Ectopic

 Pregnancy  
§  Implanta2on  of  the  blastocyst  in  areas  other  than  
the  endometrial  lining  
§  Sites:  
§  Tubal  (fimbrial,  ampullary,  isthmic,  inters22al)  –  95%  
§  Abdominal  
§  Intraligamentous  
§  Ovarian  
§  Cervical  
§  Cesarean  Scar  
 Heterotropic  Pregnancy  
§  A  mul2fetal  pregnancy  composed  of  one  
conceptus  with  normal  uterine  implanta2on  
coexis2ng  with  one  implanted  ectopically  
Ectopic  Pregnancy  –  Risk  Factors  
§  Prior  tubal  surgery  
§  Tubal  infec2on  (PID/STD)  
§  Previous  tubal  pregnancy  
§  Peritubal  adhesions  (appendici2s,  endometriosis)  
§  Smoking  
§  Infer2lity  and  ART  (assisted  reproduc2ve  
technology)  use  
 Ectopic  Pregnancy  –  Outcomes  
§  Tubal  rupture  
§  Tubal  abor2on  –  common  in  fimbrial  and  ampullary  
tubal  pregnancies  
§  Pregnancy  failure  with  resolu2on  

Timing  of  rupture  and  loca2on  of  tubal  pregnancy:  

Early  rupture  -­‐-­‐-­‐-­‐-­‐  Isthmic  (narrowest  por6on)  
Late  rupture  -­‐-­‐-­‐-­‐-­‐-­‐  Inters66al      
 Chronic  Ectopic  Pregnancy  
§  Abnormal  trophoblasts  die  early  
§  ßHCG  levels  are  low,  even  nega2ve  
§  “Classic”  symptoms  of  ACUTE  ectopic  pregnancy  
aren’t  usually  seen  
§  Rupture  occurs  late,  if  at  all  
§  Usually  presents  as  a  complex  adnexal  mass  
Ectopic  Pregnancy  –  Clinical  Manifesta2ons  
§  Classic  triad:    missed  menses,  pain,  MINIMAL  
vaginal  bleeding  or  spoWng  
§  +  passage  of  decidual  cast  
§  If  UNRUPTURED:  
§  Uterus  slightly  enlarged  due  to  hormonal  s2mula2on  
§  Adnexal  mass  
§  Tenderness  on  palpa2on  of  the  lower  abdomen  and  
adnexa  
§  Cervical  mo2on  tenderness  
Ectopic  Pregnancy  –  Clinical  Manifesta2ons  
§  In  TUBAL  RUPTURE:  
§  Severe  lower  abdominal  pain  
§  On  PE:  
§  Generalized  tenderness  on  palpa2on  of  the  abdomen  
§  Cervical  mo2on  tenderness  (“wiggling  tenderness”)  
§  Bulging  culdesac  (because  of  hemoperitoneum)  
§  Pain  in  the  neck  or  shoulder,  especially  on  inspira2on  
(indicates  diaphragma2c  irrita2on  secondary  to  sizable  
hemoperitoneum)  
§  Hypotension,  tachycardia  and  pallor  may  present  only  when  
hypovolemia  becomes  significant  
 Differen2al  Diagnosis    
for  Abdominal  Pain  in  Pregnancy  
§  Abor2on  
§  Infec2on   uterine  
§  Enlarging  or  degenera2ng  myoma  
§  Molar  pregnancy  
§  Ectopic  pregnancy  
§  Complicated  ovarian  mass  (ruptured,  torsed,   adnexal  
hemorrhagic)  
§  Appendici2s  
§  Cys22s  
non-­‐gynecologic  
§  Gastroenteri2s  
§  Urolithiasis  
 Diagnosis  
§  Clinical  findings  
§  CBC    
§ For  ruptured  ectopic  pregnancy,  Hgb  and  Hct  
levels  do  not  usually  reflect  the  hemodynamic  
status  of  the  pa2ent  un2l  a^er  several  hours  
later  
§  TVS  
§  ßHCG  
§ If  TVS  results  are  non-­‐conclusive  
§  Laparoscopy  
 ßHCG  levels  –  How  to  interpret  
•  Discriminatory  zone  –  1500  mIU/mL  
§  ABOVE  the  discriminatory  zone  
§  plus  failure  to  visualize  an  intrauterine  pregnancy  on  
ultrasound  =  ECTOPIC  pregnancy  (or  a  non-­‐viable  
pregnancy)  
§  BELOW  the  discriminatory  zone  
§  Do  serial  ßHCG  determina2ons  (every  2  days)  
§  If  values  double  every  2  days  =  live  intrauterine  pregnancy  
§  If  values  decrease  according  to  an2cipated  paBerns  =  failing  
intrauterine  pregnancy  
§  Otherwise,  it  is  ectopic  pregnancy  
Expected  rate  of  decline  in  ßHCG  levels  for  
failing  pregnancies  
Threatened  Abor2on  vs  Ectopic  Pregnancy  

