PAMANTASAN NG LUNGSOD NG MAYNILA

College of Medicine
Intramuros, Manila

Ectopic Pregnancy

Submitted by:
Hanessa Busran
Jessica Calizo
Jamie Ranella Chua
Rheza Antonette Cube
Joy Karen Damasig
Vonne Clarence David
Gabrelle Dyan De Guzman
Ma. Kriselda De Los Reyes
Vian Carlyn Dela Cruz
Leo Angelo Montalvo
Group 2
PLM CM Batch 2019 - 3A

January 22, 2018

CASE____________________________________________________________________________________________________________

T.R., 28 years old, consulted at your clinic today (January 18, 2018) because of vaginal spotting
for 2 days with associated tolerable discomfort on hypogastric area. She had positive pregnancy test 3
weeks ago.

LMP: November 2, 2017

PMP: October 5 2017

Estimated Age of Gestation:

AOG = Total days (LMP – Date of Consultation)/7
AOG = (28 + 31 + 18)/7
AOG = (77)/7
AOG = 11 weeks

Estimated Date of Confinement: August 6, 2018

OB Index: G3P2 (2-0-0-2)

Past Medical History:

Chickenpox during childhood

Family History:
(+) Hypertension and DM (father)

OB GYN History:
Menarche at 13 years old, lasted for 3 days, consumed 2 - 3 pads per day, no associated
dysmenorrhea. Subsequent menses at regular interval, lasting for 3 - 4 days, moderate in flow, no
dysmenorrhea. She had 2 pregnancies via vaginal delivery. Her children are 3 years old and 2 years
old.

GUIDE QUESTIONS:___________________________________________________________________________________________
1. Supplement the findings for the complete physical exam of this patient.

On physical examination T.R. would have pale conjunctiva, her vital signs may be
unremarkable except for a slightly increase blood pressure with >100 mmHg systolic blood pressure.
On abdominal palpation, tenderness may be noted on the hypogastric area. Pelvic exam may reveal a
closed cervical OS, tender, boggy mass palpated on one side of the uterus.

2. Now after supplementing the PE findings. What is your complete working diagnosis?
Bases?

Based on the history and supplemented physical examination findings of the patient, it can be
inferred that the patient’s working diagnosis is ectopic pregnancy. According to Van Mello (2012),
ectopic pregnancy is an early complication wherein a fertilized ovum is implanted outside the uterine
cavity - the fallopian tube being the most common site of implantation.
 In ectopic pregnancy, the signs and symptoms are often subtle or absent and even have
unremarkable changes in vital signs. The classic presentation of ectopic pregnancy is characterized by
a triad of symptoms such as delayed menstruation, pain, and vaginal bleeding or spotting, which is
manifested by the patient. Aside from that, there is tenderness noted upon palpation of the abdomen.
Also, a tender, boggy mass was felt on one side of the uterus. Lastly, the patient has a slight increase in
her systolic blood pressure of more than 100 mmHg.

Other clinical manifestations that is present in a patient with ectopic pregnancy include severe
lower abdominal and pelvic pain, which is sharp, stabbing or tearing in character, due to tubal rupture;
pain in bimanual pelvic examination; and that the posterior vaginal fornix may bulge from blood in the
rectouterine cul-de-sac. Aside from that, diaphragmatic irritation, characterized by pain in the neck or
shoulder, especially on inspiration; and a heart rate of less than 100 beats per minute can be
manifested by a patient with ectopic pregnancy (Bloom, 2014)

3. What are your differential diagnosis? Bases?

a. Implantation bleeding
Implantation bleeding is defined as bleeding that occurs 10-14 days after
conception. It is usually lighter than a menstrual period but is often confused with the
latter (Cibulka & Barron, 2013).

