AREZ ESMAIL QADR

SHAMAL M. AZIZ

ECTOPIC
PREGNANCY

Normal pregnancy implantation

Pregnancy is the period during which a
woman carries a developing fetus normally
in the uterus, starting from conception
(fertilization of ova) until the baby born.
After ovulation the ovum is picked up by the
fimbria of fallopian tubes and then swept
by ciliary action towards the ampulla where
fertilization occurs.
As soon as the zygote develops it begins
dividing very rapidly, it remains in the fallopian
tube for 3 -4 days untill reaches morula stage
(8-32 cell stage)

Normal pregnancy
implantation
The embryo proceeds through the isthmus to the uterine cavity for up
to 72 hours, by the sixth day it enters the uterus and begins to
penetrate the decidua (endometrium) this is called implantation
which takes place within the uterine cavity in normal positioned
pregnancy .
Then hCG is produced by trophoblast, which can be detected in the
serum of the mother in the first week after implantation, its level
doubles every 36-48 hours in normal healthy pregnancy starting
from 5 to 50 ,100, till reaching 1000 IU/L
Delay or obstruction of the passage of fertilized egg down the fallopian
tube to the uterus may result in implantation in the fallopian tube or
ovary or peritoneal cavity, this known as ectopic pregnancy which
eventually most fails to develop , and the hCG fails to raise
dramatically as happens in the normal intra uterine pregnancy.

Normal pregnancy
implantation

Ectopic pregnancy ?

Ectopic pregnancy
Definition:
An ectopic pregnancy, or eccysis , is a complication of pregnancy Occurs when the
site of implantation is outside of the womb (uterine cavity) either in the tubes,ovaries or
abdominal cavity, With rare exceptions, ectopic pregnancies are not viable, Pregnancy
can even occur in both the womb and the tube at the same time (heterotopic
pregnancy).
Classification:
1- tubal pregnancy:
The vast majority of ectopic pregnancies 95-98 % implant in the Fallopian tube,
among these:
80% in the ampulla
10% in isthmus
5 % in fimbria
2% interstitial
2% in a rudimentary horn of a bicornuate uterus

classification
2-Nontubal ectopic pregnancy
Rare sites (2-5%) are;
The ovaries,
broad ligaments,
Abdominal cavity and peritoneum
cervix.
3-Heterotopic pregnancy
in rare cases of ectopic pregnancy 1/1000, there may be two fertilized eggs,
one outside the uterus and the other inside. This is called a heterotopic
pregnancy.
Often the intrauterine pregnancy is discovered later than the ectopic, mainly
because of the painful emergency nature of ectopic pregnancies.

classification
Since ectopic pregnancies are normally discovered and removed very
early in the pregnancy, an ultrasound may not find the additional
pregnancy inside the uterus. When hCG levels continue to rise after
the removal of the ectopic pregnancy, there is the chance that a
pregnancy inside the uterus is still viable. This is normally
discovered through an ultrasound
Although rare, heterotopic pregnancies are becoming more
common, likely due to increased use of IVF.

Common sites for ectopic

pregnancy

epidemiology
Incidence;
22/1000 live births
16/1000 pregnancies
In USA from 1970 1992 , the risk 5x increased from 4 to 19 / 1000
pregnancies
fatality rate :
fatality rate from ectopic pregnancies dropped almost 90% (from 35.5
per 1000 ectopics to 3.8 per 1000 ectopics).
Despite the sharp improvement in the fatality rate by the end of this
period of time, ectopics were still the second leading cause of
maternal mortality in the USA (accounting for 12% of all maternal
deaths in 1987).

Why?
The reason for the increase in ectopic pregnancy during this time
period is not entirely clear, but it was thought that the increase of
risk factors were responsible for a significant portion of the
increased number of cases of ectopic pregnancy.

Risk factors
Any mechanism that interferes with the normal function of fallopian
tube increases the risk of ectopic pregnancy
The mechanism canbe:
Anatomical; scarring that blocks transport of the egg
Functional; impaired tubal mobility

Risk Factor
High Risk
PID
Tubal corrective surgery
Tubal sterilization
Previous EP
In utero DES exposure
IUD
Documented tubal pathology

