ECTOPIC PREGNANCY

• It is implantation of the conceptus outside

normal uterine cavity either outside the
uterus(Fallopian tubes, ovary or abdominal
cavity) or in abnormal position within the
uterus(cornua or cervix or over C section scar).
• It is a major health problem & important
cause of morbidity& mortality in women at
reproductive age.

• Ectopic pregnancy is still the most common

cause of pregnancy related death worldwide
but two-thirds of these deaths are associated
with substandard care.
 Epidemiology
• Incidence is 1-2% of pregnancies
• 95-97% of all ectopic pregnancies occur at the
Fallopian tube &80% of them occur at the
ampullary portion of the Fallopian tube & only
2.5% occur at the interstitial part(intramural
part which traverse the myometrium and also
called cornual pregnancy) which is responsible
for 20% of death due to rupture of ectopic
gestation.

• Over the past 30 years ,the incidence is increasing in

developed countries. This reflect increase in diagnosis due
to improved diagnostic tests as many cases may resolve
spontaneously without detection.
• However,the mortality rate from ectopic
pregnancy has decreased but still high account
for 13% of all maternal death in western
countries and may account for 30% of
maternal death in low-resources countries.

• Heterotopic pregnancy mean simultaneous

intrauterine & ectopic pregnancy.This is very
rare but the incidence increases after IVF
treatment into 1%
 RISK FACTORS
1.The incidence increases with increase maternal
age &the highest incidence between 35-44 years.
This is explained by alteration in the function of
the Fallopian tubes with increased age.
2.History of sexually transmitted diseases increase
the incidence especially chlamydia & gonorrhea
infection. Incidence higher in women with history
of pelvic infection, multiple partners & early age
of intercourse.

3.All methods of contraception and sterilization

decrease both intrauterine & extrauterine
pregnancy but ectopic rate increase in women
who get pregnant due contraception failure as
tubal ligation or IUCD or progesterone
contraception.
4.History of previous pelvic surgery especially
tubal surgery e.g. tubal ligation, salpingotomy
, and appendicectomy.
5. history of infertility and the use of assisted
reproductive techniques.
6.Women with previous ectopic have higher incidence&
the risk of recurrence increases to 10%.
7.Smoking is a major risk factor and the level of risk is
related to the number of cigarettes smoked per day. It
cause functional alteration in the Fallopian tubes.
8.Diethystilbestrol exposure inutero increases the risk.

Pathophysiology
The oocyte fertilization takes place in the Fallopian
tube & then passes into the uterine cavity.

- Mechanical & functional abnormalities of the

tubes
may lead to ectopic pregnancy.
-The most important factor is damaged tubal
mucosa & scarring due to chronic infection or
previous surgery .
• Abnormal function of tubal smooth muscles in
which oestrogen increases its activity &
progesterone inhibit it .
• Increased oestrogen cause tubal spasm which
block embryo transfer & this explain high rate
of ectopic ovarian hyperstimulation.
• Progesterone only contraception cause tubal
relaxation &if contraception fail , ectopic
pregnancy may occur.

• After implantation ,the trophoblasts will penetrate the wall of the

tube reaching the tubo-ovarian circulation&tube can not be
distended ending with tubal rupture with acute intra-peritoneal
haemorrhage.

Another p0ssibility that ectopic gestation may abort at early stages

or it may persist as chronic ectopic or gradually absorbed.
Rarely , the fetus remain alive after rupture or abortion &secondary
abdominal pregnancy may continue to variable time &very rarely
reach term.
Cinical Presentation
• Presentation is very variable.It could be:
1.Acute presentation.
2.Subacute presentation which is diagnostic
problem.
3.Chronic presentation accidently discovered.

• Most patient present with missed period ,

vaginal bleeding & pelvic pain.
• Vaginal bleeding usually mild & old brown in
color.Sometime,passage of decidual cast
misdiagnosed as abortion.In 10-20%of the
cases,there is no bleeding.
• Pelvic pain usually in one iliac fossa but
sometimes, it is bilateral when there is
intraperitoneal bleeding.
• Shoulder pain may occur due to irritation of
the diaphragm by blood.

