ECTOPIC PREGNANCY

Case 1
• 32 years old mother of two with past two LSCS
• P/C- prolonged bleeding PV with clots for 8
days.
• No hx of POA.
• On and off mild abdominal pain and nausea.
• Urine HCG positive.
• On examination • TVS –
• Heamodynamically • No IUP, Thick endomatrium,
stable. ET- 12.1mm.
• Abdomen – soft to • Right sided ovarian cyst
touch. (could be follicular cyst),
size- 22.1mm.
• No FF, No adenexeal masses
Planned to monitor with S. β hcg.

• First day -763 IU/l • TVS- no IUP, No FF.

• After 48 hrs – 559 IU/l • TVS- no IUP, No FF, Thick

(26%) endomatrium, ET- 18.9
mm
• ? RPOC
Planned for ERPC

• ERPC done.
• Uterine curetting – scanty, does not look like
retained products and it looked like
endomatrial tissue,
• Patient was asymptomatic and discharged.
• Discharge plan-
– Review with histology report.
– Repeat urine hcg in two weeks.
After two weeks

• U. hcg –still positive. Complaining of spotting type

bleeding PV since ERPC.
• No abdominal pain.
• Heamodynamically stable.
• TVS- No IUP seen. Thick endomatrium. B/L ovaries
looks normal. Left sided adenexeal irregular
mass. Size – 3.32cm× 3.42cm. Very small amount
of free fluid.
• S.β hcg- 148.7IU/l
Management Medical management
options
• I.M. Methotrexate 50mg/m².
Laparotomy /Laparoscopy
• Repeat s.β hcg on
and proceed with
– DAY 4 - 83 IU/L. (45%)
salphyngectomy – DAY 7 – 45.2 IU/L.(45%)
OR – After one week – 11.9 IU/L

Expectant management
OR
Medical management
Discharge plan

• Urine hcg in two weeks.

• Barrier contraception for three months.
ECTOPIC PREGNANCY

“Pregnancy in the fallopian tube is a black cat on a dark night. It may

make its presence felt in subtle ways and leap at you or it may slip past
unobserved. Although it is difficult to distinguish from cats of other colors
in darkness, illumination clearly identifies it” – MC. Fadyen - 1981
Introduction and Background Epidemiology

• Any pregnancy implanted out side the endometrial

cavity due to obstruction or delay of passage of fertilized
ovum.
• Incidence in UK - 11/ 1000 pregnancies and prevalence
in Sri Lanka is around 1%-2%.
• Recurrence rate – 15% after 1st and 25% after 2 ectopics.
• Maternal mortality with ectopic pregnancy is 0.2 per
1000 estimated ectopic pregnancy and among this two
third of these deaths are associated with substandard
care.
 Risk Factor Risk %
High risk
Risk Factors PID *
Tubal corrective surgery
25
21
Majority of the women with
ectopic pregnancy will have Tubal sterilization 9-3
no identifiable risk factors. Previous ectopic pregnancy 8-5
Intra Uterine device ** 4.2-45
Use of assisted reproductive Documented tubal pathology 3.8-21
technology like IVF..
Moderate risk
Infertility 2.5-21
Previous genital infection 2.5-3.7
Multiple patners 2.1
Slight risk
Previous abdominal or pelvic surgery 0.93-3.8
Smoking 2.3-2.5
Douching 1.1- 3.1
Intercourse before 18 years 1.6
Implantation
Extra Uterine
Sites
 Evaluation & Diagnosis
• Multimodality approach.
• It includes
– Proper history (cycle, pregnancy, PID, infertility, gynecological
surgery, contraception)
– Clinical examination (general, abdominal, vaginal and vital signs)
– Judicious use of investigations
• TVS
• S. b-hcg
• Diagnostic surgery – uterine curettage, laparoscopy, laparotomy.