Moderate Risk
Infertility
Previous genital infection
Multiple partners

Risk %
25
21.0
9.3
8.5
8.3
5.6
4.2-45
3.8-21
2.5-21
2.5-3.7
2.1

Slight risk
Previous pelvic or abdominal surgery

0.93-3.8

Smoking

2.3-2.5

Douching

1.1-3.1

Intercourse before 18 weeks

1.6

Risk factors
1-History of pelvic infection
PID is the most common risk factor for ectopic pregnancy
8 folds increases the risk, due to destruction of the fallopian tubes.
Chlamydia (a common sexually transmitted disease) and Gonorrhea
are both able to grow within the fallopian tubes and cause;
1-tremendous damage to the endosalpinx (lining of the inner tubal
lumen),
2-agglutination (sticking together) of the mucosal folds in the tube
3-peritubal adhesions (scar tissue).
. the risk of an ectopic pregnancy is greater when the woman with the
infection is younger
Other pelvic or lower abdominal infections can also result in pelvic
adhesions and an increase in the ectopic pregnancy rate (such as
appendicitis).
The chances of another ectopic in the same fallopian tube also in the
other tube are increased 5x

Risk factors
2-History of surgery on the fallopian tubes or within the pelvis:
Tubal ligation in the past 2 years,When a bilateral tubal ligation (tubes
tied) is followed by either an unexpected pregnancy (failed tubal
ligation) or is "reversed" with a tubal reanastomosis (tubal
reconstruction) there is an increased risk of a tubal ectopic
pregnancy.
When a woman has a history of pelvic surgery that is associated with
significant adhesion formation (such as myomectomy) there is also
an increased risk of an ectopic pregnancy.

Risk factors
3- Prior history of ectopic pregnancy.
When an ectopic pregnancy in the fallopian tube is treated conservatively
(by preserving the tube), there is a roughly 10 fold increase the risk of
recurrence in the same tube
4-History of IUD use. The use of an IUD is a classic "risk factor" for
ectopic pregnancy. Actually, all but the progesterone containing IUDs
are relatively protective against ectopic pregnancy while the IUD is in
place. That is, the number of ectopic pregnancies in women using an
IUD for contraception is about one half that of women using no
contraception. However, of IUD pregnancies there is a greater chance
of an ectopic location (3-4%) since the number of intrauterine
pregnancies with an IUD in place is markedly reduced.

Risk factors
Additionally, IUDs can be associated with infections of the uterine
cavity and fallopian tubes (especially just after insertion) which can
independently increase the chance for an ectopic pregnancy..
The reason for this increase in the nomber of EPs with progesterone
IUD is not clear. A theory is that somehow the progesterone
enhances tubal implantation.

Risk factors
5-History of Diethylstilbestrol (DES )exposure in utero.
This drug is a is a synthetic nonsteroidal estrogen that was used for
certain conditions, including breast and prostate cancers ,From
about 1940 to 1970, DES was given to pregnant women under the
mistaken belief it would reduce the risk of pregnancy complications
and losses
Later researches has shown that this drug has many bad medical
effects and female babies of women who used it were at risk of
developmental abnormalities of the genital system
Their tubes are more likely to be abnormal and predispose to ectopic
pregnancy, these females were known as DES daughters

Risk factors
6-History of destruction of the uterine cavity or lining.
Such as history of uterine synechiae (scar tissue) from previous
surgery (like endometrial ablation for dysfunctional bleeding ) or
presence of multiple submucosal fibroid tumors this cause a larger
percentage of the pregnancies to implant in a space other than the
uterine cavity.
Similar to the situation with IUDs, the total ectopic pregnancy rate may
not be increased but when a pregnancy does occur the reduced
likelihood of an intrauterine pregnancy increases the relative
percentage of ectopic pregnancies.

Risk factors
7-History of non-infectious pelvic inflammation (endometriosis,
foreign body).
Inflammation of the delicate tubal structures can result in adhesion
formation (scar tissue), which will then increase the risk of an
ectopic pregnancy. This inflammation may be due to endometriosis
or the presence of a foreign body, either of which are strongly
associated with scar tissue formation.

Risk factors
8-Use of assisted reproductive technology (such as IVF (in vetro
fertilization) and GIFT (gamete intrafallopian transfere).
When multiple embryos or gametes are placed into the uterus or the
fallopian tubes, the risk for multiple pregnancy rises significantly.
The risk of twins and heterotopic pregnancy is generally thought to
be about 1 / 30,000 pregnancies .
with ARTs the rates of ectopics and dizygotic twins have increased to
1/10,000 .
the incidence of heterotopic pregnancy may increase to as frequently
as 1 /100 pregnancies.

Tubal pregnancy

Pathophysiology
The trophoblast develops in the fertilized ovum and invades deeply
into the tubal wall.
Following implantation, the trophoblast produces hCG which
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.
The tubal pregnancy does not usually proceed beyond 8-10weeks due
to:
> 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.

