ECTOPIC

PREGNANCY

ECTOPIC PREGNANCY
In ectopic pregnancy, a fertilized ovum implants
in an area other-than the endometrial lining of
the uterus
More than 95o/o of extrauterine Pregnanciesoccuri n the fallopian tube.

Interstitial
and
cornual 23%

Isthmic
12%

Ovarian 3%
Cesarean
scar <1

Abdominal
1%

Cervical <1%

Sites of ectopic pregnancie

Ampullary
70%

Fimbrial
11%

incidence
The incidence in the United Kingdom has

changed little in the last decade with 9.6

ectopics per 1000 pregnancies in 19911993
and 11.0 per 1000 pregnancies in 20002002
This may be due, at least in part, to a higher
incidence
of salpingitis, an increase in ovularion induction
and assisted reproductive technology, and more
tubal sterilization

Increasing Ectopic Pregnancy Rates

A number of reasons at least partially explain the increased
rate of ectopic pregnancies in the United States and many
European countries. Some of these include:
1. Increasing prevalence of sexually transmitted infections,
especially those caused by Chlamydia trachomatis
2. Identification through earlier diagnosis of some ectopic
pregnancies otherwise destined to resorb spontaneously

3. Popularity of contraception that predisposes pregnancy

failures to be ectopic
4. Tubal sterilization techniques that with contraceptive
failure increase the likelihood of ectopic pregnancy
5. Assisted reproductive technology
6. Tubal surgery, including salpingotomy for tubal pregnancy
and tuboplasty for infertility.

Mortality
According to the World Health Organization (2007),

ectopic pregnancy is responsible for almost 5 percent of

maternal deaths in developed countries.

Risk factors for ectopic pregnancy

History of previous ectopic pregnancy
(IUCD) or sterilization failure
Pelvic inflammatory disease
Chlamydia infection
Early age of intercourse and multiple partners
History of infertility
Previous pelvic surgery
Increased maternal age
Cigarette smoking
Strenuous physical exercise
In utero DES exposure

TUBAL PREGNANCY
The fertilized ovum may lodge in any portion of the

oviduct, giving rise to ampullary, isthmic, and interstitial

tubal pregnancies
In rare instances, the fertilized ovum may implant in the
fimbriated extremity. The ampulla is the most frequent
site, followed by the isthmus. Interstitial pregnancy
accounts for only about 2 percent. From these primary
types, secondary forms of tubo-abdominal, tubo-ovarian,
and broadligament pregnancies occasionally develop.

Ectopic pregnancy

Clinical presentation
1-subacute clinical picture of
A. abdominal pain &vaginal bleeding in early pregnancy.
Vaginal bleeding is usually dark red, indicative old blood
B- abdominal/ pelvic pain may be localized to the iliac fossa.
C- sholder tip pain indicative of free blood in the abdominal cavity
D- dizzeness (anaemia)
Bimanual examination can reveal tenderness in the fornices and
there may be cervical excitation
2- Acute clinical presentation due to rupture ectopic pregnancy with
massive intraperitoneal bleeding. They can present with signs of
hypovolaemic shock & acute abdomen

Investigation
The following are useful investigation for the diagnosis of

ectopic pregnancy
1- observations :Bp, pulse ,temperatuer
2- laboratory investigations:
Haemoglobin. blood group(prepare blood forr cross match) &
B-HCG
A B-HCG level of less than 5mIU/ml, is considered negative for
pregnancy& any thing above 25 mIU/ml is considered positive
for pregnancy
In 85% of pregnancy the B-HCG levels almost double every 48
hours in normally developing intrautrine pregnancy

In ectopic pregnancy the rise in B-HCG is suboptimal,. However

multiple readings are required for comparison purposes.
Transvaginal ultrasound scan (TVS)
An intrauterine gestational sac should be visualized at 4.5 weeks
Gestation.the corresponding B-HCG at that gestation is around 1500
mIU/ml.By the time a gestational sac with fetal heart pulsation is
detcted (at around 5 weeks gestation)B-HCGlevel should be around
3000 mIU/ml
Thus , if there were discrepancy betwween B-HCG cocentration and
that seen on ultrasound scan(e.g.a highB-HCG with no intruterine
pregnancy on ultrasound scan), the differential diagnosis of an
ectopic pregnancy must be made.

Identification of an intruterine pregnancy(gestational sac, yolk

sac, and fetal pole) on TVS effectively excludes the possibility

of ectopic pregnancy in most patients except in those patients
with rare hterotopic pregnancy.
The presence of free fluid during TVSis suggestive of a
ruptured cetopic pregnancy
Lparoscopy:this can be used to diagnose and treat ectopic
pregnancy

Culdocentesis
This simple technique was used commonly in the
past to identify hemoperitoneum. The cervix is
pulled toward the symphysis with a tenaculum, and
a long 16- or 18-gauge needle is inserted through
the posterior vaginal fornix into the cul-de-sac. If
present, fluid can be aspirated, however, failure to
do so is interpreted only as unsatisfactory entry into
the cul-de-sac and does not exclude an ectopic
pregnancy, either ruptured or unruptured. Fluid
containing fragments of old clots, or bloody fluid
that does not clot, is compatible with the diagnosis
of hemoperitoneum resulting from an ectopic
pregnancy. If the blood subsequently clots, it may
have been obtained from an adjacent blood vessel
rather than from a bleeding ectopic pregnancy.

