A NOTE ON ECTOPIC PREGNANCY.

1. Vishnu narayanan M.R
Ectopic Pregnancy

2. Definition
– Pregnancy where the fertilised ovum is implanted and
develops outside the normal endomitrial cavity.
• commonest site – fallopian tube
• most important cause of maternal mortality in the
past
• Also called eccysis

3. SITES OF IMPLANTATION

4. Type of EP Definition
Tubal pregnancy A pregnancy occurring in the fallopian tube – most often these
are located in the ampullary portion of the fallopian tube
Interstitial pregnancy A pregnancy that implants within the interstitial portion of the
fallopian tube
Abdominal
pregnancy
Primary – the 1st and only implantation occurs on a peritoneal
surface
Secondary – implantation originally in the tubal ostia,
subsequently aborted and then reimplanted into the
peritoneal surface
Cervical pregnancy Implantation of the developing conceptus in the cervical canal
Ligamentous
pregnancy
A secondary form of EP in which a primary tubal pregnancy
erodes into the mesosalpinx and is located between the leaves
of the broad ligament
Heterotopic
pregnancy
A condition in which ectopic and intrauterine pregnancies
coexist
Ovarian pregnancy A condition in which an EP implants within the ovarian cortex

7. EPIDEMIOLOGY
• Incidence-1 per 300 normal pregnancy
• Maternal mortality-10%
• Increased incidence over past 2 decades esp in
developed countries
• Due to racial factors
genetic factors
environmental factors
social and lifestyle changes

8. AETIOLOGY
 Delayed transport of fertilized ovum through fallopian
tube
 Fallopian tube offers a congenital environment for
implantation
 Major causes
– Pelvic inflammatory diseases
• Most important cause
• Chlamydial infection leads to EP
• Pelvic TB is another cause
• Post abortal & puerperal sepsis

9. o Congenital factors
 Tubal tortuosity , accessory ostia , diverticula & partial
stenosis
 In utero exposure to diethyl stilboesterol
o Salpingitis isthimica nodosa of the tube {SIN}
 Tubal epithelium invades myosalpinx, forming a
diverticulum
 Aetiology is unknown
 EP is probably caused by entrapment of ovum in the
diverticula

10. • SURGICAL PROCEDURES
– Tubectomy,tubal recanalisation,tuboplasty partial
stenosis of the tube
– ventrosuspension kinking at the isthmic portion of
tube
– Laproscopic cauterization fistulous opening in the
medial end of tube
– 1/3 rd pregnancies after tubal sterilisation turns to be
ectopic

11. CONTRACEPTIVE METHODS
IUCD prevents intrauterine pregnancy more
effecteively than tubal pregnancy
Progesterone containing IUCD and progesterone
only pills-delay tubal peristalsis and motility
 PREVIOUS ECTOPIC
- chance of second ectopic – 12%
 AGE
- Elderly age-more at risk

12. ASSISTED REPRODUCTIVE TECHNOLOGIES-IVF
- IVF involves multiple egg transferred with fluid medium.
- leads to flushing of one egg into tubular lumen
- can also lead to implantation in uterus along with tubal
implantation-heterotopic pregnancy
 INDUCTION OF OVULATION
- by gonadotrrophins
- multiple pregnancy and ectopic pregnancy

13. FAULTY OVUM
Rapid development of trophoblast leads to premature implantation
in the tube.
TRANSPERITONEAL MIGRATION OF OVUM
Transport of ovum from the ovary to the fallopian tube on opposite
side.
Characterized by corpus luteum on ovary with ectopic pregnancy on
opposite tube.
8% cases
EXTRANEOUS CAUSES
appendicitis
endometriosis

17. ventrosuspension

18. Cauterisation Clamping of the tube
Salpingitis ishmica
nodosa

19. Pathophysiology
• The trophoblast develops in the fertilized ovum and
invades deeply into the tubal wall-INTRAMUSCULAR
IMPLANTATION
• ßhCG production by implanted trophoblast
maintains the corpus luteum.
• The corpus luteum produces oestrogen and
progesterone which change the secretory
endometrium into decidua. The uterus enlarges up
to 8 weeks and becomes soft.