Usual symptoms that occur in implantation bleeding are (American Pregnancy

Association, 2017):
• Light or faint cramping
• Mood swings
• Headaches
• Nausea
• Breast tenderness
• Lower backache

According to the American Pregnancy Association (2017), the blood in

implantation bleeding should not present with any clots, as opposed to that in regular
menses. This also ranges from only a couple of hours to a maximum of 3 days in duration
as opposed to regular menses which last 3-7 days. Lastly, the amount of blood in
implantation bleeding is lighter and most commonly presents with just vaginal spotting.

IMPLANTATION BLEEDING

RULE IN RULE OUT

 • Vaginal spotting • Positive pregnancy test
• Bleeding not coinciding with regular
menstrual period schedule
• No nausea
• No breast tenderness
• No backache

RULED OUT

b. Threatened Abortion
The clinical diagnosis of threatened abortion is presumed when bloody vaginal
discharge or bleeding appears through a closed cervical os during the first 20 weeks.
Bleeding in early pregnancy must be differentiated from implantation bleeding, which
some women have at the time of the expected menses. Almost a fourth of women
develop clinically significant bleeding during early gestation that may persist for days
or weeks. With miscarriage, bleeding usually begins first, and cramping abdominal pain
follows hours to days later. There may be low-midline clearly rhythmic cramps;
persistent low backache with pelvic pressure; or dull and midline suprapubic
discomfort. Bleeding is by far the most predictive risk factor for pregnancy loss. Overall,
approximately half will abort, but this risk is substantially less if there is fetal cardiac
activity. Even if miscarriage does not follow early bleeding, the risk for later adverse
pregnancy outcomes is increased.

Rule In Rule Out

• Vaginal Spotting • Boggy mass palpated on one

• Within first 20 weeks of side of the uterus*
pregnancy
• Closed cervical os*
• Hypogastric discomfort

RULED OUT

d. Ectopic Pregnancy
Ectopic pregnancy is defined as the blastocyst implanting elsewhere other than
the endometrial lining of the uterine cavity. It is quite common, occurring in 1-2% of all
first trimester pregnancies in the US.

95% of ectopic pregnancies occur in the ampulla while the remaining 5% occurs
in the ovary, peritoneal cavity, cervix or prior cesarean scar. Risk factors for ectopic
pregnancy are surgeries on the fallopian tube, previous ectopic pregnancy, prior tubal
infection, tubal adhesions, salpingitis isthmica nodosa, congenital fallopian tube anomalies,
infertility, ART procedures, smoking, and contraception (tubal sterilization, IUDs and
progestin-only contraceptives).
 Ectopic pregnancy may be characterized with a subtle or even absent
presentation in the early stages. With later diagnosis, the classic presentation is
characterized with a triad of:
• Delayed menstruation
• Pain
• Vaginal bleeding or spotting (60-80%)

Tubal rupture, which may also occur as a complication of the pregnancy,

presents usually with severe lower abdominal and pelvic pain that is sharp, stabbing or
tearing in nature. There is abdominal tenderness upon palpation and cervical motion.
Bulging of the posterior vaginal fornix may occur as a consequence of blood pooling in the
rectouterine cul-de-sac; this may also occur as a boggy mass felt on one side of the uterus.
A later presentation of the uterus being pushed to one side due to the enlargement of the
uterus may also occur. Diaphragmatic irritation (pain in the neck or shoulder on
inspiration) may also develop in women with sizable hemoperitoneum. Intraabdominal
hemorrhage may also occur which may cause the changes in vital signs such as slight rise
in BP and bradycardia; when significant bleeding occurs, a fall in BP and a rise in pulse rate
eventually occurs.

