Ectopic Pregnancy

Definition
Fertilized ovum is implanted and develops
outside the normal uterine cavity
 Extrauterine
• Tubal-97%
-Ampulla- 55%
-Isthmus- 25%
-Infundibulum-18%
-Interstitial- 2%
• Ovarian-0.5%
• Abdominal-1%
-Primary
-Secondary-Intraperitoneal &Extraperitoneal
 Uterine(1.5%)
• Cervical-<1%
• Cornual
• CS scar-<1%
Tubal Ectopic
 Incidence
1 in 300 to 1 in 150 deliveries.
 Etiology
Factors preventing or delaying migration of fertilized
ovum:
1.PID & salpingitis

2. Iatrogenic
- Contraceptive failure
- Tubal reconstructive surgery
- ART(ovulation induction drugs)
- Previous ectopic
- Prior induced abortion
- Developmental defects of the tube
-Transperitoneal migration of ovum
Factors facilitating nidation in the tube
• Premature degeneration of
zona pellucida

• Increase decidual reaction

• Tubal endometritis
 Outcome of Ectopic Pregnancy
Tubal mole-repeated small haemorrhages occur
in the chorio-capsular space, separating the
villi from their attachments.
Fate of tubal mole
• Complete absorption (rare)
• Abortion pelvic haematocele
 Tubal Abortion
–The frequency of tubal abortion
depends in part on the implantation
site (common in ampullary).

–Complete------ pelvic haematocele

–Incompelete --------Diffuse
intraperitoneal haemorrhage
 Tubal Rupture
– in first few weeks = isthmus
– up to 16 weeks = interstitial
– may be
– If an early conceptus is expelled into the
peritoneal cavity it may be reabsorbed,
– if larger, may remain in the cul-de-sac for years as
an encapsulated mass or even become calcified to
form a lithopedian
• Roof------Diffuse intra peritoneal haemorrhage
• Floor -----Intraligamentary haematoma

Tubal perforation
Roof------secondary abdominal pregnancy
Floor-----secondary intraligamentary pregnancy

Continuation of pregnancy -----rarest

 Changes in the tube
• Implantation occurs in intracolumnar fashion
(in between 2 mucosal fold)
• Decidual changes is minimal
• Intramuscular implantation occurs
• A pseudo capsule is formed consisting of
fibrin,lining epithelium & few muscles fibres.
• Blood vessels are eroded by the chorionic villi
& blood accumulates in between the
blastocyst & the serous coat
• The tube in the implantation site is distended
& the wall is thinned out.
• Bllod may spill from the fimbriated end ---
haemoperitoneum
• Stretching of the peritoneum results in
-episodic pain
-Tubal rupture (maximally stratched & undergo
necrosis)
• HCG production is inadequate
Uterine Changes in Ectopic Pregnancy
– increase in size
– softening of the cervix and isthmus.
– uterine decidua without trophoblast .
– Arias-Stella reaction
• Endometrial changes characterized by hypertrophic,
hyperchromatic, lobular and irregularly shaped nuclei,
and vacuolated, foamy cytoplasm with occasional
mitoses

– External bleeding – from degeneration and

sloughing of uterine deciduas
CLINICAL FEATURES
 Unruptured Acute Chronic/subacute/old

Mode of onset Acute,have got persistent Insidious

uneasiness before the acute
symptoms appear.

Amenorrhoea 6-8 wks 6-8 wks 6-8 wks

Abdominal Uneasiness Acute,agonising or coliky Varying degree

pain Colicky may Located at lower abd
be Unilateral/bilateral/may be
generalised.
Vaginal may be scanty, dark brown, scanty, dark brown,
bleeding intermittent or continuous intermittent or
Expulsion of decidual cast- continuous
5%
others Shoulder pain, Dysuria
Nausea .vomiting Frequency or retention
fainting,syncope (10%) Of urine
Rectal tenesmus
 Unruptured Acute chronic

T
General Quit, concious, perspires ill
look Looks blanched

pallor sever Varying degree

shock present absent

Abd •Lower abd tense,tumid Tenderness

exam. & tender Muscles guard
•No mass is usually felt Irregular & tender
•Shifting dullness mass felt
present Cullin’s sign
•Gut may be distended
•Muscles guard absent
 Bimanual examination
Unruptured
•Ut is slightly smaller than the
period of amenorrhoea.
•Ut is shoftshowing evidence
of early pregnancy
•A pulsatile small well
circumscribed tender mass
may be felt through the fernix
separated from the uterus.
Acute Chronic
•Vaginal mucosa blanched •Vaginal mucosa pale
white
•Ut normal in size & bulky
•Ut normal in size or slightly
bulky •Extreme tenderness on
movement of the cervix
•Extreme tenderness on
fernix palpation or on •An ill defined boggy &
movement of the cervix extremely tender mass is
felt through fernix h of
•No mass is felt throguh the extending to the pouch of
Cervix. Douglas.
•The uterus float as if in the • The mass may
water pushedthe uterus to
the opposite side
 Diagnosis
Unruptured Acute Old

•TVS •From S/S •Hb%

•Radioimmunoassay •Hb% •DC,WBC

of BhCG
•Blood •Blood grouping &
•Laparoscopy grouping & Rh Rh typing
typing
•ESR