• Acute presentation seen in ruptured ectopic

with sever intraperitoneal haemorrhage.The
patient present with sever abdominal pain,
fainting, dizziness ,diarrhea , &vomiting.
• On examination, sever pallor , hypotension
with rapid pulse may be found & it indicates
shock state.
• Abdominal examination, sever tenderness&
rigidity in case of ruptured ectopic.
• In case of subacute presentation, the patient
vital signs are normal with mild abdominal
tenderness.
• Speculum& bimanual pelvic examination is of
limited diagnostic value & may cause tubal
rupture.

Diagnosis
• Transvaginal ultrasound is the single best
diagnostic tool in evaluating woman with
suspected ectopic pregnancy.
 The diagnostic problem is to differentiate between
subacute ectopic pregnancy & early intrauterine
pregnancy complications.
 Ultrasound is a non-invasive important
diagnostic tool and the findings depend on
quality of ultrasound equipment & experience
of the operator.

• So, if sexually active premenopausal woman

presented with abdominal pain and/or vaginal
bleeding, pregnancy test should be done and
if it is positive, assessment of the pelvis by
experienced operator using transvaginal
ultrasound.
• There are two types of ultrasound:
• A.Transabdominal ultrasound.
• B.Transvaginal ultrasound which give clearer
image of pelvic organs because there is no
abdominal wall between the probe of the
machine & the pelvic organs. Also, it doesn't
need full bladder.

• The presence of inhomogeneous mass

adjacent to the ovary or extrauterine
gestational sac( with or without fetal cardiac
activity) or adnexial mass indicate ectopic
pregnancy.
• Presence of fluid in pouch of Douglas is non-
specific sign of ectopic pregnancy.
• In experienced hand, 70% of ectopics are seen
on ultrasound on the first scan.
• In experienced hands, when there no
intrauterine or extrauterine pregnancy seen
by transvaginal ultrasound, the pregnancy is
classified as pregnancy of unknown location.

• In 10-20% of ectopic pregnancies,there is

what is called pseudogestational sac in the
uterus which is small collection of fluid
surrounded by endometrial tissue and this
may be missed as intrauterine pregnancy.
 In case of pregnancy of unknown location in
haemodynamically stable patient, serial measurement
of serum hCG level every two days with transvaginal
ultrasound every 4 days is the most useful method of
diagnosis of subacute ectopic pregnancy.
The discriminatory hCG level above which the
gestational sac of intrauterine pregnancy should be
seen by transvaginal ultrasound is 1500-2000 IU/lit & if
no intrauterine gestational sac is seen, the differential
diagnoses are ectopic pregnancy, failing intrauterine
pregnancy, or early multiple pregnancy.

• In normal pregnancy (or threatened

abortion),hCG level should be doubled every 1.5
day before 5 weeks & then every 2.5 days from 5-
7 weeks of gestation.
• Abnormal slow rise in serum hCG level (less than
35% within 48 hours ) or plateauing used to
diagnose ectopic pregnancy while in miscarriage
of unhealthy pregnancy (failing pregnancy),
serum hCG will decrease & half time of 24-36
hours.
• Progeaterone value more than 25 ng/ml
nearly exclude ectopic pregnancy while level
less than 5ng/ml suggest failing intrauterine
pregnancy or ectopic pregnancy.

4.Laparoscopy& uterine curettage :

These are old methods for diagnosis & of limited
use nowadays.
Laparoscopy is now considered in a woman with
hCG level above discriminatory level in the
absence of intrauterine sac .Laparoscopy could be
diagnostic & therapeutic.
Presence of placental villi by curettage indicate
intrauterine pregnancy but this does not always
exclude ectopic pregnancy which may abort from
the tube into the uterine cavity.
 Treatment
• Clinical stability is the most important factor
when determining whether the management of
ectopic pregnancy is surgical or not.
• Ultrasound findings regarding the appearance of
the ectopic pregnancy and the presence or
absence of haemoperitonium are also important
consideration.
• The need of preservation of fertility need to be
taken in account in the decision- making of type
of treatment.
• treatment could be either:
1.Medical treatment:
It become popular treatment in which surgery will
be avoided& manage as outpatient with
preservation of fertility by preserving the
Fallopian tube which is the commonest site of
ectopic pregnancy.
Systemic methotrexate is an option of treatment
in carefully selected patients.
Methotrexate is folic acid antagonist which inhibit
DNA synthesis in trophoblastic cells.