• Wide spectrum of presentation with asymptomatic pt to

others with acute abdomen and in shock.
 Classic Symptoms Triad (3AS)
Abdominal pain
 Signs
• Abdominal/ Adnexal /Pelvic Tenderness.
• Cervical motion tenderness
• Rebound tenderness /peritoneal signs
• Pallor
• Abdominal distention
• Enlarged uterus
• Tachycardia (>100bpm) or Hypotension(<100/60mmHg)
• Orthostatic hypotension
• Shock / collapse
• Bradycardia and hypotension (vasovagal response)

**Offer urine hcg.

 Transvaginal USS (TVS)
Sensitivity- 87%-99%, specificity-94%-99.9%
Discriminatory zone- absent IUP in 4-5 wks and beta hcg 1500 IU/L
– Findings
• Inhomogeneous or noncystic adnexal mass(50–60%)
• An empty extrauterine gestational sac (20–40%) .
• An extrauterine gestational sac containing a yolk sac and/or
embryonic pole that may or may not have cardiac activity (15–20%).
• A collection of fluid may be seen within the uterine cavity, referred
to as a ‘pseudosac’. (in 20%)
• Echogenic fluid has been reported in 28–56% of ectopic pregnancies.
• Free fluid is often seen on ultrasound, but is not diagnostic of
ectopic pregnancy. A small amount of anechoic fluid in the pouch of
Douglas may be found in both intrauterine and ectopic pregnancies.
• Presence of moderate to large amount of free fluid may represent
hemorrhage into peritoneum
Implantation sites
Serum βhcg.
 A single b-hCG level cannot be used in isolation to predict an ectopic pregnancy.
 Does not predict the implantation site.
 The initial values are helpful in predicting the outcome of the preferred
management option.
 Two serum hcg measurements as near as possible to 48 hours apart (but no
earlier).

 If serum hCG levels greater than 63% after 48 hours:

 Likely to have a intrauterine pregnancy (although the possibility of an ectopic
pregnancy cannot be excluded). “Doubling sign”

 For a woman with a decrease in serum hCG levels less than 50%, or an increase less
than 63%,
 Could be ectopic or complete miscarriage and needs further evaluation

s.beta hcg <1000IU/L excludes ectopic is a misconception

Management options
Surgical Management
 Indication for Surgical Treatment

• Hemodynamically unstable & needs immediate

treatment.
• Not a stable candidate for medical therapy
• Failed medical therapy
• Heterotrophic pregnancy with viable intrauterine
pregnancy.
Surgical approach-
Laparoscopy or Laparotomy

– Hemodynamic stability
– Size and location of ectopic mass
– Surgeons expertise
Laparoscopy Laparotomy

• Less intra operative blood loss

• Shorter operation time.
• Shorter hospital stay.
• Lower analgesic requirement.
• Future intrauterine pregnancy • Future intrauterine pregnancy
rate, health benefits same rate, health benefits same.
• Lower repeat ectopic
pregnancy rate
• Lower adhesion rate

• Preferable in
hemodynamically unstable pt.
• Surgical methods
Salpingotomy or Salpingectomy

• For women with risk factors for infertility

• Women with cotralataral tube damage
Salpingectomy Salpingotomy
• Women with healthy
cotralataral tube no
significant fertility
improvements.
• In women with fertility
reducing factors higher rate of
IUP in future pregnancy
• If no fertility reducing
factors, rate of IUP in future
pregnancy is same.
• Persistent trophoblastic
diseases. 1 in 5 need
methotrexate/sulphingectomy
• Lower rate of subsequent
ectopic pregnancy • Bleeding into prtoneal cavity
after surgery
Pharmacological Management
 Systemic Methotrexate
• Folic acid antagonist and inhibits DHFR enzyme, thus deplete stores needed for DNA/RNA
synthesis during trophoblast proliferation.
• Dose – 50 mg/m², given I.M. mostly single and can be multiple dose.

• Candidate for medical management

– Hemodynamically stable patient
– Low s.b-hcg,
• Ideally < 1500 IU/L, but can be up to 5000 IU/L.
– No fetal cardiac activity in USS
– Certainty that there is no IUP
– Willingness to attend to follow up
– No known sensitivity to methotrexate.
– Unruptured ectopic pregnancy with a mass smaller than 35 mm with
no visible heartbeat.
Follow up and later management
Serum b-hCG levels on days 4 and 7 post methotrexate.
– If the b-hCG level decrease > 15% between days 4
and 7,
• measured weekly until less than 15 iu/l.
– If the level does not decrease by 15%,
• A repeat transvaginal ultrasound should be considered to
exclude ectopic fetal cardiac activity and significant
haemoperitoneum
• Consideration may then be given to administration of a
second dose of methotrexate.
Advice on
– Should avoid alcohol and folate containing vitamins.
– Avoid pregnancy for 3 moths after treatment. (barrier method)
 Predictors of Success of Methotrexate
• Initial serum b-hcg level
– Success rates are higher with lower b-hCG levels.
• If b-hcg < 1000 IU/L – success rate - 81–98%
• If b-hcg > 5000 IU/L – success rate – 38 %
• Ultrasound appearance of the ectopic pregnancy
– predictors of failure
• Yolk sac
• Fetal pole
• Fetal cardiac activity are significant .
– Success rates are higher when no gestational sac is visualised.
• Pre-treatment changes in serum b-hcg levels
– A pre treatment b-hcg increase of up to 11–20% over 48 hours higher
rates of success.
• Decrease in b-hcg levels from day 1 to day 4 after methotrexate
– if the serum b-hCG level decreases -Success rates 88–100%
– if the serum b-hCG level increases - success rate 42–62%
Adverse effects Contraindications for Methotrexate
Marrow suppression • Hemodynamic instability
Pulmonary fibrosis • Presence of IUP
Nonspecific pneumonitis.
Liver cirrhosis • Breastfeeding
Renal failure • Unable to comply with follow up
Gastric ulceration • Known sensitivity to methotrexate
Intestinal gas formation • Chronic liver disease
flatulence • Pre existing blood dyscrasia
bloating • Active pulmonary disease
Transient elevation in liver
enzymes • Immunodeficiency
Stomatitis • Peptic ulcer disease

