Ectopic pregnancy

Ectopic pregnancy
 Following fertilization & fallopian tube transit, the blastocyst
normally implants in the endometrial lining of the uterine cavity.
 “Ectopic” = implantation elsewhere
 0.5 to 1.5% of all 1st trimester pregnancies (U.S.)
 3% of all pregnancy-related deaths
 Urine & serum b-hcg assays & TVS allow earlier diagnosis 
maternal survival rates & conservation of reproductive capacity
are improved
Tubal pregnancy
 95% of ectopic pregnancies are implanted in various segments of the fallopian tube
 Ampulla (70%), isthmic (12%), Fimbrial (11%), interstitial (2%)
 Remaining 5% of nontubal ectopic pregnancies:
 Ovary, peritoneal cavity, cervix, or prior cesarean scar
 Multifetal pregnancy containing 1 conceptus with normal uterine implantation that
coexists with 1 implanted ectopically  heterotopic pregnancy
 1 per 30,000
 With assisted reproductive technologies (ART), incidence is 9 in 10,000
pregnancies
Tubal pregnancy
 Twin tubal pregnancy  both embryos in the same tube or with one
in each tube
 D-negative women with an ectopic pregnancy who are not sensitized
to d-antigen are given ig g & anti-d immunoglobulin
 Risks:
 Abnormal fallopian tube anatomy
 Surgeries for a prior tubal pregnancy, for fertility restoration, or for
sterilization  (highest Risk)
 After 1 previous ectopic pregnancy, chance for another is
increased 5-fold
Tubal pregnancy
 Risks:
 Prior STD or other tubal infections  can distort normal tubal
anatomy
 1 episode of Salpingitis can be followed by a subsequent
ectopic pregnancy in up to 9 %
 Peritubal adhesions subsequent to salpingitis, appendicitis, or
endometriosis
 Salpingitis isthmica nodosa  condition in which epithelium-lined
diverticula extend into a hypertrophied muscularis layer
 Congenital fallopian tube anomalies (secondary to DES exposure
in utero)
Tubal pregnancy
 Risks:
 Infertility & use of ART to overcome it (1.6% ectopic pregnancy
rate)
 “Atypical”implantations (cornual, abdominal, cervical, ovarian, &
heterotopic pregnancy) are more frequent
 Smoking
 With any form of contraception, absolute number of ectopic
pregnancies is decreased (pregnancy occurs less often); however,
with some contraceptive method failures, relative number of
ectopic pregnancies is increased [e.g. tubal sterilization, copper &
progestin-releasing IUDs, & progestin-only contraceptives]
Tubal pregnancy
 Evolution & Potential Outcomes:
 Fallopian tube lacks a submucosal layer  fertilized ovum burrows
through the epithelium zygote lie near or within the muscularis which is
invaded by rapidly proliferating trophoblast
 Embryo or fetus is often absent or stunted
 Outcomes:
 Tubal rupture (the invading expanded conceptus & hemorrhage can tear
rents in the Fallopian Tube); burst spontaneously or following coitus or
Bimanual examination.
 tubal abortion (pregnancy may pass out the distal fallopian tube); blood
trickles from tubal fimbria into the peritoneal cavity pools in the rectouterine
cul-de-sac. [if occluded hematosalpinx]. Aborted fetus may implant on a
peritoneal surface (abdominal pregnancy)
 pregnancy failure with resolution
Tubal pregnancy
 Evolution & Potential Outcomes:
 Outcomes:
 pregnancy failure with resolution (documented with B-hCG assays)