Pathophysiology
Separation of the gestational sac from the tubal wall leads to its
degeneration, and fall of hCG level, regression of the corpus luteum
and subsequent drop in the oestrogen and progesterone level.
This leads to separation of the uterine decidua with uterine bleeding.
Fate of tubal pregnancy
Tubal mole
Tubal abortion
Tubal rupture

Fate of tubal pregnancy

1- Tubal mole:
The gestational sac is surrounded by a blood clot and retained
in the tube.
This may remain for long period in the tube and forms so called
(chronic ectopic pregnancy),or they may be gradually absorbed
(involution)
2-Tubal abortion:
This occurs more if ovum had been implanted in the ampullary portion
of the tube.
Separation of the gestational sac is followed by its expulsion into the
peritoneal cavity through the tubal ostium.
Rarely, reimplantation of the conceptus occurs in another abdominal
structure leads to secondary abdominal pregnancy.

Fate of tubal pregnancy

If expulsion was complete the bleeding usually ceases but it may
continue due to incomplete separation or bleeding from the
implantation site.

Fate of tubal pregnancy

3-Tubal rupture:
More common if implantation occurs in the narrower portion of the tube
which is the isthmus.
Rupture may occur in the
anti-mesenteric border of the tube.
Usually profuse bleeding occurs
intraperitoneal haemorrhage.
If rupture occurs in the mesenteric border
of the tube, broad ligament haematoma
will occur.

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
The most common presenting symptoms that are suggestive for EP
are:

Clinical traid (3As)

Amenorhea
ectopic
pregnancy

Abdominal pain

Abnormal vaginal
bleeding

symptoms
Pain and discomfort
In the Lower back , abdomin, or pelvis.
Usually unilateral
Pain may be confused with a strong stomach pain, it may also feel like
a strong cramp
Shoulder pain. This is caused by free blood tracking up the abdominal
cavity and irritating the diaphragm, and is an ominous sign.
Pain while urinating
Pain while having a bowel movement

symptoms
Bleeding
Vaginal (external)bleeding usually mild. An ectopic pregnancy is usually
a failing pregnancy and falling levels of progesterone from the
corpus luteum on the ovary cause withdrawal bleeding.
Internal bleeding (hematoperitoneum) is due to hemorrhage from the
affected tube.
Dizziness, headache, weakness, fainting all may happen due to
bleeding

signs
General examination:
signs of early pregnancy (Breast tenderness, nausea and
vomitig, change of apettite )
Weakness, pallor, hypotension and tachycardia, tachypnoea
due to bleeding
Abdominal examination:
Lower abdominal tenderness and rigidity especially on one side may
be present.

signs
Vaginal examination:
Vaginal spotting
Bluish vagina and bluish soft cervix.
Uterus is slightly enlarged and soft.
Marked pain in one iliac fossa on moving the cervix from side to
side.
Ill defined tender mass may be detected in one adnexa in which
arterial pulsation may be felt.
Speculum or bimanual examination should not be performed unless
facilities for resuscitation are available, as this may induce rupture
of the tube

diagnosis
The diagnosis can be difficult
Your doctor may perform some tests to help confirm suspected ectopic
pregnancy including;
Detailed history of (cycle, pregnancy, PID,infertility, gynaecological
surgery, contraception)
Proper general, abdominal, vaginal examination and vital signs
Investigations: including

Diagnosis
1.hormonal assay
Serum -hCG
Urine pregnancy tests are positive in only 50-60% of ectopic. Detection
of -hCG in the serum by ELISA or radioimmunoassay are more
sensitive and can detect very early pregnancy about 10 days after
fertilization i.e. before the missed period.
If the test is negative (generally less than 5 IU/L), normal and abnormal
pregnancy including ectopic are excluded.
If the test is positive , and doubles every 36-48 hour till reaching 1500
IU/L which is The threshold of discrimination for intrauterine
pregnancy, this indicates a normal intrauterine pregnancy,
An abnormal rise in blood -hCG levels may indicate an ectopic
pregnancy and ultrasonography is indicated.