ECTOPIC PREGNANCY

RULE IN RULE OUT

• Vaginal spotting
• Hypogastric discomfort
• Positive pregnancy test
• Pale conjunctiva
• Slight BP increase
• Hypogastric tenderness
• Boggy mass on one side
of the uterus

CANNOT BE RULED OUT

4. What are the risk factor in the development of such disease entity?

An ectopic pregnancy is a complication of pregnancy in which the blastocyst implants

anywhere outside endometrial cavity of uterine (Parashi et al., 2014). It is the major cause of maternal
mortality during early pregnancy and accounts for 10% of all pregnancy- related deaths. Furthermore,
it increases the chances of infertility as well as incidence of the subsequent ectopic pregnancy.
Several risk factors for ectopic pregnancy have been identified including pelvic inflammatory
disease, smoking, and, previous ectopic pregnancy. Other factors, such as age, surgical history, and
obstetric history, are also thought to be involved (Bouer et al., 2002).
 Marked increase in ectopic cases of pregnancy includes major risk factors which involve pelvic
inflammatory disease (PID) in >50% of the cases, previous tubal surgery, previous ectopic pregnancy,
IUDs and termination of pregnancy. Other minor risk factors include tuberculosis salpingitis, cigarette
smoking, age of >35 years, multiple sexual partners, congenital anomalies of the fallopian tubes, and
ovum transmigration.

Several factors increase the risk of ectopic pregnancy. These risk factors share a common
mechanism of action—namely, interference with fallopian tube function. Normally, an egg is fertilized
in the fallopian tube and then travels down the tube to the implantation site. Any mechanism that
interferes with the normal function of the fallopian tube during this process increases the risk of
ectopic pregnancy. The mechanism can be anatomic (e.g., scarring that blocks transport of the egg) or
functional (e.g., impaired tubal mobility) (Tenore, 2000)

In the general population, pelvic inflammatory disease is the most common risk factor for
ectopic pregnancy. Organisms that preferentially attack the fallopian tubes include Neisseria
gonorrhoeae, Chlamydia trachomatis and mixed aerobes and anaerobes. Unlike mixed aerobes and
anaerobes, N. gonorrhoeae and C. trachomatis can produce silent infections. In women with these
infections, even early treatment does not necessarily prevent tubal damage (Cates et al., 1990)

Intrauterine devices (IUDs) used for contraception do not increase the risk of ectopic
pregnancy, and no evidence suggests that currently available IUDs cause pelvic inflammatory disease.
One explanation for the mistaken association of IUDs with ectopic pregnancy may be that when an IUD
is present, ectopic pregnancy occurs more often than intrauterine pregnancy. Simply because IUDs are
more effective in preventing intrauterine pregnancy than ectopic pregnancy, implantation is more
likely to occur in an ectopic location.

Previous ectopic pregnancy becomes a more significant risk factor with each successive
occurrence. With one previous ectopic pregnancy treated by linear salpingostomy, the recurrence rate
ranges from 15 to 20 percent, depending on the integrity of the contralateral tube. Two previous
ectopic pregnancies increase the risk of recurrence to 32 percent, although an intervening intrauterine
pregnancy lowers this rate (Hankins et al., 1995)

Endometriosis, tubal surgery and pelvic surgery result in pelvic and tubal adhesions and
abnormal tubal function. The fallopian tubes may also be affected by other, less clearly understood
causes of infertility, as well as many of the hormones that are administered to aid ovulation and
improve fertility.

In utero exposure to diethylstilbestrol (DES) is associated with uterotubal anomalies ranging

from gross structural abnormalities such as a double uterus to more subtle microscopic abnormalities
resulting in tubal dysfunction. Any uterotubal anomalies, with or without DES exposure, increase the
risk of ectopic pregnancy (Pisarska, 1998).
 Cigarette smoking has an independent and dose-related effect on the risk of ectopic pregnancy.
Cigarette smoking is known to affect ciliary action in the nasopharynx and respiratory tract. A similar
effect may occur within the fallopian tubes (Moini et al., 2014).

Multiple sexual partners, early age at first intercourse and vaginal douching are often
considered risk factors for ectopic pregnancy. The mechanism of action for these risk factors is
indirect, in that they are markers for the development of sexually transmitted disease, ascending
infection, or both.