 Acute ectopic pregnancy (high serum B-hCG level & rapid growth 
higher risk of tubal rupture)
 Chronic ectopic pregnancy (abnormal trophoblasts die early 
negative or low, static serum B-hCG levels  rupture late, if at all 
commonly form a complex pelvic mass  prompting diagnostic
surgery
Tubal pregnancy
 Clinical Manifestations
 With later diagnosis, classical triad: delayed menstruation, pain & vaginal
bleeding or spotting
 Tubal rupture: lower abdominal & pelvic pain  severe, sharp, stabbing,
or tearing
 Abdominal palpation elicits tenderness
 BPE: cervical motion causes exquisite pain
 Posterior vaginal fornix may bulge (blood in rectouterine cul-de-sac)
 Tender, boggy mass felt beside the uterus
 Uterus slightly enlarged due to hormonal stimulation
 Diaphragmatic irritation in half of women with sizable hemoperitoneum 
neck or shoulder pain on inspiration
Tubal pregnancy
 Clinical Manifestations
 Vaginal spotting or bleeding in 60 to 80%
 Significant intraabdominal hemorrhage
 Moderate bleeding  no change in vital signs, slight rise in BP, or a
vasovagal response with bradycardia & hypotension
 BP will fall & pulse will rise only if bleeding continues & hypovolemia
becomes significant.
 Vasomotor disturbances (vertigo to syncope)
 Even after substantive hemorrhage, Hemoglobin or Hematocrit readings
may show only a slight reduction at first
 After an acute hemorrhage  trending decline in Hemoglobin or
Hematocrit levels over several hours  more valuable index of blood loss
Tubal pregnancy
 Clinical Manifestations
 Inhalf of women with ruptured ectopic pregnancy, Leukocytosis
up to 30,000/uL may be documented
 Decidua (endometrium hormonally prepared for pregnancy) 
may pass a decidual cast (the entire sloughed endometrium that
takes the form of the endometrial cavity)
 Ifno clear gestational sac is seen or if no villi are identified
histologically within the cast, possibility of ectopic pregnancy must
still be considered
Tubal pregnancy
 Multimodality Diagnosis
 Differential
diagnosis for abdominal pain coexistent with
pregnancy is extensive
 from uterine conditions (micarriage, infection, degenerating or
enlarging leiomyomas, or round-ligament pain)
 Adnexal disease (ectopic pregnancy; hemorrhagic, ruptured or
torsed ovarian masses; salpingitis; or tuboovarian abscess)
 Nongynecological sources of lower abdominal pain (appendicitis,
cystitis, renal stone, & gastroenteritis)
Tubal pregnancy
 Multimodality Diagnosis
 Key components to identify ectopic pregnancy:
 Physical findings
 TVS

 Serum B-hCG level measurement (both initial & subsequent pattern of

rise or decline)
 Diagnostic surgery (D&C, laparoscopy, & laparotomy)

 Algorithm use (only for hemodynamically stable women)

 Those with presumed rupture  prompt surgical therapy
Tubal pregnancy
 Multimodality Diagnosis
 Beta-Human Chorionic Gonadotropin
 UseEnzyme-linked immunosorbent assays (ELISAs) for beta subunit of
hCG
 Lower limits of detection: 20-25mIU/ml for urine; ≤ 5mIU/ml for serum
 With bleeding or pain & a positive pregnancy test result, a TVS is
performed to identify gestation location
 If TVS is nondiagnostic  PUL
Tubal pregnancy
 Multimodality Diagnosis
 Beta-Human Chorionic Gonadotropin
 Levels above the Discriminatory Zone
 Above which failure to visualize a uterine pregnancy indicates that
pregnancy is not alive or is ectopic
≥ 1,500mIU/ml or ≥2,000mIU/ml
 With live uterine pregnancies, a gestational sac was seen 99% of the time
with discriminatory level of > 3510mIU/ml
Tubal pregnancy
 Multimodality Diagnosis
 Beta-Human Chorionic Gonadotropin
 Levels below the Discriminatory Zone
> pregnancy location often not technically discernable with TVS
 Serial
B-hCG level assays done to identify patterns that indicate wither
a growing of failing IUP
 Early normal progressing IUPs  53% 48-hour minimum rise
 (see figure 19-3)
Tubal pregnancy
 Multimodality Diagnosis
 Serum Progesterone
> 25ng/ml  excludes ectopic pregnancy (92% sensitivity)
 <5ng/ml  either a nonliving IUP or an ectopic pregnancy

