Ectopic Pregnancy

Ectopic
Pregnancy
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

FAR EASTERN UNIVERSITY – DR. NICANOR REYES MEDICAL CENTER
Definition
• Derived from the Greek
word ektopos: out of
place
• The implantation of the

blastocyst (fertilized
ovum) outside the
endometrial lining of
the uterine cavity
2016.OB-GYN.FEU-NRMF
Blastocyst implanted in the fallopian
tube
Pathogenesis
• Sites of Implantation
– Fallopian tube – most common site (ampulla) – 95%
– Ovary
– Uterine cornu
– Cervix
– Broad ligament
– Spleen 5%
– Liver
– Retroperitoneum
– Diaphragm
– Cesarean scar
Pathogenesis
Heterotopic pregnancies
• Multifetal pregnancy
composed of one
conceptus with normal
uterine implantation
with coexisting ecotpic
pregnancy
• 1 per 3,000 pregnancies
Risk factors
Risk factor Relative Risk
Previous ectopic pregnancy 3-13
Tubal corrective surgery 4
Tubal sterilization 9
Intrauterine device 1-4.2
Documented tubal pathology 3.8-21
Infertility 2.5-3
Assisted reproductive technology 2-8
Previous genital infection 2-4
Chlamydia 2
Salpingitis 1.5-6.2
Smoking 1.7-4
Prior abortion 0.6-3
Multiple sexual partners 1.6-3.5
Prior cesarean delivery 1-2.1
Contraception as a risk for Ectopic
pregnancy
– The absolute number of ectopic pregnancies is

decreased because pregnancy occurs less often.
– Relative number is increased in some
contraceptive failures (tubal sterilization, IUD,
high-dose estrogen emergency contraception,
progestin-only minipills)
Tubal Pregnancy
– Absence of submucosal layer in the fallopian
– The fertilized ovum may lodge in any portion of the
oviduct
– Ampulla is the most frequent site, followed by the
isthmus.
– Outcomes: tubal rupture, tubal abortion or
pregnancy failure
Tubal pregnancy
Tubal Rupture
• in first few weeks = isthmus
• rupture occurs later = interstitial
• usually spontaneous, but it may follow coitus or bimanual
examination
• Signs of hypovolemia are common
Tubal Abortion
• Pregnancy may abort out the distal portion of tube
• Common in fimbrial and ampullary pregnancies
Tubal Abortion
– The frequency of tubal abortion depends in part

on the implantation site (common in ampullary).
– If placental separation is complete, all of the
products of conception may be extruded through
the fimbriated end into the peritoneal cavity.
Tubal Pregnancy
Tubal Pregnancy: Clinical manifestation
• If unruptured, signs and symptoms are subtle

or even absent
• Classic presentation:
– Delayed menses
– Pain
– Vaginal spotting or bleeding
Tubal Pregnancy: Clinical manifestation
Tubal rupture
– Severe lower abdominal and pelvic pain (sharp,
stabbing or tearing)
– Cervical motion tenderness on bimanual exam
– Bulging or rectouterine cul-de-sac or tender boggy
mass
– Slightly enlarged uterus
– Vaginal spotting
– Passage of decidual cast
Decidual cast
• Due to hormonally
prepared uterus
• Entire sloughed of
endometrium that takes
the form of endometrial
cavity
• Absence of gestational
sac or villi w/in the cast
histologically
Multimodality Diagnosis
• Key Components
1. Transvaginal sonography
2. Serum β-hCG – both the initial level and
the pattern of subsequent rise or decline
3. Serum progesterone level
4. Uterine curettage
5. Laparoscopy and occasionally, laparotomy
Algorithm for the management
of hemodynamically stable
patient
Diagnosis: β-hCG
• Rapid and accurate determination of
pregnancy is essential
• Serum and urine β-hCG sensitive to levels of
10-20mIU/ml
• Discriminatory zone of β-hCG ≥1500mIU/ml
Β-hCG and discriminatory level
• More than discriminatory zone + negative TVS
• failed uterine pregnancy, completed abortion, ecotpic or
early multifetal pregnancy
• Less than the discriminatory zone

