectopic Pregnancy

Ectopic pregnancy refers to implantation of the fetus in a site other than the normal
intrauterine location; the fertilized ovum implants outside the uterus.

Sites of an ectopic pregnancy are

1the fallopian tube,
2ovary,
3cervix,
4or abdominal cavity
The majority of ectopic pregnancies (95%) are located in the fallopian tube, with 1%
located on an ovary, less than 1 % on the cervix, and 3% to 4% in the abdominal cavity,
Of all tubal pregnancies, more than half are located in the ampulla, or largest portion
of the tube. The next most common site in the isthmus, or the narrow part of the tube that
connects the interstitial to the ampullar portion. Three percent are located in the interstitial
or muscular portion of the tube adjacent to the uterine cavity. Rarely does the ectopic
pregnancy locate in the fimbria or terminal end of the tube. The outcome and gestational
length of the ectopic pregnancy will be influenced by its location in the fallopian tube.

Incidence

The incidence of ectopic pregnancy is approximately 1 out of every 60 pregnancies, or

2% with the number increasing each year worldwide. Women over 35 years old,
nonwhites, or those who have a history of infertility are at a greater risk of experiencing an
of ectopic pregnancy.

Etiology

1 Previous Tubal Infections

Previous pelvic infections caused by certain sexually transmitted diseases, such as
chlamydia and gonorrhea, postpartum endometritis and postabortal uterine infections can
predispose to a tubal infection. A tubal infection can cause damage to the mucosal
surface of the fallopian tube, causing intraluminal adhesions that interfere with the
transportation of the fertilized ovum to the uterine cavity.

2 Previous Tubal or Pelvic Surgery

During surgery, if blood is allowed to enter the fallopian tubes, tubal adhesions can result
from the irritation of the mucosal surface. Salpingectomy, for previous ectopic pregnancy
or for treatment of an inflammatory process, and salpingoplasty, for infertility are the
surgeries that most frequently cause tubal adhesions. Occasionally irritation results from
an appendectomy.

3 Hormonal Factors
Altered estrogen/progesterone levels or inappropriate levels of prostaglandins can
interfere with normal tubal motility of the fertilized ovum.

4 Contraceptive Failure
Ectopic pregnancies occur with the use of an intrauterine device (IUD) in approximately 2
per 1000 users each year. The cause is unknown but may be related to altered tubal
motility or a tubal infection. There is increased risk for an ectopic pregnancy with the
progestin-only oral contraceptive because of the decreased motility - induced effect of
progesterone.

5 Stimulation of Ovulation
There is a 3% increased incidence of an ectopic pregnancy associated with ovulation
-stimulating drugs such as human menopausal gonadotropin and clomiphene citrate.
These drugs alter the estrogen/progesterone level, which can affect tubal motility.

6 Infertility Treatment
There is an increased risk of an ectopic pregnancy with in vitro fertilization (IVF) or
gamete intrafallopian transfer (GIFT) since underlying tubal damage is frequently one of
the causative factors predisposing one to this type of infertility treatment.

7 Environmental Effect
Maternal cigarette smoking at the time of conception was found in a case-controlled
study, to be associated with an increased risk of an ectopic pregnancy.

8 Transmigration of Ovum
Migration of the ovum from one ovary to the opposite fallopian tube can occur by an
extrauterine or intrauterine route. This can cause a potential delay in transportation of the
fertilized ovum to the uterus. Then trophoblastic tissue is present on the blastocyst before
it reaches the uterine cavity, and therefore the trophoblastic tissue implants itself on the
wall of the fallopian tube.

9 Endometriosis
The presence of endometrial tissue located outside the uterine cavity increases the
receptivity of the fertilized ovum to an ectopic implantation.

