1. Ectopic PregnancyEctopic Pregnancy

2.  An ectopic pregnancy is a gestationAn ectopic pregnancy is a gestation
that implants outside of thethat implants outside of the
endomitrial cavity. It represents aendomitrial cavity. It represents a
serious hazard to a woman’s healthserious hazard to a woman’s health
and reproductive potential, requiringand reproductive potential, requiring
prompt recognition and earlyprompt recognition and early
aggressive intervention.aggressive intervention.

3.  More than 95% of ectopic pregnanciesMore than 95% of ectopic pregnancies
implant in various anatomic segments ofimplant in various anatomic segments of
the fallopian tube, including thethe fallopian tube, including the
interstitial (1%), isthmic (5%), ampullaryinterstitial (1%), isthmic (5%), ampullary
(85%), and infundibular portions (9%).(85%), and infundibular portions (9%).
Other less common sites of ectopicOther less common sites of ectopic
implantation are the uterine cervix, ovary,implantation are the uterine cervix, ovary,
and the peritoneal cavity (Fig. 1).and the peritoneal cavity (Fig. 1).

4. Fig. 1. Possible locations of ectopic pregnancyFig. 1. Possible locations of ectopic pregnancy

6. EpidemiologyEpidemiology
 Since the early 1970s, the incidence ofSince the early 1970s, the incidence of
ectopic pregnancy has tripled, andectopic pregnancy has tripled, and
currently this condition represents thecurrently this condition represents the
fourth leading cause of maternal mortalityfourth leading cause of maternal mortality
overall (4%) and the most common causeoverall (4%) and the most common cause
of maternal mortality in the firstof maternal mortality in the first
trimester. Several factors have beentrimester. Several factors have been
implicated as contributing to thisimplicated as contributing to this
increased incidence:increased incidence:

7.  Improved technology, which has allowedImproved technology, which has allowed
for earlier and more complete diagnosisfor earlier and more complete diagnosis
of some patients whose condition wentof some patients whose condition went
undetected in the past.undetected in the past.
 The rising incidence of acute and chronicThe rising incidence of acute and chronic
salpingitis, induced abortion, tubalsalpingitis, induced abortion, tubal
ligation, tubal reconstructive surgery, andligation, tubal reconstructive surgery, and
conservative management of tubalconservative management of tubal
pregnancy, all of which result inpregnancy, all of which result in
histologic and structural damage to thehistologic and structural damage to the
tubes.tubes.

8.  The use of intrauterine contraceptiveThe use of intrauterine contraceptive
devices (IUDs). Women with IUDs aredevices (IUDs). Women with IUDs are
four times more likely to suffer from anfour times more likely to suffer from an
ectopic pregnancy. This effect is due toectopic pregnancy. This effect is due to
the better protection afforded by IUDsthe better protection afforded by IUDs
against intrauterine compared withagainst intrauterine compared with
extrauterine pregnancy and the higherextrauterine pregnancy and the higher
incidence of pelvic inflammatory diseaseincidence of pelvic inflammatory disease
among IUD users.among IUD users.

9. The overall incidence ofThe overall incidence of
ectopic pregnancy is estimatedectopic pregnancy is estimated
to be at least one in every 200to be at least one in every 200
pregnancies.pregnancies.

10. EtiologyEtiology
 Probably as many as 50% of cases result fromProbably as many as 50% of cases result from
alteration of tubal transport mechanismsalteration of tubal transport mechanisms
secondary to damage to the ciliated surface ofsecondary to damage to the ciliated surface of
the endosalpinx caused by infections such asthe endosalpinx caused by infections such as
Chlamydia and gonorrhea. Others are theChlamydia and gonorrhea. Others are the
result of intrinsic abnormalities of theresult of intrinsic abnormalities of the
fertilized ovum and possibly transmigration offertilized ovum and possibly transmigration of
the oocyte to the contralateral tube, withthe oocyte to the contralateral tube, with
resulting delays in passage.resulting delays in passage.