Ultrasound
With the advent of diagnostic ultrasound and

the increasing use of conservative treatment,

the diagnosis of ectopic pregnancy is
increasingly made without the help of surgery.

Gestational sac
with a live
embryo
and a
yolk sac
Uterus

In women with ectopic pregnancies bleeding

within the
uterine cavity may resemble an early
intrauterine pregnancy (pseudosac).
The presence of free fluid in the pouch of
Douglas is a
frequent finding in women with normal
intrauterine pregnancies and it should not be
used to diagnose an ectopic. However, the
presence of blood clots is important and is a
common finding in ruptured ectopics

In women with intrauterine pregnancy on the

scan a
possibility of heterotopic pregnancy should be
excluded.
This is particularly the case in women who
conceived after stimulation of ovulation orIVF
(in vitro fertilization).

Serum Progesterone. A single progesterone measurement

can be used to establish with high reliability that there is a
normally developing pregnancy. A value exceeding 25
ng/mL excludes ectopic pregnancy with 92.5-percent
sensitivity .
Conversely, values below 5 ng/mL are found in only 0.3
percent of normal pregnancies . Thus, values 5 ng/mL
suggest either an intrauterine pregnancy with a dead fetus
or an ectopic pregnancy. Because in most ectopic
pregnancies, progesterone levels range between 10 and 25
ng/mL, the clinical utility is limited

Novel Serum Markers. A number of

preliminary studies have
been done to evaluate novel markers to detect ectopic
pregnancy. These include vascular endothelial growth
factor (VEGF), cancer antigen 125 (CA125), creatine
kinase, fetal fibronectin, and mass spectrometry-based
proteomics None of these are in current clinical use.

Differential diagnosis

The diagnosis is from any other acute abdominal

catastrophe such as rupture of a viscus or acute
peritonitis. The clinical picture is so typical that in
most cases diagnosis presents no difficulty. Other
diagnoses which may confuse are:
inevitable miscarriage;
bleeding with an ovarian cyst;
pelvic appendicitis;
acute salpingitis.

Manageme
nt

Expectant management
Expectant management has important advantages over
medical treatment as it follows the natural history of the
disease and is free from serious side effects of methotrexate.
Expectant management requires prolonged follow-up and it
may cause anxiety to both women and their carers.
However, the main limiting factor in the use of expectant
management is the relatively high failure rate and
the inability to identify with accuracy the cases that are
likely to fail expectant management. To minimize the
risk of failure many authors have used very strict selection
criteria for expectant management such as the initial
hCG <250 IU

Surgery
Surgery has been traditionally used both for the
diagnosis and treatment of ectopic pregnancy.
With recent advances in operative laparoscopy,
the minimally invasive approach has also
become accepted as the method of choice to
treat most tubal ectopic pregnancies.
There are important advantages of laparoscopic
over open surgery which include less postoperative pain, shorter hospital stay and
faster resumption of social activity

Laporatomy
In a case of severe haemorrhage in ruptured
ectopic pregnancy , the patient must be taken
immediately to the operating theatre. Little
time should be wasted in attempting
resuscitation which can prove useless and
may only increase bleeding. An intravenous
drip should be set up and a blood transfusion
given as soon as possible.

Surgical Management

Laparoscopy is the preferred surgical treatment for ectopic

pregnancy unless the woman is hemodynamically
unstable
Tubal surgery is considered
*conservative when there is tubal salvage.
Examples include salpingostomy,
salpingotomy, and fimbrial expression of the
ectopic pregnancy.
*Radical surgery is defined by salpingectomy.

Laparoscopy techniques exist to:

kill the embryo with a direct injection of
methotrexate or mifepristone allowing
absorption
so requiring no surgery on the tube;
incise the swollen tube over the ectopic
pregnancy,
aspirate the embryo, and achieve
haemostasis (salpingostomy).

Salpingostomy. This procedure is used to remove a small

pregnancy that is usually less than 2 cm in length and
located in the distal third of the fallopian tube . A 10- to
15- mm linear incision is made with unipolar needle
cautery on the antimesenteric border over the pregnancy.
The products usually will extrude from the incision and
can be carefully removed or flushed out using highpressure irrigation that more thoroughly
removes the trophoblastic tissue

Linear salpingostomy for ectopic pregnancy

Salpingotomy. Seldom performed today, salpingotomy

is essentially the same procedure as salpingostomy except

that the incision is closed with delayed-absorbable suture..

Salpingectomy. Tubal resection may be

used for both ruptured and unruptured ectopic

pregnancies. When removing the oviduct, it is advisable to
excise a wedge of the outer third (or less) of the interstitial
portion of the tube. This so-called cornual resection is
done in an effort to minimize the rare recurrence of
pregnancy in the tubal stump. Even with cornual
resection, however, a subsequent interstitial pregnancy is
not always prevented .