20. Changes in uterus
 enlarged – myohyperplasia & hypertrophy
 endometrium shows typical histological pattern – arias
stella phenomenon –Hyperplasia of glands with loss of
polarity,cytoplasmic vacuolisation,hyperchromatic nucleus.
 absence of chorionic villi in the endometrial curettings
 arias stella reaction along with absence of chorionic villi
ectopic pregnancy

21. • Does not usually proceed to more than 10weeks
> lack of decidual reaction in the tube,
> the thin wall of the tube,
> the inadequacy of tubal lumen,
> bleeding in the site of implantation as trophoblast
invades.
• Separation of the gestational sac from the tubal wall leads
to its degeneration, and fall of ß hCG level, regression of
the corpus luteum and subsequent drop in the oestrogen
and progesterone level.
• Separation of the uterine decidua with uterine bleeding-
DECIDUAL CAST

22. DECIDUAL CAST

23. Fate of tubal pregnancy
1- Tubal mole:
The gestational sac is surrounded by a blood clot and
retained in the tube.
• may remain for long period in the tube- chronic
ectopic pregnancy
• may be gradually absorbed- involution
• May be expelled out through the ostia-tubal abortion

24. Tubal mole

25. 2-Tubal abortion:
• Common in ampullary pregnancy
• Separation of the gestational sac is followed by its
expulsion into the peritoneal cavity through the tubal
ostium with variable amount of haemorhage
• Complete expulsion blood collected in pouch of
douglas- pelvic hematocele
• Incomplete expulsion diffuse intraperitoneal
haemorrhage

27. 3-Tubal rupture:
• More common in isthmic and interstitial implantation
• Isthmic rupture---6-8 weeks
• Ampullary rupture---8-12 weeks
• Interstitial rupture---4 months
• Rupture may occur in the anti-mesenteric border of the
tube→ intraperitoneal haemorrhage.
• If rupture occurs in the mesenteric border of the tube,
broad ligament haematoma →intraligamentous pregnancy
• Secondary abdominal pregnancy

31. Presentation
Early symptoms are either absent or subtle. Clinical
presentation of ectopic pregnancy occurs at a mean
of 7.2 weeks after the last normal menstrual period,
with a range of 5 to 8 weeks

32. Clinical traid (3As)
Amenorrhea
ECTOPIC
PREGNANCY
Abdominal pain Abnormal vaginal
bleeding

33. Symptoms
1.Pain and discomfort
• Mainly due to intraperitoneal bleeding
• In the Lower back , abdomen, or pelvis.
• Acute agonizing/colicky
• Usually unilateral
• Shoulder pain – accumulation of blood in subdiaphramatic
regions → stimulate phrenic nerve→shoulder tip pain
• Pain while urinating and passing bowels

34. 2.Bleeding
• Vaginal bleeding usually mild.
Withdrawal bleeding due to decreased progesterone from corpus
luteum in the failing ectopic pregnancy
• Internal bleeding (haemaoperitoneum) is due to hemorrhage from the affected
tube.
• Dizziness, headache, weakness, fainting all may happen due to bleeding
• Irregular bleeding in a sexually active women should always suggestive of
ectopic, until proved otherwise
3.Amenorrhea
Not always present
4.Retention of urine
5.Fever,vomiting,fainting attacks

35. Signs
General examination:
• Weakness, pallor, hypotension,thready pulse with tachycardia,
tachypnea,cold extremities-features of shock
• Signs of early pregnancy (breast tenderness, nausea and
vomiting, change of apettite …)
Abdominal examination:
• Lower abdominal tenderness and rigidity especially on one side
may be present.
• No mass felt
• Shifting dullness
• Distended bowels
• Muscle guarding-usually absent

36. Vaginal examination:
1.RUPTURED
• Vaginal spotting with blanched white mucous
• Bluish vagina and bluish soft cervix.
• Uterus is slightly enlarged and soft.
• Extreme tenderness on fornix palpation or on movement of cervix
• No mass usually felt
• Uterus floats as in water
2.UNRUPTURED
• Ill-defined mass with arterial pulsations
Speculum or bimanual examination should not be performed unless
facilities for resuscitation are available, as this may induce rupture
of the tube

37. Diagnosis of ruptured ectopic
o patient may be in shock with pallor , tachycardia ,
hypotension & cold clammy extrimities
o Abdominal examination - all signs of intra
abdominal haemorrhage
o cullens sign may be present
o Abdomen – distended with tenderness , guarding ,
rigidity& shifting dullness
o Vaginal examination – normal or bulky uterus with
tenderness on moving the cervix

38. Culdocentesis
• A needle is inserted into the space at the top of the vagina, behind
the uterus and in front of the rectum to aspirate fluid
• Determines if there is blood in the space behind the uterus
• If non-clotting blood is aspirated from the Douglas pouch ,
intraperitoneal haemorrhage is diagnosed. But if not, ectopic
pregnancy cannot be excluded.