Diagnosis
Progesterone
The second most common hormone after hCG in pregnancy is
progesterone.
Generally, a progesterone concentration of greater than 25 ng/mL is
highly correlated with a normal intrauterine pregnancy while a
concentration of less than 5 ng/mL is highly correlated with an
abnormal and nonviable pregnancy

Diagnosis
2-Ultrasound
In general, a positive -hCG test with empty uterus by sonar adnexial
mass indicates ectopic pregnancy.
Discriminatory hCG zones:
Diagnosis of ectopic pregnancy is made if there is:
An empty uterine cavity by abdominal sonography with b -hCG value
above 6000 mIU/ml.
An empty uterine cavity by vaginal sonography with b -hCG value
above 2000 mIU/ml.

Ultrasound

Diagnosis
3-Culdocentesis
in this test, 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 and
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.

Diagnosis
4-laparoscopy or laparotomy can also be performed to visually confirm an
ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred.
Laparoscopy: an endoscope is inserted through a small incision in the
womans abdomen
This allows you to see the fallopian tubes and other organs
This takes place in an operating room with anaesthesia

Uncommon Sites of Ectopic

Pregnancy
1-Cornual angular pregnancy
2-Pregnancy occurs in the blind rudimentary horn of a bicornuate
uterus.
3-Cervical pregnancy
4-Ovarian pregnancy
5-Abdominal (peritoneal) pregnancy

Cornual angular pregnancy

It is implantation in the interstitial portion of the tube.
It is uncommon but dangerous because when rupture occurs bleeding
is severe and disruption is extensive that needs hysterectomy.
In some cases, the pregnancy is expelled into the uterus and rupture
does not occur.

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Pregnancy in a rudimentary
horn
Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.
As such a horn is capable of some hypertrophy and distension, rupture
usually does not occur before 16-20 weeks.

Cervical pregnancy
Implantation in the substance of the cervix below the level of uterine
vessels.
May cause severe
vaginal bleeding.
Can be diagnosed by
trans vaginal ultrasound

Ovarian pregnancy
Aetiology:
* Pelvic adhesions.
* Favourable ovarian surface for implantation as in ovarian
endometriosis.
Pathogenesis:
* Fertilization of the ovum inside the ovary or,
* implantation of the fertilized ovum in the ovary.

Ovarian pregnancy
Spiegelberg criteria for diagnosis of ovarian pregnancy:
* The gestational sac is located in the region of the ovary,
* the ectopic pregnancy is attached to the uterus by the ovarian
ligament,
* ovarian tissue in the wall of the gestational sac is proved
histologically,
* the tube on the
involved side is intact.

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Abdominal (peritoneal)
pregnancy
Types:
Primary: implantation occurs in the peritoneal cavity from the
start.
Secondary: usually after tubal rupture or abbortion.
Intraligamentous pregnancy: is a type of abdominal but
extraperitoneal pregnancy. It develops between the anterior and
posterior leaves of the broad ligament after rupture of tubal
pregnancy in the mesosalpingeal border or lateral rupture of
intramural (in the myometrium) pregnancy.

Abdominal (peritoneal) pregnancy

Diagnosis:
History: of amenorrhoea followed by an attack of lower abdominal
pain and slight vaginal bleeding which subsided spontaneously.
Abdominal examination:
Unusual transverse or oblique lie.
Foetal parts are felt very superficial with no uterine muscle wall
around.
Vaginal examination:
The uterus is soft, about 8 weeks and separate from the foetus.
No presenting part in the pelvis.

Abdominal (peritoneal) pregnancy

Special investigations:
Plain X-ray: shows abnormal lie. In lateral view, the foetus
overshadows the maternal spines .
Ultrasound: shows no uterine wall around the foetus
Magnetic resonance imaging (MRI): has a particular
importance in preoperative detection of placental anatomic
relationships.

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DIFFERENTIAL

DDX

DIAGNOSIS

(1) NON GYNECOLOGICAL

Appendicitis (Perforated)

Acute Pancreatities
Myocardial Infarct
Pelvic Abcess
Splenic Rupture
Perforated Gastric or Duodenal
Ulcer

(2) Gynecologic disorders

Septic
Abortion

Rupture of
Follicle or
Corpus
Luteum Cyst

Degenerating
leiomyoma

Threatened
Abortion

Acute pelvic
inflammatory
disease

Retroverted
Gravid
Uterus

Pyosalpinx
Pelvic
Abcess

Twisted
Ovarian
Cyst

TREATMENT
Ec
c top

Rx

 SURGICAL
MANAGEMENT
MEDICAL
MANAGEMENT
EXPECTANT
MANAGEMENT

3
2
1

Treatment options

EXPECTANT

MANAGEMENT

 Criteria for selection

asymptomatic women no evidence
of rupture or hemodynamic
instability
less than 100 ml fluid in the pouch
of Douglas
hCG less than 1000 iu/l at initial
presentation
Adnexal mass less than 3cm
they should objective evidence of
resolution, such as declining bhCG
levels.
They must be fully compliant and
must be willing to accept the
potential risks of tubal rupture.