11. EvolutionEvolution
 Tubal pregnancies rapidly invade theTubal pregnancies rapidly invade the
mucosa, feeding from the tubal vessels,mucosa, feeding from the tubal vessels,
which become enlarged and engorged.which become enlarged and engorged.
The segment of the affected tube isThe segment of the affected tube is
distended as the pregnancy grows.distended as the pregnancy grows.
Possible outcomes of such abnormalPossible outcomes of such abnormal
gestations are as follows:gestations are as follows:

12.  The pregnancy is unable to survive owingThe pregnancy is unable to survive owing
to its poor blood supply, thus resulting into its poor blood supply, thus resulting in
a tubala tubal abortionabortion andand resorptionresorption, or it is, or it is
expelled from the fimbriated end into theexpelled from the fimbriated end into the
abdominal cavity.abdominal cavity.
 The pregnancy continues to grow untilThe pregnancy continues to grow until
the overdistended tubethe overdistended tube ruptureruptures, withs, with
resulting profuse intraperitoneal bleeding.resulting profuse intraperitoneal bleeding.

13.  In rare instances, a tubal pregnancy willIn rare instances, a tubal pregnancy will
be expelled from the tube and seed ontobe expelled from the tube and seed onto
sites in the abdominal cavity (e.g. thesites in the abdominal cavity (e.g. the
omentum, the small or large bowel, or theomentum, the small or large bowel, or the
parietal peritoneum), and gives rise to aparietal peritoneum), and gives rise to a
viableviable abdominal pregnancyabdominal pregnancy..

16. Symptoms and Clinical DiagnosisSymptoms and Clinical Diagnosis
 High risk factors can beHigh risk factors can be
summarized as follows:summarized as follows:

17.  A history of tubal infection (ectopic rateA history of tubal infection (ectopic rate
of 1 in 24, as opposed to 1 in 200 inof 1 in 24, as opposed to 1 in 200 in
noninfected patients)noninfected patients)
 Prior ectopic pregnancy (15% to 50%Prior ectopic pregnancy (15% to 50%
increase in incidence of ectopic gestationincrease in incidence of ectopic gestation
in subsequent pregnancies)in subsequent pregnancies)
 History of tubal sterilization within theHistory of tubal sterilization within the
past 1 to 2 years (higher incidence ifpast 1 to 2 years (higher incidence if
cauterization was used)cauterization was used)

18.  History of tubal reconstructive surgeryHistory of tubal reconstructive surgery
(tuboplasty or end-to-end reanastomosis(tuboplasty or end-to-end reanastomosis
for sterilization reversal)for sterilization reversal)
 Pregnancy with an IUD in place or aPregnancy with an IUD in place or a
history of IUD use.history of IUD use.
 Infertility.Infertility.

19.  More than one therapeutic abortionMore than one therapeutic abortion
(controversial)(controversial)
 Pregnancy resulting from failed postcoitalPregnancy resulting from failed postcoital
contraception (probably associated withcontraception (probably associated with
abnormal tubal transport)abnormal tubal transport)

20. The classic symptom triadThe classic symptom triad
amenorrhea,amenorrhea,
vaginal bleeding,vaginal bleeding,
abdominal pain.abdominal pain.

21.  Abdominal pain, usually in the lower abdomenAbdominal pain, usually in the lower abdomen
in early cases, or generalized in rupturedin early cases, or generalized in ruptured
ectopics with a hemoperitoneum. Amenorrheaectopics with a hemoperitoneum. Amenorrhea
or a history of an abnormal last menstrualor a history of an abnormal last menstrual
period is found in 75% to 90% of ectopicperiod is found in 75% to 90% of ectopic
pregnancies. Vaginal bleeding, from spottingpregnancies. Vaginal bleeding, from spotting
to the equivalent of a menstrual period, resultsto the equivalent of a menstrual period, results
from a low human chorionic gonadotropinfrom a low human chorionic gonadotropin
(hCG) production by the ectopic trophoblast(hCG) production by the ectopic trophoblast
and is seen in 50% to 80% of patients.and is seen in 50% to 80% of patients.