 TVS
 Endometrial findings:
 intrauterine gestational sac visible between 4.5 & 5weeks
 Yolk sac appear between 5 & 6 weeks
 Fetal pole with cardiac activity 5.5 to 6 weeks
Tubal pregnancy
 Multimodality Diagnosis
 TVS
 Ectopic pregnancy: trilaminar endometrial pattern
 PUL  No normal IUP had a stripe thickness of <8mm
 Adnexal findings:
 Visualization of an adnexal mass separate from the ovary
 Extrauterine yolk sac, embryo or fetus identified
 Hyperechoic halo or tubal ring surrounding an anechoic sac
 60%are seen as an inhomogeneous mass adjacent to the ovary, 20% appear
as a hyperechoic ring, & 13% have an obvious gestational sac with a fetal
pole
Tubal pregnancy
 Multimodality Diagnosis
 TVS
 Ringof Fire = placental blood flow within the periphery of the
complex adnexal mass seen with transvaginal color Doppler
imaging (finding can also seen with a corpus luteum cyst)
 Hemoperitoneum (blood in the peritoneal cavity)
 Free fluid in the Morison pouch near the liver = volume 400 – 700ml
 Culdocentesis: a long gauge-18 needle is inserted through the
posterior vaginal fornix into the rectouterine cul-de-sac.
 Ifpresent, fluid can be aspirated  fluid containing fragments of old
clots or bloody fluid that does not clot
Tubal pregnancy
 Multimodality Diagnosis
 Culdocentesis: a long gauge-18 needle is inserted through the posterior
vaginal fornix into the rectouterine cul-de-sac.
 Ifpresent, fluid can be aspirated  fluid containing fragments of old clots or
bloody fluid that does not clot
Endometrial sampling
 Endometrial changes accompanying ectopic pregnancy lack coexistent
trophoblast.
 Decidual reaction in 42%, secretory in 22%, proliferative endometrium in 12%
 Absence of trophoblastic tissue should be confirmed with D&C before
Methotrexate treatment is given
 Frozensection of curettage fragments to identify products of conception is
accurate in >90% of cases
Tubal pregnancy
 Multimodality Diagnosis
 Laparoscopy
 Direct visualization of the fallopian tubes and pelvis
 Permits a ready transitionto definitive operative therapy
Tubal pregnancy
 Medical Management:
 Regimen Options
 antimetabolite Methotrexate (MTX)  Folic acid antagonist
 Highly effective against rapidly proliferating tissues (trophoblasts)
 Resolution rate: 90%
 Drawback: bone marrow, GI mucosa & respiratory epithelium can be
harmed; directly toxic to hepatocytes
 Renally excreted
A potent teratogen (craniofacial and skeletal abnormalities & fetal growth
restrictions)
 Excreted into the breast milk and may accumulate in neonatal tissues 
interfere with neonatal cellular metabolism
Tubal pregnancy
 Surgical Management:
 Laparoscopy
 Preferred unless woman is hemodynamically unstable
 Salpingostomy
 used to remove a small unruptured pregnancy
 10 – 15 mm linear incision made on antimesenteric border of FT
 Flushed out using high-pressure irrigation that thoroughly removes trophoblastic tissue
 Incision is left unsutured to heal by secondary intention
 Serum B-hCG levels decline rapidly over days (mean resolution time: 20 days)
 Salpingotomy: same procedure but incision is closed with delayed-absorbable suture
Tubal pregnancy
 Surgical Management:
 Salpingectomy
 Tubal resection may be used for both ruptured and unruptured
 Complete excision of FT is advised

 Expectant Management:
 1/3 of tubal pregnancies < 3cm and with B-hCG levels < 1500 mIU/ml
resolve without intervention
Tubal pregnancy
 Interstitial Pregnancy
 Implants within proximal tube segment that lies within the muscular uterine wall.
 Cornual pregnancies (conception that develops in the rudimentary horn of a
uterus with Mullerian anomaly)
 Rupture following 8 to 16 weeks of amenorhhea
 Due to proximity to the uterine and ovarian arteries, hemorrhage can be severe
 Mortality rate 2.5%
 Empty uterus, gestational sac seen separate from endometrium & >1cm away
from the most lateral edge of the uterine cavity, & a thin <5mm myometrial
mantle surrounding the sac
 “Interstitial line sign” = echogenic line extending from gestational sac to the
endometrial cavity  represents interstitial portion of FT
Tubal pregnancy
 Interstitial Pregnancy
 Laparoscopically, an enlarged protuberance found lying outside the round
ligament & coexistent with a normal distal FT & ovary
 Management:
 Surgical: either cornual resection or cornuostomy (laparotomy or laparoscopy)