Normal Physiology

The fallopian tube is very muscular and narrow and contains very few ciliated cells at
the interstitial area. In the ampullar area the fallopian tube becomes less muscular, the
luminal size increases, and the ciliated cells are more abundant.
The fimbriated end of the fallopian tube has the unique function of moving the ovum
and sperm in opposite directions almost simultaneously by peristaltic (muscular
contraction) and ciliated activity. This tubal activity is initiated by two or more adjacent
pacemakers in the ampullar and isthmic areas of the fallopian tube by sending out
myoelectrical activity is in either direction. The net directional movement in the fallopian
tubes will vary during the menstrual cycle. During menstruation the net directional force is
toward the uterus starting from the ampullar area to prevent menstrual blood reflux into
the tube. This is stimulated primarily by estrogen induced prostglandins. Just before
ovulation, the directional force from the ampullar area is inward in order to pick the
released ovum from the ovary and moved it into the ampullar area of the fallopian tube. At
the same time the directional force from the uterine area is just the opposite in order to
facilitate sperm motility toward the ovum. This is influenced by estrogen primarily. After
fertilization the directional force varies in the ampullar area, which delays ovum transport.
Approximately 5 days after ovulation, the net directional force from the middle of the
ampullar area is inward through the isthmus in order to transport the ovum to the uterus.
This is influenced by increasing progesterone and prostaglandin E 2 (PGE). Approximately
7 days after ovulation, the myoelectrical activity become variable again, moving in both
directions from each of the pacemakers.
The fertilized ovum should reach the uterine cavity in 6 to 7 days, just about the time
the trophoblast cells begin to secrete the proteolytic enzyme and start to develop the
threadlike projections called chorionic villi that initiate the implantation process.
The uterus is normally prepared by estrogen and progesterone to accept the fertilized
ovum, now called a blastocyst. As the chorionic villi invade the endometrium, the villi
are held in check by a fibrinoid zone. The uterus is also supplied with an increased blood
supply capable of nourishing the products of conception.

Pathophysiology

Tubal Ectopic Pregnancy

Because most ectopic pregnancies initially implant in a fallopian tube, the

pathophysiology will focus on tubal ectopic pregnancies. The blastocyst burrows into the
epithelium of the tubal wall, tapping blood vessels, by the same process as normal
implantation into the uterine endometrium. However, the environment of the tube is quite
different because of the following factors:

1. There is a decreased resistance to the invading trophoblastic tissue by the

fallopian tube.
2. There is a decreased muscle mass lining the fallopian tubes; therefore their
dispensability
3. The blood pressure is much higher in the tubal arteries than in the uterine
arteries is greatly limited.
4. There is limited decidual reaction; therefore human chorionic gonadotropin
(hCG) is decreased and the signs and symptoms of pregnancy are limited.

It is because of these characteristic factors the termination of a tubal pregnancy occurs

gestationally early by an abortion, spontaneous regression, or rupture, depending on the
gestational age and the location of the implantation. If the embryo dies early in gestation,
spontaneous regression often occurs. If spontaneous regression fails to occur, then
usually an ampullar or fimbriated tubal pregnancy ends in an abortion and an isthmic or
interstitial pregnancy ends in a rupture

A tubal abortion primarily occurs because of separation of all or part of the placenta.
This separation is caused by the pressure exerted by the tapped blood vessels or tubal
contractions.

With complete separation, the products of conception are expelled into the abdominal
cavity by way of the fimbriated end of the fallopian tube.

With an incomplete separation, bleeding continues until complete separation takes

place, and the blood flows into the abdominal cavity collecting in the rectouterine cul-de-
sac of Douglas.

Tubal rupture results from the uninterrupted invasion of the trophoblastic tissue or
tearing of the extremely stretched tissue. In either case the products of conception are
completely or incompletely expelled into the abdominal cavity or between the folds of the
broad ligaments by way of the torn tube.
 The duration of the tubal pregnancy depends on the location of the implanted embryo
or fetus and the distensibility of that part of the fallopian tube. For instance, if the
implantation is located in the narrow isthmic portion of the tube, it will rupture very early,
within 6 to 8 weeks; the distensible interstitial portion may be able to retain the pregnancy
up to 14 weeks of gestation.

Abdominal Ectopic Pregnancy

An abdominal pregnancy almost always results from an implantation secondary to a

tubal rupture or abortion through the fimbriated end of the fallopian tube. In these cases
the placental continues to grow following attachment to some abdominal structure, usually
the surface of the uterus, broad ligaments, or ovaries. However, it can be any abdominal
structure including the liver, spleen, or intestines. Because the invading trophoblastic
tissue is not held in check, it can erode major blood vessels at any because they are not
cushioned by the myometrium.