22.  Making the diagnosis of an acutelyMaking the diagnosis of an acutely
ruptured ectopic pregnancy is fairlyruptured ectopic pregnancy is fairly
straightforward. The patient presents withstraightforward. The patient presents with
symptoms of increasing abdominal pain,symptoms of increasing abdominal pain,
abdominal distention, and hypovolemia.abdominal distention, and hypovolemia.
The entire abdomen is acutely tender withThe entire abdomen is acutely tender with
guarding and rebound tenderness.guarding and rebound tenderness.

23.  Physical examination in patients with an unrupturedPhysical examination in patients with an unruptured
ectopic pregnancy may be extremely variable. Ninetyectopic pregnancy may be extremely variable. Ninety
percent have abdominal tenderness, but only 45%percent have abdominal tenderness, but only 45%
have positive rebound tenderness, and only 50 %have positive rebound tenderness, and only 50 %
have an adnexal mass on pelvic examination. In halfhave an adnexal mass on pelvic examination. In half
the cases, the mass is contralateral to the ectopicthe cases, the mass is contralateral to the ectopic
pregnancy and represents the corpus luteum. Twentypregnancy and represents the corpus luteum. Twenty
percent present with bilateral adnexal masses owingpercent present with bilateral adnexal masses owing
to the presence of a contralateral coupus luteum cyst.to the presence of a contralateral coupus luteum cyst.
The uterus is soft and either of normal size or slightlyThe uterus is soft and either of normal size or slightly
enlarged.enlarged.

24. Differential DiagnosisDifferential Diagnosis
 Many gynecologic andMany gynecologic and
nongynecologic disorders havenongynecologic disorders have
symptoms in common with ectopicsymptoms in common with ectopic
pregnancy. Gynecologic disorders topregnancy. Gynecologic disorders to
be considered includebe considered include::

25.  Threatened or incomplete abortion (alsoThreatened or incomplete abortion (also
presenting with pain, bleeding, and apresenting with pain, bleeding, and a
positive pregnancy test)positive pregnancy test)
 A ruptured corpus luteum cystA ruptured corpus luteum cyst
(abdominal pain, moderate to severe, at(abdominal pain, moderate to severe, at
times coexisting with a history oftimes coexisting with a history of
amenorrhea, vaginal spotting, andamenorrhea, vaginal spotting, and
presence or absence of pregnancy, andpresence or absence of pregnancy, and
evidence of hemoperitoneum)evidence of hemoperitoneum)

26.  Acute pelvic inflammatory disease withAcute pelvic inflammatory disease with
fever, abdominal pain, leukocytosis, and,fever, abdominal pain, leukocytosis, and,
at times, adnexal masses.at times, adnexal masses.
 Adnexal torsionAdnexal torsion
 Degenerating leiomyoma (common inDegenerating leiomyoma (common in
pregnancy)pregnancy)

27.  The key to the successful management ofThe key to the successful management of
ectopic pregnancy is early diagnosis. Althoughectopic pregnancy is early diagnosis. Although
the number of new cases has increasedthe number of new cases has increased
threefold, fewer are arriving at the hospitalthreefold, fewer are arriving at the hospital
ruptured, with the patient already inruptured, with the patient already in
hemorrhagic shock. This decrease is evidencehemorrhagic shock. This decrease is evidence
that a high index of suspicion and vigorousthat a high index of suspicion and vigorous
efforts at early diagnosis are effective.efforts at early diagnosis are effective.

28. β-hCG testingβ-hCG testing
 Human chorionic gonadotropin is consisting ofHuman chorionic gonadotropin is consisting of
two linked subunits, αandβ. β-hCG is secretedtwo linked subunits, αandβ. β-hCG is secreted
by both the cytotrophoblast and theby both the cytotrophoblast and the
syncytiotrophoblast and has the sole functionsyncytiotrophoblast and has the sole function
of supporting the corpus luteum. Abnormalβ-of supporting the corpus luteum. Abnormalβ-
hCG can not provide information on thehCG can not provide information on the
location of the pregnancy. Ultrasonographylocation of the pregnancy. Ultrasonography
must be used to locate the gestation.must be used to locate the gestation.