Should monitor LFT, U&E, FBC on Day 1,4,7 of therapy

 Outcome
• 65-95% - successful treatment with single
dose regime
• 3-27% - require second dose of methotrexate.
• 10% - require final surgical management.
• Similar reproductive outcome in previously
healthy woman as expectant and surgical
management.
Expectant Management
Selection criteria for expectant management:
– clinical stability with no abdominal pain
– no evidence of significant haemoperitoneum on
ultrasound scan
– an ectopic pregnancy measuring less than 30 mm in mean
diameter with no evidence of embryonic cardiac activity
– a serum b-hCG level of less than 1500 IU/L.
– the woman’s consent.
Follow up
– With s. b- hcg on day 2, 4, 7 and weekly (can varied)
• level should drop by 15% from initial day
– Follow up until the serum b-hCG level was less than 20
IU/L
Management discontinued when
– Women opted out
– Significant pain
– S.beta hcg-sustained increase or increased to > 2000
IU/L.
Predictors of success
– Success inversely proportional to initial s.b-hcg levels.
– Decreasing s.b-hcg level in follow up.
– Pre treatment b-hcg ratio (s.b-hcg at 48hrs/s.b-hcg at 0 hrs)
• Good predictor of likely success of expectant and medical management.
• If ratio id < 0.8 – expectant management is likely to succeed

There is no difference in the primary treatment success rate of single-

dose Methotrexate versus expectant management
Case 2
• 34 years old female, subfertile for 4 yrs.
• Past two miscarriages and one ectopic
pregnancy.
• Right sided salphyngectomy done.
• Presented at POA of 5weeks with left
abdominal pain and bleeding PV.
• P/M/H- type 2 DM
• On examination
• Heamodynamically
stable
• TVS
• Tenderness over left
lower abdomen • No IUP seen. ET- 2 cm.
• Mild bleeding PV. No • Left sided adenexeal mass
products at os. separate from ovary, size
– 3.76cm× 1.5cm.
• Mild FF in POD.

• S.β hcg – 644.9 IU/L.

Management options
Laparotomy /laparoscopy- sulphyngotomy/
sulphyngectomy.

OR

Manage medically
Medical management

• Patient was heamodynamically stable

• I.M. methotrexate 50 mg/m².
• Monitored the response with S.β hcg.

• BUT

• On day 4 s.β hcg – 1372.4 IU/L (113%)

• TVS- no IUP seen, organized mass in the left adenexea.
No FF
On following days

• S. β hcg
– On day 7 – 844 IU/L. (38%)
– On day 11 – 58.7 IU/L. (93%)
• Discharge plan:
– Review with s.β hcg in one week.
– Barrier contraceptive method for three months.
– Hydrotubation to check the tubal patency of the
remaining tube with gentamycine cover in 3
months.
 Long term Fertility Prospects
with surgical, medical, expectant management

In the absence of a history of subfertility or tubal pathology, there is

no difference in
• the rate of fertility,
• the risk of future tubal ectopic pregnancy or
• tubal patency rates
Women with a previous history of subfertility and age over 35 yrs
–with expectant or medical management
•improved reproductive outcomes than radical surgery
Fertility outcome
–No difference in medical, surgical or expectant management.
Ovarian reserve after medical management
–No effect in antimullarian hormone, antral follicle counts or ovarian
responsiveness