MONITORING
Initial follow up
twice weekly with serial
hCGmeasurements
weekly by transvaginal examinations
By the first week
drop in HCG level
Adnexal mass size
Otherwise reassess the options
(Medical/Surgical)
If the fall of HCG & reduction in size of
adnexal mass satisfatory
weekly hCG and transvaginal ultrasound
examinations

 4570% of pregnancies of unknown

location resolve spontaneously with
expectant management
Ectopic pregnancy was subsequently
diagnosed in 1428% of cases of
pregnancy of unknown location
Intervention has been shown to be
required in 2329% of cases.

MEDICAL
MANAGEMENT

CRITERIA for

MEDICAL MANAGEMENT

Selection criteria
Minimal symptoms & The patient must be
hemodynamically stable
no signs or symptoms of active bleeding or
haemoperitoneum.
Absence of foetal heart beat
Normal FBC,U&E(urea & electrolytes),LFT(liver
function tests)
Exclusion criteria
Any hepatic dysfunction, thrombocytopenia
(platelet count <100,000), blood dyscrasia(WCC
<2000 cells cm3).
Difficulty or unwillingness of patient for
prolonged follow-up (average follow-up 35days).
Ectopic mass >3.5cm
The presence of cardiac activity in an ectopic
pregnancy

SYSTE
MIC

Methotrexate

LOCA
LLY

injections of prostaglandins,
potassium chloride OR
hyperosmolar glucose OR
local methotrexate

METHOTREXATE

Methotrexate a drug that destroys actively growing tissues such as the

placental tissues ,is used as an injection in selected cases to avoid surgery (in
non ruptured ectopic)
Side effects include abdominal pain for 3 7 days in 50% of cases and mild
symptoms of nausea, mouth dryness and soreness and diarrhoea,
Methotrexate-Intramuscular(buttock or lateral thigh)
Dose calculated from body surface area
Usual dose ranges between 75-95 mg
HCG checked on day 4 & day 7
If fall is less than 15 % consider second dose of methotrexate

Anti-D should also be given if required

Rest up to one hour after the injection.
Check for any local reaction.

ADVICES

Patient should be given information on(preferably

written)
Need for further treatment
Adverse effects
Women should be able to return easily for
assessment at any time during follow-up
Advice
avoid sexual intercourse during treatment
to maintain fluid intake
use reliable contraception for three months
after methotrexate has been given, barrier or
hormonal)
Avoid exposure to sunlight.
Avoid alcohol and vitamin preparations
containing folic acid until the hormone level is
back to zero.
Avoid aspirin or drugs such as Ibuprofen for

OUTCOME
90% successful treatment with single dose
regime.
Recurrent ectopic pregnancy rate 10 20%.
Tubal patency approximately 80%.
14 % of medical management second dose of
methotrexate
75% would experience abdominal painseparation pain. This usually occurs between
day 3-7
10% would finally require surgical management

COST BENEFITS
cheap in the initial period
but considering the cost of follow
up & the loss of work time for
patient & carers
no cost saving was seen at serum
hCG levels above 1500 IU/l due to
the increased need for further
treatment and prolonged followup.

3
SURGICAL
MANAGEMENT

Indications for surgical treatment

The patient is not a suitable candidate for
medical therapy.
Medical therapy has failed.
The patient has a heterotopic pregnancy with a
viable intrauterine pregnancy.
The patient is hemodynamically unstable and
needs immediate treatment.

EMERGENC
Y

RUPTURED

ECTOPIC

PREGNANCY

Get help- call senior /Consultant on call

ABC of resuscitation
give facial oxygen
Site two IV lines , commence IV fluids (crystalloid)
Send blood for FBC, Clotting screen and cross-match at least 4 units
of blood.
insert indwelling catheter
arrange theatre for laparotomy
whilst awaiting transfer to theatre continue fluid resuscitation and ensure
intensive monitoring of haemodynamic state
do not wait for BP and pulse to normalise prior to transfer-resuscitation
and surgery need to go hand in hand.
Pfannensteil incision,
salpingectomy and wash out of abdomen
assess bloods /consider CVP
record operative findings including the state of the remaining tube/pelvis
Anti D immunoglobulin (250 IU)to be given to Rhesus negative women