39. Diagnosis of unruptured ectopic
 pregnancy test is +ve
 TVS
 β hCG
 Curettage
 laproscopy

40. 1.TVS
• Intrauterine gestational sac with a yolksac and double
decidual sign---INTRAUTERINE PREGNANCY
• Psuedosac---ECTOPIC PREGNANCY
• Diagnosis made by
1. An empty uterus
2. An empty uterus with adnexal mass
3. Bagel sign
4. Presence of a gestational sac in adnexa with fetal heart

41. BAGEL SIGN

42. Ring sign — a hyperechoic ring around an extrauterine gestational sac.
D

43. 2.Serum β-hCG
• If the test is negative (generally less than 5 IU/L),
normal and abnormal pregnancy including ectopic
are excluded.
• Test positive with 1500IU/L WITH
1. and an intrauterine gestational sac seen—
intrauterine pregnancy
2. w/o any intrauterine sac---ectopic pregnancy
• If β-hCG < 1500IU/L, second assay after 48hrs
1. If doubling after 48hrs---intrauterine pregnancy
2. No doubling---failing/ectopic pregnancy

44. Change in the hCG Level in
Intrauterine Pregnancy,
Ectopic Pregnancy, and
Spontaneous Abortion.
An increase or decrease in the
serial hCG level in a woman
with an ectopic pregnancy is
outside the range expected for
that of a woman with a
growing intrauterine
pregnancy or a spontaneous
abortion 71% of the time.
However, the increase in the
hCG level in a woman with an
ectopic pregnancy can mimic
that of a growing intrauterine
pregnancy 21% of the time,
and the decrease in the hCG
level can mimic that of a
spontaneous abortion 8% of
the time.

45. 3.Curettage
• Curettage of the uterus
• Flotation test---floating of chorionic villi in water
• Confirmed by microscopic examination of presence of villi
• CHORIONIC VILLI ABSENT IN ECTOPIC PREGNANCY

46. 4-laparoscopy
an endoscope is inserted through a small incision in the woman’s
abdomen
This allows you to see the fallopian tubes and other organs
This takes place in an operating room with anaesthesia
Gold standard

48. DIFFERENTIAL
DIAGNOSIS

49. Appendicitis (Perforated)
Acute Pancreatities
Perforated Gastric or Duodenal Ulcer
Pelvic Abcess
Splenic Rupture
Myocardial Infarct
(1) NON GYNECOLOGICAL

50. Septic Abortion
Threatened
Abortion
Pyosalpinx
Pelvic Abcess
Twisted Ovarian
Cyst
Acute pelvic
inflammatory
disease
Rupture of
Follicle or Corpus
Luteum Cyst
Degenerating
leiomyoma
Retroverted
Gravid Uterus
(2) Gynecologic disorders

51. • Patient usually in shock-resusciation done
• Immediate arrangements of laparotomy with necessary
arrangements like blood
• If tubal rupture-immediate salpingectomy
• If rupture at isthmial region –segmental resection of ruptured
site
• Cornual rupture—hysterectomy

52. 1
•EXPECTANT MANAGEMENT
2
•MEDICAL MANAGEMENT
3
•SURGICAL MANAGEMENT
Treatment of
unruptured ectopic

53. INDICATIONS
1. Clinically stable asymptomatic women
2. Initial ß hCG < 1000IU/L and subsequent falling levels
3. Gestational sac size <4cm
4. No fetal heartbeat on TVS
5. No evidence of rupture/bleeding
• Proper monitering of ß hCG twice weekly

54. INDICATIONS
Similar as in expectant management
Only difference—hCG level<4000IU/L
ADVANTAGES
• Avoidance of surgery and anaesthesia
• Less expense
• Less tubal damage
• Less chance of future sterility

55. • Methotrexate—
• antineoplastic
• folate antagonist
• Active against proliferating
trophoblast
SYSTEMIC
• injections of prostaglandins,
potassium chloride OR
hyperosmolar glucose OR
local methotrexate
LOCALLY