• Serial β-hCG to identify the patterns that indicate either
growing or failing uterine pregnancy
• Repeat β-hCG after 2 days
Diagnosis: Serum progesterone
• A value exceeding 25ng/mL excludes ectopic pregnancy
(92.5% sensitive)
• Values below 5ng/mL suggest either an intrauterine
pregnancy with a dead fetus or an ectopic pregnancy
• In most ectopic pregnancies, progesterone levels range
10-25ng/ml, thus clinical utility is limited
Transvaginal Ultrasound
• Use of Transvaginal ultrasound (TVS)

– Intrauterine vs ectopic pregnancy
• Endometrial cavity
– Trilaminar endometrial pattern
Diagnosis: SONOGRAPHY
Transvaginal sonography of a normal pregnancy
•Intrauterine gestational sac usually present bet. 4 ½ to
5 weeks
•Yolk sac bet. 5-6 weeks
•Yolk sac w/ cardiac activity 5 ½ to 6 weeks
•“Intradecidual sign” – early gestational sac and
eccentrically located within one of the endometrial
stripes
NORMAL
intrauterine
pregnancy
Sonography of Ectopic pregnancy
• Pseudogestational sac – fluid collection bet.
Endometrial layers and conforms to the cavity
shape
• Decidual cyst – anechoic area lying within the
endometrium but remote from canal and often at
the endometrial-myometrial layer
*** Can also be seen in an early pregnancy but
presence of which increases the likelihood of
ectopic pregnancy
Gestational sac vs Pseudogestational sac
TVS: Adnexal findings
• Sonographic diagnosis of ectopic rests on
visualization of adnexal mass separate from
ovary
• Presence of ring of fire
– Placental blood flow w/in the periphery of the
complex mass
– Can also be seen with a corpus luteum of
pregnancy
Ectopic
pregnancy
“Ring of Fire”
(due to increased vascularity)
Diagnosis: Hemoperitoneum
• Added valuable clinical information
• TVS: (+) anechoic or hypoechoic fluid at
rectouterine cul-de-sac.
– A little as 50ml can be seen
• Culdocentesis
Diagnosis: Hemoperitoneum
CULDOCENTESIS
– used commonly in the past to identify
hemoperitoneum
– The cervix is pulled toward the symphysis with a
tenaculum, and a long 16- or 18-gauge needle is
inserted through the posterior fornix into the
cul-de-sac
– Fluid containing fragments of old clots, or bloody
fluid that does not clot, is compatible with the
diagnosis of hemoperitoneum resulting from an
ectopic pregnancy
Hemoperitoneum
TVS Culdocentesis
Diagnosis: Laparoscopy
• Direct visualization
• Reliable diagnosis in most cases of ectopic
pregnancies
TREATMENT
OPTIONS
Medical Management: METHOTREXATE
• An anti-neoplastic drug that acts as a folic acid
antagonist
• Blocks reduction of dihydrofolate to tetrahydrofolate
(active form of folic acid) arrest DNA, RNA and
protein synthesis
Contraindications:
– Intra-abdominal hemorrhage
– Breast feeding
– Immunodeficiency
– Alcoholism
– Liver or renal disease
– Blood dyscrasias
– Active pulmonary disease
– Peptic ulcer
METHOTREXATE: Patient seclection
• Best candidate is a patient who is
asymptomatic, motivated and compliant
• Initial β hCG single best prognosticator for
success
• Adnexal mass size of <3.5cm
Treatment Side Effects
• Increasing pain in women initially
• Liver involvement
• Stomatitis
• Gastroenteritis
• Bone marrow depression
• Monitoring Efficacy of Therapy
– For single dose therapy repeat serum β-hCG is
done at 4 and 7 days
– For variable dose methotrexate, serum β-hCG
concentrations are measured at 48-hour intervals
until they fall > 15%
– After successful treatment, weekly determinations
are done until β-hCG is undetectable
Surgical Management: CONSERVATIVE
• Salpingostomy
– Used to remove a small
pregnancy usually <2 cm in
length and located in the distal
third of the fallopian tube
– A 10-15 mm linear incision is
made on the antimesenteric
border immediately over the
ectopic pregnancy, and is left
unsutured to heal by secondary
intention
– Readily performed through a
laparoscope
– Gold standard surgical method
used for unruptured ectopic
pregnancy
Surgical Management: CONSERVATIVE
• Salpingotomy
– Procedure is the same as salpingostomy except
that the incision is closed with a suture
• Surgical Resection & Anastomosis