•  Both  may  present  with  missed  menses,  pain  and  

vaginal  bleeding  
•  PROMPT  diagnosis  of  ectopic  pregnancy  is  of  utmost  
importance  
•  Means  of  ascertaining  an  INTRAUTERINE  pregnancy:  
–  Serial  ßHCG:  doubling  2me  every  48  hours  
–  Serum  progesterone  level  
•  <5  ng/mL:  dying  pregnancy/ectopic  pregnancy  
•  >20  ng/mL:  healthy  pregnancy  
–  TVS  
•  Gesta2onal  sac  4.5  weeks  ßHCG  1500-­‐2000  mIU/mL  
•  Yolk  sac      5.5  weeks  10mm  GS  diameter  
•  Embryo      5-­‐6  weeks  embryonic  length  1-­‐2mm  
•  Fetal  cardiac  ac2vity  6-­‐6.5  weeks  embryonic  length  1-­‐5mm  
           MSD  13-­‐18mm  

Dead  Fetus  
•  No  embryo  within  a  sac  with  a  mean  sac  diameter  
(MSD)  of  16-­‐20mm  (>20mm)  
•  No  cardiac  ac2vity  in  a  5-­‐mm  embryo  (>10mm)  

Be  wary  of  a  pseudogesta*onal  sac  which  may  be  seen  in  ectopic  pregnancies  
 TVS  
•  Endometrial  findings  
§  Thickened  endometrium,  usually  trilaminar  
§  Decidual  cyst  
§  Pseudogesta2onal  sac  
§  Adnexal  findings  
§  Visualiza2on  of  an  in  homogenous  complex  adnexal  mass  
separate  from  the  ovary;  or  an  extrauterine  gesta2onal  sac/yolk  
sac  with  or  without  an  embryo  
§  With  Doppler  imaging,  “ring  of  fire”  is  demonstrated  
(represen2ng  placental  blood  flow  at  the  periphery  of  the  mass)  
§  Culdesac    
§  Anechoic  or  hypoechoic  fluid  in  the  culdesac  may  signify  
hemoperitoneum  (as  liple  as  50ml  can  be  detected  by  TVS)  
“ring  of  fire”  
Culdocentesis  

•  Has  been  largely  

replaced  by  TVS  
•  Used  to  diagnose  
presence  of  
hemoperitoneum  
§  Non-­‐cloWng  blood  =  
hemoperitoneum  
 Medical  Management  

§ Use  Methorexate  
§ Pa2ent  should  be  asymptoma2c,  
compliant,  mo2vated  
§ For  UNRUPTURED  ectopic  pregnancy  
§ Criteria  for  px  selec2on:  
§ Ini2al  B-­‐HCG  level  <1000  mIU/mL  
§ Size  <3.5cm  
§ Absent  fetal  cardiac  ac2vity  
 Surgical  Management  
§  Either  via  Laparoscopy  or  Laparotomy  
§  Salpingostomy  
§  Size  <2cm  
§  Loca2on:  distal  third  of  the  fallopian  tube  
§  Linear  incision  made  over  the  pregnancy,  on  the  
an2mesenteric  border  -­‐-­‐-­‐  contents  evacuated  -­‐-­‐-­‐  incision  le^  
unsutured  to  heal  by  secondary  inten2on  
§  Salpingotomy  
§  Same  as  Salpingostomy  except  that  the  incision  is  closed  by  
suturing  
§  Salpingectomy  
§  En2re  length  of  the  affected  tube  is  removed  

LAPAROSCOPY  should  not  be  done  in  hemodynamically  unstable  pa2ents.