•Culdocentesis
 Multi-Modality Diagnosis
1. Vaginal sonography
– If the uterus is empty, an ectopic pregnancy can
be diagnosed based on visualization of an
adnexal mass separate from the ovaries
2.Serum β-hCG – both the initial level and the
pattern of subsequent rise or decline
– An empty uterus with a serum β-hCG
concentration of 1500 mIU/mL (discriminatory
level) or higher is 100% accurate in excluding a live
intrauterine pregnancy (dead fetus vs ectopic
pregnancy

– Failure to maintain this rate of increased β-hCG

production along with an empty uterus is
suggestive for an ectopic pregnancy.
3. Serum progesterone
– Serum levels of at least 25ng/mL after
spontaneous conception provide reassurance that
an ectopic pregnancy is unlikely.

4. Uterine curettage
– Used to differentiate between incomplete
abortion and ectopic pregnancy
 Multi-Modality Diagnosis
5. Laparoscopy and, less frequently, laparotomy
– Laparoscopy
– Laparotomy
 Management
Acute-
• Resuscitation & laparotomy
• Not resuscitation followed by laparotomy
Principle of laparotomy- ‘quick in quick out’
• Salpingectomy
• If ovary is damaged oophorectomy
• Subtotal hysterectomy/hysterectomy-in case
of interstitial pregnancy where rupture rent is
so big.
 Unruptured
Medical Management
• Methotrexate -An anti-neoplastic drug that
acts as a folic acid antagonist, and is highly
effective against rapidly proliferating
trophoblasts
 Criteria

– hCG is rising
– Hemodynamically stable
– The tubal mass should be <3.5 cm in
diameter
– The fetus is dead/No cardiac activity
– Β-hCG is <3000 IU/L
– Pt desires future pregnancy
Single Dose
• Methotrexate, 50 mg/m2 IM

Variable Dose
• Methotrexate, 1mg/kg IM, days 1, 3, 5, 7

• Leukovorin, 0.1 mg/kg IM, days 2, 4, 6, 8

 Contraindications
–Intra-abdominal hemorrhage
–Breast feeding
–Immunodeficiency
–Alcoholism
–Liver or renal disease
–Blood dyscrasias
–Active pulmonary disease
–Peptic ulcer
 Surgical Management (conservative)
• Salpingostomy
– Gold standard surgical method used for
unruptured ectopic pregnancy
– Used to remove a small pregnancy usually <2 cm
in length and located in the distal third of the
fallopian tube
 Salpingostomy
– 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
• 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
 Anti-D Immunoglobulin
• D-negative women with an ectopic pregnancy
who are not sensitized to D-antigen should be
given anti-D immunoglobulin
ABDOMINAL PREGNANCY
• Almost always secondary
• The primary site being
-Tube
-ovary
-The uterus
• Incidence-1 in 3000
• with the use of ART incidence is found rising
 Symptoms
• Pain lower abd
• Vaginal bleeding
• Exaggerated minor ailments
• Nausea
• Vomiting
• Constipation
• Pain abdomen
• Increase fetal movement
 Signs
• Contour is not well defined
• Braxton-Hicks contraction is absent
• Fetal parts are felt easily
• Persistentabnormal attitude & position of the
fetus
• Abnormal high position in intra peritoneal
preg
• Fetus is lying low in intra-ligamentary preg
 Internal examination
• Ut is difficult to separate from the abdominal
mass
• Cx is not typically soft & usually displaced
depending upon the sac
 Imaging studies
• USG
• MRI
• CT
 Highly suggestive features
• Repeated failure of induction for IUD
• During induction by oxytocin uterine
contraction could not be excited

Surest evidence-Laparotomy
 Fetal Outcome
Fetal malformation and deformations –
• facial or cranial asymmetry, or both
• various joint abnormalities
• limb deficiency
• CNS anomalies

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

resorbed, it may undergo
– Suppuration
– Mummification/ Lithopedian formation
– Calcification
 Management
• Urgent laparotomy irrespective of period of
GA
• Ideal-is to remove the entire sac-fetus, the
placenta& the membranes(if the placenta is
attached to removable organ)
• Surgery may precipitate torrential hemorrhage
due to the lack of constriction of
hypertrophied blood vessels after placental
separation.
 Management
Leaving the placenta inside the abdominal
cavity may cause
infection, abscess, adhesion
intestinal obstruction, wound dehiscence

but it may be less grave than the

hemorrhage that sometimes result from
placental removal during surgery.
OVARIAN PREGNANCY
 Spiegelberg Criteria
1. The tube on the affected side must be intact
2. The fetal sac must occupy the position of the
ovary
3. The ovary must be connected to the uterus
by the ovarian 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

• TVS has resulted in the more frequent

diagnosis of unruptured ovarian pregnancies
 Management
• Classical management: Surgical
– Laparotomy with ovarian wedge resection or
cystectomy, ovariectomy

• Methotrexate, for unruptured ovarian

pregnancy

• Laparoscopic resection or laser ablation

CERVICAL PREGNANCY
 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
 Rubin’s Criteria
• Cervical glands 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 antero posterior uterine surfaces

• Fetal elements must not be present in the uterine

corpus
 Management
• 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