ECTOPIC PREGNANCY

DR PANG

ECTOPIC PREGNANCY
Dr. Pang
 History
 Abu Al-Qasim was an
Andalusian-Arab
physician and has
been credited to be
the first to describe
ectopic pregnancy in
963, at that time a
fatal affliction.
 1884 -- Robert Lawson Tait of Birmingham
prformed the first successful
Salpingectomy operation
 1953 -- Stromme – Conservative surgery
of Salpingostomy
 1973 -- Shapiro & Adller – Laparoscopic
Salpingectomy
 1991 -- Young et al – Laparoscopic
Salpingotomy
 Definition
 Ektopos’ – Out of
place (Greek)
 Implantation of the
fertilized ovum on
any tissue other
than the
endometrium of the
uterus
 when the conceptus implants either

● outside the uterus ● abnormal

position within
the uterus
- fallopian tubes - cornua
- ovary - cervix
- abdominal cavity

none of these anatomic sites can accommodate

placental attachment or a growing embryo
 Sites of an Ectopic
Ampulla (>85%)

1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian 6)Cervical

7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament
10)Primary abdominal
 Incidence
 19 per 1000 pregnancies
 Incidence has been 
  6x since 1970
 Malaysia – Est >6000 cases / year1
 In Seremban ~ 50 to 70 cases a
year with about 1/3 ruptured
ectopics
 However mortality & morbidity
rate has dropped almost 90%
(from 35.5 per 1000 ectopics to
3.8 per 1000 ectopics). .
 Numbers in HBS
Ectopic
80 Pregnancies
70
60
50
40
30
20
10
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
 Aetiology ADHESIONS

Mechanical
 pelvic inflammatory disease
(salphingitis, peritubal
adhesions)
 multiple sexual partners
 early age at first intercourse
 endometriosis
●Functional
 tubal surgery
- cigarette smoking
 pelvic surgery
- older age
 previous ectopic pregnancy
→ progressive loss of
 uterotubal anomalies
ciliary action
• Tubal distortion dt tumours

→ blocks transport of the fertilized Other Factors

egg - Failed Contraception ( BTL, IUCD)
- assisted reproductive technology
 Relative Risk
Risk Factor Odds Ratio
High Risk
1.Tubal surgery 21.0
2.Sterilization 9.3
3.Previous ectopic pregnancy 8.3
4.Use of IUCD 4.2-45.0
5.Documented tubal pathology 3.8-21.0
Moderate Risk
1.Infertility 2.5-21.0
2.Previous genital infections 2.5-3.7
3.Multiple sexual partners 2.1
Slight Risk
1.Cigarette smoking 2.3-2.5
2.Early age at 1st intercourse (<18yrs) 1.6
 IUCD and Ectopic Pregnancy
IUCDs used for contraception do not increase the
risk of ectopic pregnancy.
This mistaken association of IUDs with ectopic
pregnancy may be dt the fact that when IUD is
present, ectopic pregnancy occurs more often
than intrauterine pregnancy.
Simply because IUDs are more effective in
preventing intrauterine pregnancy
than ectopic pregnancy.
Clinical Presentation
Silent

Sub-Acute

Acute
 No pathognomonic Signs
Pain (95-100%)

PV Bleeding Delayed Menses

(79%) (75-90%)
 Non Specific
 Poor Positive Predictive Value
Botash RJ, Spirt BA: Ectopic pregnancy: review and update. Appl Radiol 2000; 7-12.
Centers for Disease Control: Ectopic pregnancy--United States, 1990-1992.
MMWR Morb Mortal Wkly Rep 1995 Jan 27; 44(3): 46-8[Medline].

Albayram F, Hamper UM: First-trimester obstetric emergencies: spectrum of

sonographic findings. J Clin Ultrasound 2002 Mar-Apr; 30(3): 161-77[Medline].
High Index of Suspicion if …

• Pregnant
• 1st trimester
• Bleeding
• Abdominal pain
• Adnexal mass/
tenderness
 Acute
 Tubal rupture – massive
intraperitoneal hemorrhage –
acute abdominal pain - shock
 Symptoms
 Pain – abdomen, shoulder
 Signs
 Shock – hypotension, tachycardia
 Abdomen – rigid, rebound
tenderness
 Generalised pelvic tenderness, but
> near affected site
 Subacute
 Difficult to diagnose
 May have
 Pain, PV bleeding, syncopal attacks, shoulder pain,
discomfort from blood in Pouch of Douglas (Pain on
defecation / sitting square on a hard seat)
 Lower abdominal tenderness, guarding, uterine
changes of pregnancy (Softening & slight  size)
 Bimanual palpation – Adnexal  cervical motion
tenderness. Adnexal mass
 Silent ( Not leaking )
 Usually detected by chance at the
antenatal clinic.
 Only symptoms are those of pregnancy
with US  empty uterus
 Some may admit to having slight pain, eg
dyspareunia
 Localised tenderness in 1 fornix  swelling
 Investigating a Case
When used together have 1
- Positive predictive value 98%
 -hCG - Negative predictive value 98%
 Ultrasound - Permits correct diagnosis in
 Trans abdominal up to 90% of the cases before
life threatening haemorrhage
 Trans vaginal from tubal rupture occurs, if -
 Laparoscopy hCG levels are detected
 Others
 Serial Serum Progesterone, Endometrial secretory
proteins, etc
 Curettage
 Culdocentesis
1. Cacciatore B., Stenman U-H, & Ylostalo P. Diagnosis of ectopic pregnancy by
vaginal ultrasonography in combination with a discriminatory serum hCG level
of 1000IU/L. Br H Obstet Gynaecol, 1989, 73, 770-4
 Serial -hCG
 Detected when > 2 mIU/mL Absence of an intrauterine
 8-10 days after conception gestational sac in conjunction
 Doubling time: bhCG levels double with a b-hCG level of greater
 approximately every 2 days than 6,500 IU/L → ectopic
→ healthy intrauterine pregnancies pregnancy