29.  The sensitivity of the current methods forThe sensitivity of the current methods for
detection of β-hCG in the maternal serumdetection of β-hCG in the maternal serum
allows the confirmation of pregnancyallows the confirmation of pregnancy
even before a missed period.even before a missed period.

30. UltrasonographyUltrasonography
 This field has shown rapid technologicalThis field has shown rapid technological
improvements in recent years, and itsimprovements in recent years, and its
application to the diagnosis of ectopicapplication to the diagnosis of ectopic
pregnancy, alone and in combination withpregnancy, alone and in combination with
hCG testing, is now the standard of care.hCG testing, is now the standard of care.
Transvaginal ultrasonography has allowed theTransvaginal ultrasonography has allowed the
detection of an intrauterine gestational sac atdetection of an intrauterine gestational sac at
as early as 5 weeks of amenorrhea (2 mmas early as 5 weeks of amenorrhea (2 mm
diameter).diameter).

31.  If the sac is not visualized at the uterineIf the sac is not visualized at the uterine
cavity, special attention is needed tocavity, special attention is needed to
differentiate between a true sac and adifferentiate between a true sac and a
pseudosac, which is a ring-like structurepseudosac, which is a ring-like structure
produced on ultrasound by a prominentproduced on ultrasound by a prominent
decidual echo. Evidence ofdecidual echo. Evidence of
hemoperitoneum may be inferred by thehemoperitoneum may be inferred by the
sonographic description of “free fluid insonographic description of “free fluid in
the cul-de-sac.”the cul-de-sac.”

34. CuldocentesisCuldocentesis
 Culdocentesis is the technique by which a needle,Culdocentesis is the technique by which a needle,
attached to a syringe, is inserted transvaginallyattached to a syringe, is inserted transvaginally
through the posterior vaginal fornix into the pouch ofthrough the posterior vaginal fornix into the pouch of
Douglas to detect any fluid within the peritonealDouglas to detect any fluid within the peritoneal
cavity (Fig. 2). Although the procedure is simple,cavity (Fig. 2). Although the procedure is simple,
inexpensive, and rapid, it is quite uncomfortable forinexpensive, and rapid, it is quite uncomfortable for
the patient and is of limited use in an unrupturedthe patient and is of limited use in an unruptured
ectopic pregnancy. It is unnecessary when theectopic pregnancy. It is unnecessary when the
diagnosis is obvious and has a high false-negativediagnosis is obvious and has a high false-negative
rate.rate.

35. Fig. 2. Technique for culdocentesisFig. 2. Technique for culdocentesis

36. ManagementManagement
 Emergency treatmentEmergency treatment
 Surgical treatmentSurgical treatment
LaparotomyLaparotomy
laparoscopylaparoscopy
 Medical treatmentMedical treatment
 Expectant managementExpectant management

37. Emergency treatmentEmergency treatment
 Immediate surgery is indicated when theImmediate surgery is indicated when the
diagnosis of ectopic pregnancy withdiagnosis of ectopic pregnancy with
hemorrhage is made. Transfusion withhemorrhage is made. Transfusion with
whole blood or an appropriate bloodwhole blood or an appropriate blood
component therapy as soon possible iscomponent therapy as soon possible is
indicated when the patient is in shock.indicated when the patient is in shock.

38. Surgical treatmentSurgical treatment
 Rapid entry into the abdomen should beRapid entry into the abdomen should be
accomplished, as control of hemorrhage can beaccomplished, as control of hemorrhage can be
lifesaving. Careful, fast exploration of thelifesaving. Careful, fast exploration of the
abdominal cavity should be done at once.abdominal cavity should be done at once.
Remove products of conception, clots, and freeRemove products of conception, clots, and free
blood. At operation the damaged tube isblood. At operation the damaged tube is
usually removed. This procedure is the mostusually removed. This procedure is the most
common for ectopic pregnancy.common for ectopic pregnancy.