56. Dosage of methotrexate
SINGLE DOSE REGIME
• 50mg/m2 –IM/IV
• Baseline investigations—full bloodcount,LFT,RFT
• May develop abdominal cramps initially
• ß hCG monitoring on day 4 and 7—15% fall by 7days
• Folicacid tablets-C/I
• Postmethotrexate abdominal pain
MULTIPLE DOSE REGIME
• Methotrexate and folinic acid on alternate days
• Also in persistant trophoblastic disease
• Less popular
• Ideal for cornual and cervical pregnancy

57. • Laparoscopy has become the recommended
approach in most cases.
• Laparotomy is usually reserved for patients:
 who are hemodynamically unstable
patients with cornual ectopic pregnancies.
Extensive abdominal and pelvic adhesions making
laproscopy difficult

58. 1.Conservative surgery
• Indicated when woman not completed her family
• 5%cases—persistant ectopic noted
• hCG monitoring and single dose methotrexate continued
after surgery
• Includes--1.linear salpingostomy
2.segmental resection
3.milking of the tube
2.Radical surgery—salpingectomy
Indications-
• When the tube is not salvageable
• Recurrent ectopic
• Childbearing completed
• Previous sterilisation

61. 1. heterotopic pregnancy
– ectopic pregnancy coexist with intra uterine
pregnancy
– incidence has ↑sed due to ART
– Surgical management with continuation of
intrauterine pregnancy

62. 2.Interstitial pregnancy
– implantation – interstitial part of tube
– pregnancy advance to a later date – myometrium
– abdominal pain & collapse – rupture of uterine wall
– TREATMENT-immediate laprotomy with salpingectomy
wedge resection of cornua
reconstruction of uterine wall
if severe uterinewall damage-hysterectomy

63. 3. Intraligamentous pregnancy
– Rare
– due to penetration of tubal wall by the trophoblast & its
advancement b/w the two layers of broad ligament
– 2º to tubal pregnancy
– clinical findings are similar to abdominal pregnancy

64. 4. cornual pregnancy
 seen in rudimentary horn of bicornuate uterus
 condn very difficult to diagnose before rupture
 rupture is inevitable around 12 – 20 weeks with massive
intraperitonial haemorrhage
 during laprotomy it may be confused with interstitial
pregnancy
 round ligament is attached lateral to the sac
 Excision of rudimentary horn if diagnosed earlier

65. 5. Abdominal pregnancy
 as itself is rare –satisfy studiford criteria-
1.normal tubes &ovaries
2. no uteroperitoneal fistula
3. Pregnancy related exclusively to peritoneal surface
 seen secondarily after early tubal rupture or abortion
 implantation – peritoneum
 usual outcome is early rupture or death of fetus – suppuration
or calcification -LITHOPEDIAN
 uncomfortable with nausea & abdominal pain { fetus moves }
 Fetal malpositions and abnormalities
 Braxton hicks contractions-not felt
 Diagnosis by ultrasound
 Management-laprotomy

66. Abdominal pregnancy

67. 6. Cervical pregnancy
 implantation – endocervical canal below the internal os
 rarely continues beyond 20wks & is complicated by
bleeding
 Rubins criteria were used in the past for diagnosis
1.cervical glands opposite to placental attachment
2.placental attacment to cervix below the entrance of
uterine vessels or below peritoneal reflection
3.fetal elements entirely in the endocervix
4.closed internal os and partially opened external os
 now first trimester US is done

68. • Ultrasound criteria for cervical pregnancy
1. Empty uterus
2. Hourglass shape of uterus
3. Balloned out cervical canal
4. Gestational sac and placental tissue in cervical canal
5. Internal os closed

69. Radiological uterine Arterial
embolization followed by
evacuation
If bleeding continues or
extensive rupture occurs
hysterectomy is needed.
MANAGEMENT
Choice of treatment-multiple dose methotrexate
Failure of medicine--

70. 7. Ovarian pregnancy
 very rare
 consequence – early rupture
 speigelberg criteria is used for its diagnosis
1.intact tube on affected site
2.fetal sac must occupy position of ovary
3.ovary connected to uterus by ovarian ligament
4.definite ovarian tissue in the sac wall
 Management-methotrexate for unruptured
ovariotomy if rupture occurs

71. 8.Caesarian scar ectopic pregnancy
• Recently reported
• Ultrasound-empty uterus and cervix
gestational sac attached low to the lower segment
caesarian scar
• Diagnosis confirmed by doppler imaging
• Gestational sac embedded in myometrium
• Fibrosis of the pregnancy
• Management-surgery