Normal Pregnancy

Ectopic
 Ultrasound
 Transvaginal
 IUGS should be visible when -hCG 1500 - 2000 IU/L
 Much clearer visualisation of uterine cavity & adnexae
 Preferred over Transabdominal1
 Transabdominal
 Intrauterine sac visible 1 week after it is visible on TVS
(hCG ~6000IU/L)
 better evaluation of the superior uterus
 free peritoneal fluid and/or hemorrhage beyond the cul de
sac 2

1. Cacciatore B., Stenman U-H, & Ylostalo P. Diagnosis of ectopic pregnancy by vaginal
ultrasonography in combination with a discriminatory serum hCG level of 1000IU/L. Br H Obstet
Gynaecol, 1989, 73, 770-4
2. Hertzberg BS, Kliewer MA, Bowie JD: Sonographic evaluation for ectopic pregnancy: transabdominal
scanning of patients with nondistended urinary bladders as a complement to transvaginal sonography.
AJR Am J Roentgenol 1999 Sep; 173(3): 773-5 [Medline]
 Normal intrauterine sac
 Regular, Well defined
 Intradecidual sign (eccetric
position)
 Double ring – decidua
parietalis & capitalis
 Ectopic Pregnancy
 Only thickened
decidualised endometrium
 Pseudogestational sac
 In advanced ectopics :
decidual sloughing –
intracavitary fluid/blood
 Usually smaller, > central
& irregular compared to
normal sac
Demonstration of the True IUGS with viable fetus
extrauterine gestational sac
with or without a live embryo
(Begel’s sign)

Pseudo Sac
Begel’s sign

Uterus

Endometrium Ectopic
If TVS only shows an empty uterus
 If -hCG >1000IU/L + empty uterine cavity
– Likely to have ectopic pregnancy

 If -hCG <1000IU/L + empty uterine cavity

 Ectopic pregnancy / early intrauterine
pregnancy
 Management – if patient stable, serial
ultrasound
 Beware the Heterotopic Pregnancy
Where an intrauterine pregnancy is associated with an ectopic twin
gestation.
Exceedingly rare 1/10 000 in natural conception
But may complicate 0.5% of pregnancies arising from IVF treatment

Eutopic + Cervical
 Laparoscopy
 Useful when definitive
diagnosis is difficult
 Therapeutic as well
 But needs expertise,
equipment
 Not for pts who are
hemodynamically
unstable
 Curretage
 Of practically no value
 Ectopic pregnancy
very likely if only
decidua without
chorionic villi
recovered
 Culdocentesis : Limited Value
 Transvaginal passage of
needle into posterior cul-de-sac
 To look for free (unclotted)
blood in abdomen
 Not done because
 Positive result is not diagnostic
– blood may be present in
other conditions, eg
hemorrhagic corpus luteum
 Negative result may rule out
ruptured or leaking ectopic but
not an intact one  Negative Tap Inconclusive

Only application is exclusion of ectopic if

Yellowish/straw-colored fluid is tapped
→ ruptured ovarian cyst
 General Examination Pelvic Examination
- restless/semiconscious ● Per speculum
- signs of hypovolemic - cervix – blood
shock
Vaginal examination
- signs of peritonitis
- cervical excitation - positive
- adnexa - palpable mass
- tender
- Pouch of Douglas - boggy
- tender
 Woman, child bearing age, Lower abd pain,
amenorrhea,  PV bleeding…

Diffential Diagnosis
Ovarian Cyst
Miscarriage
Acute appendicitis
PID
 Management Depends on the
Clinical Situation
2 Large bore IV lines
Collapsed & Shocked Pt IV fluids
+ve UPT GXM blood  transfusion
Emergency Laparatomy

Stable
+ve UPT
Diagnostic Laparoscpoy
+ve S&S
TVS : Empty Uterus

-hCG
> 1500mIU/mL (TVS) Laparoscopy
Stable > 6000mIU/mL (TAS)
+ve UPT
No S&S < 1500mIU/mL (TVS) Recheck -hCG.
TVS : Empty Uterus < 6000mIU/mL (TAS) If Abn - Laparoscopy