39.  The type of procedure performed by eitherThe type of procedure performed by either
laparoscopy or laparotomy will be dictated bylaparoscopy or laparotomy will be dictated by
local findings at the time of surgery and thelocal findings at the time of surgery and the
desire of the woman for future fertility. Indesire of the woman for future fertility. In
patients who with to conserve fertility, a linearpatients who with to conserve fertility, a linear
salpingostomysalpingostomy is the treatment of choice inis the treatment of choice in
unruptured ampullary pregnancies. In ampullaryunruptured ampullary pregnancies. In ampullary
pregnancies that have already ruptured, apregnancies that have already ruptured, a
segmantal resection orsegmantal resection or partial salpingectomypartial salpingectomy cancan
be offered, which implies the removal of onlybe offered, which implies the removal of only
the affected segment of tube, leaving the restthe affected segment of tube, leaving the rest
intact.intact.

42. Medical treatmentMedical treatment
Unruptured ectopic pregnancyUnruptured ectopic pregnancy
can be treated withcan be treated with
Methotrexate (MTX).Methotrexate (MTX).

43. IndicationsIndications
 no contraidications to MTXno contraidications to MTX
 type of unruptured or abortiontype of unruptured or abortion
 unruptued mass <4 cm at its greastestunruptued mass <4 cm at its greastest
dimensiondimension
 β-hCG level <2000mIU/mlβ-hCG level <2000mIU/ml
 without signs of hemoperitoneumwithout signs of hemoperitoneum

44. Expectant managementExpectant management
 As many as 80% of ectopic pregnancies withAs many as 80% of ectopic pregnancies with
hCG levels of 1000mIU/ml or less will nothCG levels of 1000mIU/ml or less will not
ruture spontaneously or bleed profusely butruture spontaneously or bleed profusely but
will undergo spontaneous resolution.will undergo spontaneous resolution.
Expectant management is generally reservedExpectant management is generally reserved
for reliable, relatively asymptomatic patientsfor reliable, relatively asymptomatic patients
in whom the hCG titers are <200mIU/mlin whom the hCG titers are <200mIU/ml
and delining.and delining.

45. Treatment of Uncommon Types ofTreatment of Uncommon Types of
Ectopic PregnanciesEctopic Pregnancies
 Ectopic pregnancy and tubal pregnancy areEctopic pregnancy and tubal pregnancy are
terms used interchangeably because other sitesterms used interchangeably because other sites
of ectopic implantation are rare. A pregnancyof ectopic implantation are rare. A pregnancy
can implant on the surface of the ovary. Thecan implant on the surface of the ovary. The
treatment is aimed at removing the pregnancytreatment is aimed at removing the pregnancy
and sacrificing as little as possible of the ovarianand sacrificing as little as possible of the ovarian
tissue.tissue.

46.  Cervical pregnancy usually presents with profuseCervical pregnancy usually presents with profuse
vaginal bleeding, and attempts at removal of thevaginal bleeding, and attempts at removal of the
pregnancy are often unsuccessful. Hysterectomypregnancy are often unsuccessful. Hysterectomy
is frequently indicated and is usually quiteis frequently indicated and is usually quite
difficult. In more recent years, methotrexate anddifficult. In more recent years, methotrexate and
arterial embolization have been used to managearterial embolization have been used to manage
cervical pregnancy.cervical pregnancy.

47. All of the following therapeutic procedures areAll of the following therapeutic procedures are
recommended for ectopic pregnancy EXCEPT:recommended for ectopic pregnancy EXCEPT:
A salpingectomyA salpingectomy
B salpingo-oophorectomyB salpingo-oophorectomy
C partial salpingectomyC partial salpingectomy
D salpingostomyD salpingostomy

48. Likely reasons for the establishment of an ectopicLikely reasons for the establishment of an ectopic
tubal pregnancy include all of the followingtubal pregnancy include all of the following
EXCEPT:EXCEPT:
 A pelvic infectionA pelvic infection
 B peritubal adhesionsB peritubal adhesions
 C transmigration of fertilized ovumC transmigration of fertilized ovum
 D uterine myomaD uterine myoma