Persistent Trophoblast. Incomplete removal of

trophoblast
may result in persistent ectopic pregnancy. Because of this,
administered a prophylactic 1 mg/m2 dose of
methotrexate postoperatively. Persistent trophoblast
complicates 5 to 20 percent of salpingostomies and can be
identified by persistent or rising hCG levels. Usually hCG levels fall quickly and are at about 10 percent of
preoperative values by day 12 . Also, if the postoperative
day 1 serum - hCG value is less than 50 percent of the
preoperative value, then persistent trophoblast rarely is a
problem

Medical Management with Methotrexate

This folic acid antagonist is highly effective against rapidly
proliferating trophoblast, and it has been used for more
than 40 years to treat gestational trophoblastic disease

Selection criteria for conservative management of ectopic

pregnancy
1. Minimal clinical symptoms
2. Certain ultrasound diagnosis of ectopic
3. No evidence of embryonic cardiac activity
4. Size <5 cm
5. No evidence of haematoperitoneum on ultrasound scan
6. Low serum hCG (methotrexate <3000 IU/l; expectant
7. <1500 IU/l)

The followin are resonable indications for

methotrexate use
1-cornual pregnancy
2-Prsistant trophoblastic disorders
3- patient with one fallopian tubeand fertility
desired .
4-patient who refuse surgery or whome
surgery is risky
5-treatment of ectopic pregnancy where
trophoblast is adherent to bowel or blood
vessel

Contrindications of medical
treatment
1- chronic liver, renal or haematological disordes
2- active infection
3-immunodeficency
4- breast feeding

Side effect of methotrexate

nausea.vomiting ,stomatitis, cojuctivitis, GI upset,
photosensitive skin reaction Abdominal pain
Advise the women to take contraception for three
months after methotreate. It is also important to
avoid alcohol & exposure to sunlight during treatment

Non-tubal ectopics

Interstitial ectopics
The implantation of the conceptus in the proximal portion
of the Fallopian tube, which is within the muscularwall
of the uterus, is called an interstitial pregnancy. The
incidence of interstitial ectopic is 1 in 25005000 live
births and it accounts for26% of all ectopic pregnancies

Ruptured interstitial pregnancy usually presents

dramatically with severe intra-abdominal bleeding, which
requires urgent surgery. Haemostasis can usually be
achieved by removing the pregnancy tissue and suturing
the rupture site. However, in cases of extreme bleeding a
cornual resection or in rare cases a hysterectomy may be
necessary to arrest the bleeding.

The sac is completely surrounded by a

myometrial mantle, which is typical of
interstitial pregnancy.

Pregnancies located below the internal os

cervical
and Caesarean scar ectopics
Cervical
pregnancy
is
defined
as
the
implantation of the conceptus within the
cervix, below the level of the internal os.
Caesarean scar pregnancy is a novel entity,
which refers to a pregnancy implanted into a
deficient uterine scar following previous lower
segment Caesarean section

An attempt to remove cervical or Caesarean

section
pregnancy is likely to cause severe vaginal
bleeding and
hysterectomy rates of 40% have been
described when
a D&C was attempted without pre-operative
diagnosis
of cervical pregnancy

Ovarian pregnancy

Ovarian
pregnancy
is
defined
as
the
implantation of the
conceptus on the surface of the ovary or inside
the ovary,
away from the fallopian tubes
. The diagnosis of ovarian pregnancy is rarely
achieved
pre-operatively; hence most women are treated
surgically as the diagnosis is reached only at
operation

Abdominal pregnancy
Abdominal pregnancy is a rarity that only a few
gynaecologists will encounter during their professional
career. Most abdominal pregnancies are the result of
reimplantation of ruptured undiagnosed tubal ectopic
pregnancies.
With the increasing accuracy of first-trimester
transvaginal scanning it is likely the prevalence of
advanced abdominal pregnancy will decrease even
further
in the future.

The clinical and ultrasound features

of an early abdominal pregnancy are very similar to
tubal ectopic pregnancies. However, viable abdominal
pregnancies, which progress beyond the first trimester,
are typically missed on routine transabdominal scanning.
Abdominal pregnancy should be suspected in women
with persistent abdominal pain later in pregnancy and
in those who complain of painful fetal movements.

Treatment of abdominal pregnancy is surgical. In

advanced abdominal pregnancies
accompanied by normal fetal development
diagnosed in the late second trimester
termination of pregnancy may be delayed for a
few weeks until the fetus reaches viability.
At surgery the gestational sac should be opened
carefully
avoiding disruption of the placenta. The fetus
should be
removed, the cord cut short and the placenta
should be left in situ .

Any attempt to remove the placenta may result

in massive uncontrollable haemorrhage.
Adjuvant treatment with methotrexate is not
necessary and the residual placental tissue
will absorb slowly over a period of many
months, sometimes a few years. The placental
tissue left in situ may become infected leading
to the formation of a pelvic abscess, which
may require drainage.