Stable If pt well & stable, can pursue conservative Mx

-hCG levels dropping Need Serial -hCG & Ultrasound
 Surgical Management
 Traditionally – procedure of choice was
total salpingectomy.
 completed childbearing and no longer desires
fertility, history of an ectopic pregnancy in the
same tube, or severely damaged tubes
 Conservative Surgery ie preservation of
fallopian tube
 Salpingostomy / salpingotomy1
 ‘Milking’ the tubes
 Salpingostomy / salpingotomy
Marginally better future reproductive outcome but higher rate of recurrence
compared to salpingectomy1
Need for follow-up
 4.5% residual trophoblast
 Need for weekly hCG level monitoring. Usually not detected by12th
POD
 Segmental resection with subsequent
anastomosis
 Isthmus
 Hysterectomy
 Eg cervical ectopics which may be associated with
massive hemorrhage
 Oophorectomy
 Ovarian pregnancy
 Abdominal pregnancy
 Delivery of fetus, ligate umb cord near placenta.
 Leave placenta in place to avoid hemorrhage
SURGICAL TREATMENT OF
ECTOPIC PREGNANCY
The debate goes on
LAPAROTOMY?
VS.
LAPAROSCOPY?

SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?
 Salpingostomy Salpingectomy
Intrauterine 60 % 40 %
Pregnancy
Rec. Ectopic 15 % 10 %
Pregnancy Rate

The choice of surgery depends on the

patient’s risk of recurrent ectopic
pregnancy and health of contralateral
tube.
COMPARING LAPAROTOMY Vs LAPAROSCOPY

L’tomy L’scopy
Hospital cost More? Less?
Post operative adhesions More Less
Risk of future ectopic Same Same
Future fertility Same Same
Experience of Surgeon Trained Special
Instruments General Special
 Methotrexate
 Systemic Methotrexate in multiple IM doses is
comparable to laparoscopic surgery for small
unruptured pregnancies1
 There is also a role for Direct injection of Methotrexate
into the gestational sac
 Effective only
 Small
 Unruptured
 Aymptomatic
 Problems
 Toxicity esp marrow suppression, dermatitis, high
failure rate

1. Hajenius PJ, Mol BW, Bossuyt PM et al. (2000) Interventions fo rtubal ectopic
pregnancy (Cochrane Review) The Cochrane Lobrary, issue 2. Oxford: Update Software.
 SAM TREATMENT
 Aim- trophoblastic destruction without
systemic side effects
 Technique- Injection of trophotoxic
substance into the ectopic pregnancy sac
or into the affected tube by-
 Laparoscopy or
 Ultrasonographically guided
 Transabdominal (Porreco, 1992)
 Transvaginal (Feichtingar, 1987)
 With Falloposcopic control (Kiss, 1993)
 SAM TREATMENT
 Trophotoxic substances used-
 Methtrexate (Pansky, 1989)
 Potassium Chloride (Robertson, 1987)
 Mifiprostone (RU 486)
 PGF2 (Limblom, 1987)
 Hyper osmolar glucose solution
 Actinomycin D
 Prognosis
 Recurrence rate : 15% after 1st, 25%
after 2
 Subsequent delivery rate : 50-60%
 When the contralateral fallopian tube is
normal, the subsequent fertility rate is
independent of the type of surgery
 PERSISTENT ECTOPIC
PREGNANCY (PEP)
 This is a complication of salpingotomy /
salpingostomy when residual trophoblast
continues to survive because of incomplete
evacuation of the ectopic pregnancy.
 Diagnosis is made because of a raised
postoperative serum HCG
 If untreated, can cause life threatening
hemorrhage
 PERSISTENT ECTOPIC
PREGNANCY (PEP)
 TREATMENT is by-
 Reoperation and further evacuation /
Salpingectomy
 Administration of IM / oral Methtrexate in
a single dose of 50 mg/m2 of body
surface
 EXPECTANT TREATMENT
 Tubal Pregnancies are known to Abort /
Resolve
 Befor the advent of salpingectomy in 1884,
ectopic pregnancies were being treated
expectantly with 70% mortality.
 Today only selected cases are managed
expectantly, screened and identified by
high resolution ultrasound scanner and
monitored by serial serum HCG assay
 EXPECTANT TREATMENT
 Identification criteria (Ylostalo et al , 1993)-
 Diameter of ectopic pregnancy <4 Cm.
 No sign of intrauterine pregnancy
 No sign of rupture by TVS
 No sign of acute bleeding by TVS
 Falling level of serum HCG at 2 day intervals

 If any deviation from the above criteria

occurs, then emergency treatment is
necessary.
 EXPECTANT TREATMENT
 Spontaneous resolution occurs in 72%,while
28% will need laparoscopic salpingostomy
 In spontaneous resolution, it may take 4-67
days (mean 20 days) for the serum HCG to
return to non pregnant level.
 The percentage fall in serum HCG by day 7
is a better indicator than the percentage fall
by day 2.
 Warning: - Tubal pregnancies have been
known to rupture even when Serum HCG
levels are low.
 SUMMARY - KEY POINTS
 Incidence of ectopic pregnancy is rising while
maternal mortality from it is falling.
 Early diagnosis is the key to less invasive
treatment.
 The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
 Ruptured ectopics should be unusual with
compliant patients and appropriate medical care.