ECTOPIC

PREGNAN
CY
Bethel Mulugeta
Year III Medical Student of
AAU
August 26, 2016

Outline
Introduction
Definition
Incidence
Epidemiology

Classification
Risk factors
Natural course

Diagnosis

History
Physical examination
Lab investigation
Imaging studies

Principles of
management

Ectopic Pregnancy

Introduction
Ectopic pregnancy is the implantation of
blastocyst outside the endometrial
cavity or uterine proper
It causes:
major maternal morbidity & mortality
adversely affects future reproductive function &
economic burden of health care for women
Ectopic Pregnancy

Contd
Incidence
1-2% of pregnancies
Through time the incidence is increasing;

PID
Contraceptives use
Early Diagnosis
ART
Tubal surgery

Ectopic Pregnancy

Contd
Epidemiology
Accounts for 2% of all 1st trimester pregnancies
Leading cause of maternal mortality during 1st
trimester (10-14%)
Around 9% of all pregnancy related deaths

Ectopic Pregnancy

Classification
Based on the involvement of the tubes:
Tubal (95%)

Ampullary (70%)
Isthmic (12%)
Fimbria (11%)
Interstitial (2.4%)

Nontubal (5%)..20% of
-

Cervix (rare) fatalities

Ovary (3.2%)
Abdominal (1.3%)
CS site
Intraligamentary
Intramural

Ectopic Pregnancy

Ectopic Pregnancy

Risk Factors
Congenital
Tubal hypoplasia
Partial stenosis of the tubes
In utero DES exposure
Congenital diverticulitis

Acquired
Inflammatory PID [6x], STI, purperal sepsis, post abortal infection
Surgical Constructive (tubal) surgery [4-5x], infertility surgery,
Apendicitis surgery, tubal sterilization
Tumor Ovarian, myoma
Miscellaneous Endometriosis, previous ectopic pregnancy [7x],
decreased ciliary motility, smoking, IUCD [6-10x], previous CS,
Other Increasing age, blacks, low socioeconomic status, infertile
Ectopic Pregnancy

Contd
Risk of recurrence rate:
With 1 EP = 15%
With 2 EP = 25%
Generally, 7x higher
i.e. Patient counseling and screening is
important!
Ectopic Pregnancy

Natural course

Tubal rupture
Rupture in the first week . Isthmic EP
Associated hypovolemia

Tubal abortion
Ampullary EP

Involution/resorption of conceptus

Re-implant

Conceptus resolved, encapsulated or becomes calcified to

Ectopic Pregnancy
form - lithopedion

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Diagnosis

History
Physical examination
Lab investigation
Imaging studies

Ectopic Pregnancy

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Contd

History
Variable presentation:

Unruptured Usually asymptomatic mild pain

Ruptured
Triad of symptoms (in 50%)
Abdominal pain , Amenorrhea and Vaginal bleeding
On the other 50% --- Often confused with GI disorder, IUP, PID
Shoulder pain, Urge to deficate, Syncope, breast
tenderness, frequency urination, and nausea

Ectopic Pregnancy

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Contd
Physical Examination
Vital sign
Abdomen
Acute abdomen - direct or rebound tenderness
Sign of fluid accumulation

Pelvic

Cervical motion tenderness

Adnexal mass and tenderness
Bulged posterior fornix
Mild uterine enlargement
Ectopic Pregnancy

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Investigation
Clinical diagnosis based on the results of:
the imaging studies (ultrasound) and
laboratory tests (hCG)
Other basic diagnostic tools: CBC, BG/Rh,
urinalysis, pregnancy test
Ectopic Pregnancy

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Discriminatory zone:

Contd

the serum hCG level above which a gestational

sac should be visualized by ultrasound examination
if an intrauterine pregnancy is present.
1500 - 2000 IU/L with TVS at the 5th and
6500 IU/L with TAS at the 6th weeks of gestation
The absence of an IU GS at hCG level above the
discriminatory zone with echo complex or cystic
adnexal mass and empty uterus strongly suggests an
ectopic or nonviable intrauterine pregnancy.
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Contd
A negative ultrasound examination at
hCG levels below the discriminatory zone
is consistent with:
an early viable intrauterine pregnancy
or
an ectopic pregnancy or
Non viable intrauterine pregnancy.
Such cases are termed "pregnancy of
Ectopic Pregnancy
unknown location"
and 8 to 40 percent16

Contd
Other diagnostic tests:
Serum progesterone level --- below 5-10ngm/mL
Doppler US ---- Ring of Fire (cyst surrounded by BV)
Curettage
Laparoscopy --- Gold Standard
Culdocentesis
MRI
i.e. Do not provide additional clinically useful information.
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Principles of Management
Depends on:
Level of hCG
Size of the mass
Site of the ectopic pregnancy
General condition of the patient (Hemodynamic stability)
Available recourses

Three types of treatment options

Surgical
Medical
Expectant

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Contd
Surgical
Indicated especially at hemodynamic
instability and emergency cases

Laparatomy QUICKELY!!
Salphingectomy
Salphingostomy
Salphingotomy

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Contd
Medical therapy (MTX)

Contraindications
Candidates:
hemodynamically stable,
willing and able to
comply with post
treatment follow-up,
B hCG 5000 mIU/mL,
no fetal cardiac activity
size < 3.5cm

Hemodynamically unstable
hepatic/renal dysfunction
Immunodeficiency,
Breast feeding
peptic ulcer disease
Hypersensitivity to MTX
Coexistent viable intrauterine pregnancy
unable to be compliant with posttherapeutic monitoring
Do not have timely access to a medical
institution
Ectopic Pregnancy

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Contd
Expectant
Indicated only at;

Decreasing hCG titers (less than 1500 mIU/mL )

Tubal location
No evidence of rupture or significant bleeding
size < 4 cm
Highly motivated patient with strong desire to avoid both surgery and medical
management
Hemodynamically stable healthy woman
Absence of fetal heart tones

i.e. Its is associated with tubal loss and maternal mortality.

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Chronic ectopic pregnancy

Silent minor ruptures or abortions of an ectopic pregnancy
instead of a single episode of bleeding, incites an
inflammatory response often leading to the formation of a
pelvic mass.
Its clinical features are often confusing, and laboratory
evaluations are often misleading.
Serum hCG level is in low range, because trophobalsts grow very
slowely

Surgery difficult since chronic inflammatory changes and

Ectopic Pregnancy
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adhesions distort the normal
anatomy.

Reference Material
Williams Obestetrics 23rd edition
Current Diagnosis & Treatment Obstetrics &
Gynecology, Tenth Edition
Berek & Novak's Gynecology, 14th Edition

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Thank You!!!
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