 VS. …
 Angular pregnancy: implantation within endometrial cavity but at one cornu &
medial to uterotubal junction & round ligament  displaces the round ligament
upward &outward  sometimes carried to term but with increased risk of
abnormal placentation
Tubal pregnancy
 Cesarean Scar Pregnancy
 Implantation within the myometrium of a prior cesarean delivery scar
 Incidence: 1 in 2000
 Pathogenesis similar to placenta accrete  similar risk for serious hemorrhage
 Difficult to differentiate from Cervicoisthmic IUP
 Management:
 Expectant
 Hysterectomy in those desiring sterility
 Fertility-preserving options (Methotrexate)
Tubal pregnancy
 Cervical Pregnancy
 Rare; cervical glands noted histoligcally opposite the placental
attachment site & by all or part of the placenta found below the
entrance of the uterine vessels or below the peritoneal reflection on the
anterior uterus
 Endocervix is eroded by trophoblast
 Pregnancy develops in the fibrous cervical wall
 Predisposing factors: ART, prior uterine curettage
 Painless vaginal bleeding  1/3 are massive
 A distended, thin-walled cervix with a partially dilated external os
 Identification: speculum exam, palpation & TVS
Tubal pregnancy
 Cervical Pregnancy
 TVS: hourglass uterine shape & ballooned cervical canal; gestational tissue at
level of cervix; absent intrauterine gestational tissue
 Management:
 Medical or surgical
 Conservative management: to minimize hemorrhage, resolve the pregnancy &
preserve fertility (Methotrexate)
 Intracervical vasopressin injection or cerclage as internal os to compress feeding
vessels if cervical curettage is planned
 Adjuct: Uterine artery embolization
 Suction curettage or Hysterectomy
 Ligation of cervical branches of the uterine artery (3 & 9 o’clock positions)
Tubal pregnancy
 Abdominal Pregnancy
 Rare
 Implantation in the peritoneal cavity exclusive of tubal, ovarian or
intraligamentous implantations
 Follow early tubal rupture or abortion with reimplantation
 Not unusual for placenta to be still partially attached to the uterus or adnexa
 Maternal serum alpha-fetoprotein levels can be elevated
 Fetus seen separate from the uterus
 Lack of myometrium between fetus and maternal anterior abdominal wall or
bladder
 Extrauterine placental tissue
 MRI
Tubal pregnancy
 Abdominal Pregnancy
 Management:
 Depends on gestational age
 Conservative  maternal risk for sudden & dangerous hemorrhage
 Fetal malformations and deformations in 20%
 termination when diagnosis is made
 Before 24 weeks, conservative is rarely justified
 Blood vessels supplying the placenta should be ligated first
 If placenta is left in place, post-op Methotrexate is controversial
Tubal pregnancy
 Ovarian Pregnancy
 Rare
 Implantation of fertilized egg in the ovary
 Diagnosed if 4 criteria are met:
 Ipsilateral tube is intact & distinct from the ovary
 Ectopic pregnancy occupies the ovary
 Ectopic pregnancy is connected by the uteroovarian ligament to the uterus
 Ovarian tissue can be demonstrated histologically amid the placental tissue
 TVS:an internal anechoic area is surrounded by a wide echogenic ring,
which in turn is surrounded by ovarian cortex
Tubal pregnancy
 Ovarian Pregnancy
 Management:
 Evidence-based
 Surgical: ovarian wedge resection or cystectomy for smaller lesions;
oophorectomy for larger lesions
 Conservative surgery: B-hCG levels should be monitored to exclude remnant
trophoblst
Tubal pregnancy
 Other Ectopic Sites
 Pregnancy implanted towards the mesosalpinx may rupture into a space formed
between the broad ligament leaves  intraligamentous or broad ligament
pregnancy
 Laparotomy is required in most cases
 Ectopic placental implantations in less expected sites: omentum, liver &
retroperitoneum
 Intramural uterine implantations at sites other than a cesarean scar in women
with prior uterine surgeries, ART, or adenomyosis
 Management: Laparotomy or Laparoscopic excision by those with suitable skills
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