Cervical Ectopic Pregnancy

In very rare cases the fertilized ovum bypasses the uterine endometrium and implants
itself in the cervical mucus. Painless bleeding begins shortly after implantation, and
surgical termination is usually required before the fourteenth week of gestation.

Signs and Symptoms

Before Rupture

 Abdominal Pain

Abdominal pain occurs close to 100% of the time. It is usually first manifested by a dull
pain caused by tubal stretching following by a sharp colicky tubal pain caused by further
tubal stretching and stimulated contractions. It is diffuse and is bilateral or unilateral.

 Amenorrhea

A history of a late period for approximately 2 weeks or a higher than usual or irregular
period is reported by 75 % to 90 % of the patients

 Abnormal Vaginal Bleeding

Mild to intermittent dark red or brown vaginal discharge occurs in 50 % to *0 % of the

cases related to uterine decidual shedding secondary to decreased hormones.

 Absence of Common Signs of pregnancy

Absence of common signs of pregnancy is secondary to decreased pregnancy hormones
and occurs 75 % of the time.

 Abdominal Tenderness
Abdominal Tenderness occurs in approximately 95 % of the cases.

 Palpable Pelvic Mass

Referred Shoulder Pain approximately 50 % of the cases. It may be in the opposite
abdominal quadrant from the ectopic growth related to a corpus luteum cyst.

Rupture

Exacerbation of the pain occurs during rupture in an ectopic pregnancy.

After Rupture

 Dizziness
Faintness and dizziness occur in the presence of significant bleeding Generalized,
Unilateral, or Deep Lower Quadrant Acute

 Abdominal Pain
Pain is caused by blood irritating the peritoneum

 Referred Shoulder Pain

Referred shoulder pain is related to diaphragmatic irritation from blood in the peritoneal
cavity

 Signs of Shock
Shock is related to the severity of the bleeding into the abdomen.

Maternal Effects
 Ectopic pregnancies account for approximately 10% of all maternal deaths.
 They are the fourth leading cause of maternal mortality, but they are the number
one cause of maternal mortality in the first trimester of pregnancy.
 Hemorrhage is the cause of death in 85 % to 89 % of the cases and occurs more
frequently with an interstitial or abdominal ectopic pregnancy.
 The greater risk of mortality related to an ectopic pregnancy is associated with an
abdominal ectopic growth, which has a 7.7 times greater risk when compared to
other types of ectopic pregnancies.

Fetal and Neonatal Effects

Death is almost certain for the fetus in an ectopic pregnancy. From 5 % to 25 % of

abdominal ectopic pregnancies will reach viability. However, it is not recommended to
continue an abdominal pregnancy if diagnosed early because of the extreme risk of
hemorrhage at any time during the pregnancy. The risk of fetal deformity is also high; 20
% to 40 % of the fetuses that live beyond 20 weeks of gestation will have such deformities
as facial asymmetry, severe neck webbing, joint deformities, and hypoplastic limbs These
are pressure deformities caused by oligohydramnios.

Medical Diagnosis
 Early diagnosis before extrauterine rupture or abortion can decrease maternal mortality
from hemorrhage and simplify the management of an ectopic pregnancy.

Pregnancy Tests

*0 Because of the lower levels of hCG being secreted by an ectopic implanted

placenta related to poor vascularization, the pregnancy test must be highly sensitive for
beta-human chorionic gonadotropin (beta- hCG) to confirm a if an ectopic pregnancy is
suspected.

*1 The most common urine pregnancy tests such as the latex agglutination inhibition
slide test are only 50 % to 60 % accurate in confirming a pregnancy that is ectopic
*2 Radioimmunoassay tests are able to detect minute amounts of hCG (5 to 10
mIU/mI) and have proven to be almost 100 % accurate in detecting an ectopic pregnancy.
However, they take several hours to run.

*3 The new monoclonal antibody pregnancy tests such as

 the enzyme-linked immunosorbent assay (ELISA) and
 the immunofluorometric assay (IFMA) are specific for the beta-hCG submit and
therefore are 95 % to 99 % accurate. It takes only minutes to run these tests.