• Methotrexate can be given as single-dose i.m.

injection or multiple-dose regimen. The dose
calculated as 1mg/Kg body weight with minimum
dose of 50 mg.
• Contraindications for methotrexate treatment
are:
1.Chronic liver , renal or haematological disorders.
2.Active infection.
3.Immunodeficiency.
4.Breast feeding.
• Criteria for treatment with methotrexate include:
1.Minimal clinical symptoms & haemodynamically stable
patient.
2.Ultrasound showed no evidence of embryonic cardiac
activity in the ectopic sac.
3.Size of the ectopic sac is less than 3.5 cm by ultrasound.
4.No evidence of haemoperitoneum by ultrasound.
5.Seum B-hCG level less than 3000 IU/lit.
6.No contraindications to the use of methotrexate.
7.Patient compliance with follow up visit to the hospital.
8.No intrauterine pregnancy on ultrasound scan.

• In clinical practice, ectopic pregnancies

suitable for methotrexate treatment account
about 25-30% of all ectopic pregnancy cases.
• There is studies to use methotrexate if B-hCG
less than 5000 IU/L .Although it can be
successful but this usually need longer
duration for follow up, further doses of
methotrexate & increased likelihood of
surgical treatment.
• There is always risk of rupture of ectopic
pregnancy,so patient treated with
methotrexate should be closely followed up
with serum B-hCG which should be done on
Day 4 & 7 after treatment.
• The level of B-hCG start to rise slightly before
it start to fall& therefore , it is not done earlier
than Day 4 .

• If the B-hCG not fall by 25% by Day 7, a repeat dose of

methotrexate is given.
• Then, weekly testing until B-hCG is less than 25 IU/lit which
usually take 4-5 weeks.
• Patient should avoid sexual intercourse during treatment and
use contraception for 3 months after methotrexate treatment
because of its teratogenic effect.
• Side effects of methotrexate include nausea
&vomiting ,stomatitis, conjunctivitis,
photosensitive skin reaction, disturbance of
hepatic & renal function & 2/3 of the patients
suffer from non specific abdominal pain.

2.Surgical treatment:
This treatment needed in haemodynamically
unstable woman and/or the presence of large
ectopic mass containing embryonic pole with
cardiac activity.
-Either through laparotomy or laparoscopy.
Laparotomy is indicated in case of acute
presentation with shock state.
- Operative laparoscopy is more in use as it is
less invasive, less postoperative pain, shorter
hospital stay & faster recovery.

• The surgical operation either salpingectomy

(removal of the tube) or tubal conservative
procedures which include salpingotomy (small
linear opening of the tube & removal of the
ectopic gestation& suturing of the incision) or
salingostomy ( small tubal incision over the tubal
ectopic and removal of ectopic pregnancy and
leave the incision to be healed by secondary
intention).
• Conservative surgery has higher risk of
intraoperative & postoperative bleeding & 10-
15% risk of persistent trophoblastic tissue
which need further surgical or medical
treatment that’s why it should be followed up
by B-hCG monitoring and it is done only if
patient desire further pregnancy & there is
contralateral tube damage.

• Salpingectomy is done if the a woman has

complete her family, if the patient did not
complete her family and the other tube is
healthy, if she has a repeated ectopic at the
same tube, if bleeding can not be controlled
or if the tube is severely damaged by the
ectopic pregnancy.
3.Expectant management:
Non-intervention management based on the
finding that significant number of tubal
pregnancy will resolve without any treatment.

It is free from side effects of methotrexate but not all

patients are suitable for this type of treatment & strict
criteria should be considered which are ectopic mass less
than 3 cm in diameter and serum hCG should be less than
1000IU/lit & same ultrasound findings for medical
treatment with regular monitoring of serum hCG for follow
up.
• Non sensitized Rh –ve women with confirmed
ectopic pregnancy should receive Anti D
immunoglobulin 250 iu( 50 microgm)

Future Effects of Ectopic Pregnancy

1.There increased risk of ectopic in a patient
with recurrence rate of 10%.
2.Fertility will decrease in which possibility of
intrauterine pregnancy is 50-70%.