Laparascopy OR laparatomy??
Laparoscopy has become the recommended approach in
most cases.
Laparotomy is usually reserved for patients:
who are hemodynamically unstable
patients with cornual ectopic pregnancies.
for surgeons inexperienced in laparoscopy and in patients
where laparoscopic approach is difficult

Laparoscopy

Laparotomy

Less intraoperative
blood loss
Shorter operation time
Shorter hospital stay
Lower analgesic
requirement
Future intrauterine
pregnancy rate same
Lower repeat ectopic
pregnancy rate

Future intrauterine
pregnancy rate same

Preferable in the
haemodynamically
unstable patient

Salpingectomy OR Salpingotomy ??
Salpingectomy
Salpingectomy (tubal removal) is the principle treatment especially
where there is tubal rupture

Salpingotomy
Conservative surgical management may be employed when the ectopic
has not ruptured and where the tube appears normal

Total salpingectomy is the procedure of choice:

In a patient who has completed childbearing and no
longer desires fertility
in a patient with a history of an ectopic pregnancy in the
same tube.
in a patient with severely damaged tubes,

Salpingectomy

Salpingotomy
There may be a higher
subsequent intrauterine
pregnancy rate
associatedwith
salpingotomy but the
magnitude of this benefit
may be small
Trend towards higher
subsequent ectopic
pregnancy
small risk of tubal
bleeding in the immediate
postoperative period
potential need for further
treatment for persistent

Persistent trophoblast

When salpingotomy is done, protocols should

be in place for the identification and treatment
of women with persistent trophoblast.
Monitoring serum HCG levels would help to
identify the persistent trophoblast.
Most Easily Treated With MTX

er
vi
ca
O
va
He
l
ria
te
Ab
ro
n
tr
do
op
m
ic
in
al

Mx Other Types

Cervical pregnancy
Evacuation and cervical packing with
haemostatic agent as fibrin glue and
gauze.

Arterial embolization

If bleeding continues or extensive

rupture occurs hysterectomy is
needed.

Ovarian pregnancy
Laparotomy and inoculation of the
ectopic pregnancy and
reconstruction of the ovary if
possible. Otherwise, removal of the
affected ovary is indicated.
Ovarian cystectomy is the
preferred treatment
Treatment with MTX and
prostaglandin injection has also
been reported

Abdominal (peritoneal)
pregnancy
The condition should be terminated surgically
through Laparotomy once diagnosed
MTX treatment appears to be contraindicated
because of the high rate of complications due to
rapid tissue necrosis

Heterotropic pregnancy
Depends upon
the state of the
woman
and the skill of
the doctor.
.Surgical

 Laparoscopy is the ideal surgical method to

remove an ectopic pregnancy before it ruptures
without interrupting the viable pregnancy.
Although the intrauterine pregnancy can still
survive if the ectopic pregnancy ruptures, there
is an increased danger of miscarriage. The
surgery must be done with great skill and it is
important that bleeding be addressed quickly.
Medical therapies include injecting the ectopic
pregnancy in order to terminate the gestation.

Anti D
Non sensitized women who are rhesus
negative with a confirmed or suspected
ectopic pregnancy should receive anti-D
immunoglobulin.
In accordance with RCOG Guideline it is
recommended that anti-D immunoglobulin at a
dose of 250 IU (50 micrograms) be given to all
non sensitized women who are rhesus negative
and who have an ectopic pregnancy.

ADVICE

Not using IUCD

Not using progesterone only pills
Treatment for any PID
Follow up by HCG that should disappear after 1
month
Do HSG after 40 day to see patency of the tube
Use barrier method of contraception
Timing of pregnancy, visit specialist in any
missed period

COMPLICATION

Recurrence of ectopic
Infertility
Shock & death
Tubal rupture & organ damage
Psychological
Surgical Rx
Medical Rx

Prognosis
Fertility following ectopic pregnancy
depends upon several factors, the most
important of which is a prior of infertility.
The treatment choice history , whether
surgical or nonsurgical, also plays a role.
For example, the rate of intrauterine
pregnancy may be higher following
methotrexate compared to surgical
treatment. Rate of fertility may be better
following salpingostomy than
salpingectomy.

Reference
1.Gynecology & obstetrci by Ten
teachers 19th edition
2.RCOG guidelines (Royal college of
obstetric & gynecology)
3.ACOG(American college of
obstetric & gynecology)
4.ASRM(American society of
reproductive medicine)
5.Wikipedia .com
6.Livemedicine.com
7.Dr.Abraham ( laparascopy Video)

THANK
YOU