Ultrasound

The usefulness of ultrasound in the diagnosis of an ectopic pregnancy is improving

continuously.
*4 With the more sophisticated real-time equipment and an expert technician,
characteristic changes of an ectopic pregnancy can be picked up with pelvic ultrasound.
*5 With transvaginal ultrasound, the location of the gestational sac of an early ectopic
pregnancy can be visualized with 82 % to 84 % accuracy
*6 Therefore transvaginal ultrasound is becoming an important diagnostic tool in an
ectopic pregnancy before rupture because the probe can be placed closer to the pelvic
structures.

Culdocentesis

Culdocentesis can be used to diagnose intraperitoneal bleeding if a rupture ectopic

pregnancy is suspected.

*7 The procedure involves passing a needle through the cul-de-sac of Douglas to

aspirate fluid from the peritoneal cavity.

Example:
in a woman of reproductive age and abdominal pain, a positive pregnancy test from the
presence of human chorionic gonadotropin (HCG), ultrasound examination to determine if
a gestational sac is present within the uterus or a mass outside the uterus, and
culdocentesis with presence of blood are helpful in making the diagnosis of ectopic
pregnancy. Seen here is tubal epithelium at the right, with rupture site and
chorionic villi at the lower left.
Laparoscopy
If any question remains, an endoscope may be inserted through a small abdominal
incision to visualize the peritoneal cavity for an ectopic implanted pregnancy

Medical treatment

Tubal Ectopic Pregnancy Before Rupture

 Surgical treatment
The type of surgical management depends on the location depends on
 the location and
 cause of the ectopic pregnancy,
 the extent of tissue involvement, and the patient’s wishes for future fertility.
The choice of treatment for an unruptured ampullar or fimbriated tubal pregnancy is a
salpingostomy, in which a longitudinal incision is made over the pregnancy site and the
products of conception are gently removed, being very careful to prevent or control the
bleeding.

Segmental resection and subsequent end-to-end anastomosis after the swelling and
infection have subside may be necessary if the ectopic pregnancy was located in the
proximal isthmus portion of the tube.

Nonsurgical Treatment

A methotrexate type of chemotherapy has been successfully used as an alternative to

surgery. Provided there are no signs of bleeding, a dose of 1 ml/kg can be given
intramuscularly every other day for 4 days. In clinical studies a single dose of 12.5mg has
been proven effective when locally injected into the ectopic site. This cytotoxic drug
causes dissolution of the ectopic mass.

Tubal ectopic pregnancy After Rupture

 Following a ruptured tubal pregnancy, a salpingectomy (removal of the affected
fallopian tube) is the most common surgical treatment. Occasionally a
salpingooophorectomy (removal of the affected fallopian tube and adjacent ovary) is
performed if the blood supply to the ovary is affected or the ectopic pregnancy involved
the ovary. Otherwise, preservation of the ovary is recommended. If the couple does not
wish to have more children, then a hysterectomy may be done if the woman’s condition is
stable.

Abdominal Ectopic Pregnancy

For an abdominal pregnancy, hemorrhage is a serious possibility because the placenta

can separate from its attachment site at any time.
Abdominal surgery to remove the embryo or fetus is usually done as soon as an
abdominal pregnancy is diagnosed. Unless the placenta is attached to abdominal
structures that can be removed, such as the ovary or exterior of the uterus, or the blood
vessels that supply blood the placenta can be ligated, the placenta is left without being
disturbed.

If the placenta is removed, large blood vessels would be opened and there would not
be a constricting muscle such as the uterus to apply a sealing pressure. If left intact, the
placenta is usually absorbed by the body, but unfortunately it may cause such
complications as infection, abscesses, adhesions, intestinal obstruction, paralytic ileus,
postpartum preeclampsia, and wound dehiscence. These complications are less
threatening than the hemorrhage that could result, if removed.

Cervical Ectopic Pregnancy

In the case of a cervical pregnancy, the risk of hemorrhage is great as any other type of
ectopic pregnancy.

A vaginal delivery should be attempted if the gestational age is less than 12 weeks and
the couple desires to have more children. The cervical branch of the uterine artery is
ligated and the cervix is then packed or a Foley catheter balloon inflated in an attempt to
curtail the bleeding from opened blood vessels after the removal of the placenta.

If this does not stop the bleeding, amputation of the cervix or a hysterectomy must be
done.

If the couple does not wish to have any more children, an abdominal hysterectomy is
generally the method of treatment.