5. Discuss the pathophysiology of the working diagnosis.

Fig. 1. Pathophysiology of ectopic pregnancy

Ectopic pregnancy occurs when the blastocyst implants outside its normal location within the
uterine cavity. Most ectopic pregnancies occur in the fallopian tubes, but may also occur in the ovary or
abdominal cavity. Normally, implantation of the fertilized ovum occurs in the endometrial cavity.
However, if transport of the ovum is delayed, implantation of the ovum may take place in the fallopian
tube, which is the common site of ectopic pregnancy. Factors such as a previous infection in the
fallopian tubes, which leads to scarring and fusion of tubal folds that retard the passage of the fertilized
egg; and, failure of the muscular contractions of the tubal wall to propel the fertilized egg through the
tube predisposes a woman to develop this complication. Also, the lack of submucosal layer within the
fallopian tube allow for easy implantation of the fertilized ovum through the epithelium and into the
muscular wall (Schorge et al., 2008).

Once the fertilized egg is implanted in the fallopian tube it causes the tube to gradually distend.
The embryo may develop normally for a time but rarely survives for more than a few months. As the
embryo grows, trophoblasts rapidly proliferates which leads to the erosion of tubal blood vessels
causing bleeding into the lumen and wall of the fallopian tube and/or into the tissues surrounding it. A
woman with ectopic pregnancy will experience signs and symptoms of early pregnancy and miss her
expected menstrual period, as with normal intrauterine pregnancy. Distention of the fallopian tube and
irritation of the pelvic peritoneum due to bleeding in the tubal wall and adjacent tissues will cause the
patient to experience abdominal pain and tenderness. If blood leaks from the tubal implantation site, it
will escape into the uterus and into the vagina, manifested as vaginal bleeding or spotting (Crowley,
2010).

6. What are the possible complications?

The most common complication of ectopic pregnancy is rupture of the fallopian tubes with
internal bleeding which may lead to hypovolemic shock. Rupture is, of course, accompanied with
severe bleeding/hemorrhage. Death from rupture is still the leading cause of death in the first
trimester of the pregnancy. If rupture occurs in the first few weeks, the pregnancy is most likely
located in the isthmic portion. Tubal ectopic pregnancies usually burst spontaneously but may
occasionally rupture following coitus or bimanual examination. The pregnancy may abort out the
distal fallopian tube, and the frequency of this depends in part on the initial implantation site. Abortion
is common in fimbrial and ampullary pregnancies, whereas rupture is the usual outcome with those in
the tubal isthmus (Katke, 2015).

Another common complication for ectopic pregnancy is abortion. Tubal abortion can lead to
several outcomes such as resorption of the products of conception, intraluminal extension with
expulsion of gestational products, and perforation and rupture into the peritoneal cavity (Katke, 2015)
These events may induce other uncommon complications include peritonitis and infertility. Ectopic
pregnancy can damage the fallopian tube, which can make it difficult to become pregnant in the future.

7. Discuss the appropriate management for the case.

Initially the diagnosis of ectopic pregnancy should be established through the use of diagnostic
examinations such as ultrasonography and β-hCG levels. CBC can also be ordered to assess the
patient’s general condition or presence of underlying condition such as bleeding.
 Methotrexate is the medical treatment of choice for ectopic pregnancy. This folic acid
antagonist that inhibits DNA synthesis and cell replication resulting to selective killing of
cytotrophoblasts. After which it is reabsorbed by the body. However, this treatment is not suggested
for patients with gestational sac >3.5cm or β-hCG levels.
In cases where Methotrexate treatment is contraindicated, surgery is another option that can
be considered. Patient can choose depending on the goal of management whether salpingectomy or
salpingostomy for tubal pregnancies. For our patient, salpingostomy is preferred since it can preserve
the patient’s fertility. β-hCG level is taken weekly after surgery to observe for inadequate evacuation of
the products of conception and a recurrence of symptoms (Barash, Buchanan, & Hillson, 2014)

References:

ACOG practice bulletin no. 3. Medical management of tubal pregnancy. Clinical management guidelines for obstetrician-
gynecologists. Washington, D.C.: American College of Obstetricians and Gynecologists, 1998.
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