– Sometimes used for an unruptured isthmic
pregnancy
Surgical Management: RADICAL
• Salpingectomy
– Tubal resection
– May be used for both
ruptured and unruptured
ectopic pregnancies
– Performed if the fallopian
tube is extensively diseased
or damaged
– Cornual resection – a wedge
of the outer third (or less) of
the interstitial portion of the
tube is excised to minimize
the rare recurrence of
pregnancy in the tubal stump
Persistent Trophoblast
• Factors that increase the risk of persistent
ectopic pregnancy
1. Small pregnancies, less than 2 cm
2. Early therapy, before 42 menstrual days
3. Β-hCG serum levels exceeding 3000mIU/mL
4. Implantation medial to the salpingostomy site
Expectant Management
• Criteria:
1. Decreasing serial β-hCG levels
2. Tubal pregnancies only
3. No evidence of intra-abdominal bleeding
or rupture as assessed by vaginal
sonography
4. Diameter of the ectopic mass not greater
than 3.5 cm
Interstitial Pregnancy
Interstitial Pregnancy
• Implants w/in the proximal tubal segment that
lies within the muscular uterine wall
• If undiagnosed, usually ruptures following 8-
16 weeks of amenorrhea
• Mortality rate is high due to torrential
hemorrhage bec. of the proximity to the
ovarian artery
Diagnosis
Criteria by TVS:
•Empty uterus
•Gestational sac separate from the endometrium
•> 1cm away from the most lateral edge of the
uterine cavity
•Thin <5mm myometrial mantle surrounding the
sac
•“Interstitial line sign” – echogenic line extending
from the gestational sac to the endometrial cavity
Empty Uterus Mass
Management:
• Cornual resection or
cornuostomy via
laparotomy or
laparoscopy
• Wedge incision is used
for resection
ABDOMINAL PREGNANCY
Abdominal Pregnancy
• Implantation in the peritoneal cavity exclusive of
tubal, ovarian or intraligamentous implantations
• Rare, 1 in 10,000-25,000 livebirths
• Diagnosis may be difficult.
– Symptoms are vague or absent
– Laboratory tests are uninformative
– Maternal serum alpha fetoprotein elevated
Diagnosis
• Clinically, abnormal fetal position palpated or
cerix is displaced
• Sonographically difficult
– Fetus separate from the uterus or eccentrically
positioned within the pelvis
– Lack of myometrium bet the fetus and the
maternal anterior abdominal wall
– Extrauterine placental tissue
Abdominal Pregnancy
Management
• Life-threatening
• Depends on the gestational age at diagnosis
• Awaits until fetal viability with close
surveillance
• Conservative management carries maternal
risk for sudden and dangerous hemorrhage
• Before 24 weeks, conservative treatment is
rarely justifiable
Management
• Assess placental implantation
• Preoperative angiographic embolization
Perioperative considerations:
• Insertion if ureteral catheters
• Bowel preparation
• Assurance of sufficient blood products
• Availability of multidisciplinary team
Management
• In-hospital expectant management if pregnancy is
diagnosed after 24 weeks
• Surgery may precipitate torrential hemorrhage due to

the lack of constriction of hypertrophied blood vessels
after placental separation
• Adequate blood must be immediately available and

techniques for monitoring the adequacy of the
circulation should be employed
• The infant should be delivered, and the cord severed

close to the placenta
Management
• Leaving the placenta inside the abdominal cavity
may cause infection, abscess, adhesion, intestinal
obstruction, and wound dehiscence, but it may
be less grave than the hemorrhage that
sometimes result from placental removal during
surgery
• Methotrexate has been recommended to hasten

placental involution, however its use is
controversial.
Fetal Outcome
• Fetal malformation and deformations – facial or
cranial asymmetry, or both, various joint
abnormalities, limb deficiency and CNS anomalies
• If the fetus dies after reaching a size too large to

