ECTOPIC

PREGNANCY

Ectopic

(Ektopos) out of place

Definition
Ectopic pregnancy: fertilized embryo
implanted outside the uterine cavity

Classification of ectopic pregnancy

>95%

Mechanical factors
Congenital: long narrow tube, diverticulae and accessory ostia.
Traumatic: operation on the tube as salpingoplasty and tubal reversal
following ligation.
Inflammatory: Chronic salpingitis
Neoplastic: Narrowing of the tube by a fibroid or a broad ligament tumor.
Functional: As tubal spasm or antiperistaltic contractions.
endometriosis in the tube. encourages embedding of the fertilized ovum.

RISK FACTORS
Hz of tubal surgery
Hx of STDs (such as chlamydia)
Hx of ART
Hx of ectopic (esp if conservatively
managed without surgery)
Smoking
IUD in place at time of conception

Prior history of PID (pelvic inflammatory

disease)

TUBAL SURGERY

Pathology of Ectopic Pregnancy

Outcomes
1. Tubal abortion

2.Rupture of tubal pregnancy

Ruptured ectopic pregnancy

Extraperitoneal rupture (rupture through oor of the tube)

may lead to broad ligament hematoma with death of
the ovum, or intraligamentary pregnancy.

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3. Secondary abdominal pregnancy

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Symptoms & Signs:

In a woman of child bearing age with
pelvi-abdominal pain and/ or vaginal
bleeding ALWAYS.think


Clinical
Finding: Undistrubed ectopic

Amenorrhoea

A dull aching pain is usually present in one iliac fossa. It is

due to distension of the tube and stretching of its peritoneal coat.

Classic signs
adnexal or cervical motion
tenderness.

Signs:
Abdominal examination: Tenderness in one iliac fossa.
Vaginal examination:

(cervical motion tenderness or jumping sign) The cervix is soft

and severe pain occurs when it is moved from side to side
A mass may be felt to one side of the uterus. It is very tender, soft
and may be pulsating.

Subacute type:Symptoms:

Short period of amenorrhea in (25%) no history of amenorrhea due

to occurrence of post conceptional bleeding that mistaken as a true
menstrual period
Pain: It is felt in one iliac fossa. It may be dull aching or sharp
stabbing or colicky
Fainting attacks or even shock
Vaginal bleeding occurs after pain

With ruptured ectopic pregnancy

abdominal guarding and rigidity,
shoulder pain
fainting attacks
and shock.

When a woman presents with an early

pregnancy
Ask yourself two questions

Where is this pregnancy?

Is it viable?

Where is this pregnancy?

In a woman with an early pregnancy you
must determine if the pregnancy is
intrauterine or an ectopic, because her
life could depend on it!

How to you determine location of the pregnancy?

First determine dating by LMP
Then perform ultrasound
If you can see location of the pregnancy, you are done!
If you cannotit becomes more complicated

-hCG discriminatory value (or zone)

It is the lower limit of hCG at which an
examiner can reliably visualize pregnancy
on ultrasound. It is 1000-2000 IU/L with
vaginal ultrasound and 5000-6000 IU/L
with abdominal ultrasound.

If -hCG levels above the discriminatory value

The absence of uterine pregnancy signifies

an abnormal pregnancy; ectopic,
incomplete abortion
If -hCG levels are still below the
discriminatory value, serial -hCG and
ultrasound should be done.

Doubling sign:
In normal pregnancy a 66% or greater increase in serum -hCG levels
should be observed every 48 hours (nearly doubles).
Inappropriately rising serum -hCG levels suggest (but do not
diagnose) an abnormal pregnancy including ectopic, however, they do
not identify its location.

Tran abdominal US

Transvaginal ultrasound ( TVS):

Early pregnancy with unknown location

Check a serum BHCG

If it is above the discriminatory zone (DZ)an intrauterine pregnancy
should be seen
Then do an ultrasound to see if you see the pregnancy

LAPROSCOPY

Treatment of tubal pregnancy

If the patient is shocked: antishock measures.
If the patient is Rh negative and not sensitized anti-D serum is
given.
Medical therapy:
methotrexate (a folic acid antagonist).
IM methotrexate given as a single dose.

 The best candidate is the woman who is asymptomatic, compliant

with follow-up, with an initial serum value <5000 IU/L.

Contraindications:
Breastfeeding
Immunodeficiency / active infection
Chronic liver disease
Active pulmonary disease
Active peptic ulcer or colitis
Blood disorder
Hepatic, Renal or Haematological
dysfunction

Signs and Treatment failure and tubal

rupture:
nSignificantly worsening abdominal pain,
nHaemodynamic instability
nLevel of HCG do not decline by at least 15% between
Day 4 & 7 post treatment
n or plateauing HCG level after first week of
treatment

Follow-Up:
If the -hCG level does not decline (plateau or increase), the patient
may require either a second dose of methotrexate or surgery.
Surgical management:
Laparoscopy approach salpingostomy
Laprotomy salpingostomy salpingectomy

v Salpingostomy / Salpingotomy is only indicated

when:

1. The patient desires to conserve her fertility

2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 4Cm. In size
5. Contralateral tube is absent
or damaged

Segmental resection: removal of

a portion of the affected tube.

laparatomy (if the mass is greater than 3.5 cm in

diametar, internal bleeding, cardiovascular colapse)

Treatment:
-metotrexate (if the mass is less then 3.5 cm in diametar)

-laparascopy,or Laprotomy
SALPINGOSTOMY
blood then peritoneal toilet.

SALPINGECTOMY Removal of any pelvic hematomas or intrapertoneal

Algorithm for the diagnosis of unruptured ectopic pregnancy

without laparoscopy.

Management of ectopic pregnancy

11- Positive pregnancy test

Lowe abdominal pain +

Minimal Vaginal bleeding

Asymptomatic with factors

for ectopic pregnancy

2. History + clinical examination

If sure of date of LMP and /or

Regular cycle, i.e.
>6 wks. gestation,
Arrange TV ultrasound

If unsure of date of LMP

and /or irregular cycle,
Measure serum hCG

If hCG <1000
(?early Intrauterine/
? Ectopic pregnancy

If Hcg >1000, use

protocol for
suspected
Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000
Meet criteria for
Methorexate treatment
Use methotrexate
protocol

Does not meet criteria

for methotrexate treatment
Laproscopic /salpingotomy/
Salpingectomy ?Proceed to
laparotomy OR Laparotomy if
haemodynamically unstable