be resorbed, it may undergo
– Suppuration
– Mummification/ Lithopedian formation
– Calcification
Broad Ligament Pregnancy
• If zygotes implant toward the mesosalpinx and
rupture occurs, the gestational contents may
be extruded into a space formed between the
folds of the broad ligament and then become
an intraligamentous or broad ligament
pregnancy
OVARIAN PREGNANCY
Spiegelberg Criteria
1. Ipsilateral tube is intact
and distinct from the
ovary
2. Ectopic pregnancy
occupies the ovary
3. Ectopic pregnancy must be
connected to the uterus
by the uteroovarian
ligament
4. Definite ovarian tissue
must be found in the sac
wall
Diagnosis
• Findings are likely to mimic those of a tubal
pregnancy or a bleeding corpus luteum
• The increased use of vaginal ultrasound has

resulted in the more frequent diagnosis of
unruptured ovarian pregnancies
• Rupture at an early stage
Management
• Classical management: Surgical
– Laparotomy with ovarian wedge resection or
cystectomy, ovariectomy
• Methotrexate, for unruptured ovarian

pregnancy
• Laparoscopic resection or laser ablation
CERVICAL PREGNANCY
Rubin’s Criteria
• Cervical glands cervical must be present opposite
placental attachment
• Attachment of placenta to cervix must be intimate
• The placenta must be below the entrance of the

uterine vessels or below the peritoneal reflection on
the anteroposterior uterine surfaces
• Fetal elements must not be present in the uterine

corpus
Diagnosis
• Cervical pregnancy rarely extends beyond 20
weeks, and is usually surgically terminated
because of bleeding
• High degree of clinical suspicion coupled with
sonography
– Sonographic findings of an empty uterus and a
gestation filling the cervical canal
Management
• Cerclage
• Curettage and tamponade – suction curettage
followed by insertion of foley catheter and
vaginal pack
• Uterine artery embolization with gelfoam
• Methotrexate – first line therapy in stable
women
• Hysterectomy – if other interventions fail
CESAREAN SCAR PREGNANCY (CSP)
Cesarean scar pregnancy
• 1 in 2000 normal pregnancies
• Implantation w/in the myometrium of a prior
cesarean delivery scar
• Signs and symptoms are usually early, pain
and bleeding most common
• Diagnosis sonographically is difficult. TVS is
the first line
Diagnosis and management
• A high clinical index of suspicion is warranted
in a woman with a prior cesarean delivery
• Management is gestational-age dependent
and includes:
– methotrexate treatment
– curettage
– hysteroscopic resection
– uterine-preserving resection by laparotomy or
laparoscopy, a combination of these
– hysterectomy
Cesarean
Scar
Pregnancy
End of lecture!J
Thank You.J
2016.OB-GYN.FEU-NRMF Reference: Williams OB 24th ed.

Ectopic Pregnancy

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ectopic Pregnancy

Uploaded by

Copyright:

Available Formats

Ectopic

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

• The implantation of the

Previous ectopic pregnancy 3-13

Tubal corrective surgery 4

Intrauterine device 1-4.2

Documented tubal pathology 3.8-21

Assisted reproductive technology 2-8

Previous genital infection 2-4

Prior abortion 0.6-3

Multiple sexual partners 1.6-3.5

Prior cesarean delivery 1-2.1

– The absolute number of ectopic pregnancies is

– The frequency of tubal abortion depends in part

• If unruptured, signs and symptoms are subtle

• Less than the discriminatory zone

• Use of Transvaginal ultrasound (TVS)

• Surgical Resection & Anastomosis

• Surgery may precipitate torrential hemorrhage due to

• Adequate blood must be immediately available and

• The infant should be delivered, and the cord severed

• Methotrexate has been recommended to hasten

• If the fetus dies after reaching a size too large to

• The increased use of vaginal ultrasound has

• Methotrexate, for unruptured ovarian

• Laparoscopic resection or laser ablation

• Attachment of placenta to cervix must be intimate

• The placenta must be below the entrance of the

• Fetal elements must not be present in the uterine

You might also like