Ectopic Pregnancy

Dr .Urmila Karki
Department of Ob/Gyn
K M C Teaching Hospital
 Introduction
• Pregnancy that is implanted outside the uterine
cavity
• Site by nature is not designed anatomically or
physiologically to accept the concept or to permit
its growth and development
• Fallopian tube is the most common site of ectopic
pregnancy
• “The great masquerader”- presents with wide
spectrum of symptoms and signs
• Exclude ectopic pregnancy in all women of
reproductive age who presents with lower
abdominal pain
 Incidence
• Exact incidence remains largely unknown-
diagnosis is missed when ectopic pregnancy
resolves spontaneously at an early stage
• 0.25 to 1.5 % of all pregnancies including live
births, induced abortions and ectopic gestation
• Denominators to report the incidence- per 1000
live birth/ per 1000 reported pregnancies/per
10,000 women aged 15-44 years
• Declining trend as a consequence of a reduced
incidence of Pelvic inflammatory disease.
 Mortality and Morbidity
• Still causes significant mortality and morbidity
• USA (1988)- 44 Deaths- 15% of maternal
death
• UK – 9 deaths (1991-1993) to 12 (1994-1996)
• Over 100 years ago Tait in one of his classic
articles indicated how deaths from ectopic
pregnancy can be avoided
• “If an operation is to be done, it must be
done without delay” - Tait 1884
 Etiology and Risk factors
• Remains enigmatic
• Delay in Ovum transport – Ovum becomes too
large to pass through certain areas of fallopian
tube, particularly the isthmic segment and
uterotubal junction.
• Growth and proliferation of the trophoblast may be
advanced- implantation of the fertilized ovum
begins before reaching the uterine cavity
• Loss of myoelectrical activity of the wall of the
fallopian tube. Myoelctrical activity allows
approximation and fertilisation of gametes as well
as propulsion of zygote into uterine cavity.
 Etiology and Risk factors
• Loss of ciliated epithelium of fallopian tube due to
salpingitis –delayed propulsion of Zygote towards
the uterine cavity
• Steroid hormones influence cilia formation and
movements- Oestrogens stimulate epithelial cell
hyperplasia and ciliogenesis/ High level of
progesterone is associated with deciliation and
atrophy of the fallopian tube
• Theoretically all sexually active women are at risk
of experiencing ectopic pregnancy but definitely
there are some risk factors associated with
increased risk
 Risk factors
• Previous tubal pregnancy-
Chance of repeat ectopic
10-20%/ Intrauterine
pregnancy 60-80%
• Previous tubal surgery
• sterilization risk within 2
years
• Reversal of sterilization-
15%
• Tubal reconstruction and
repair – salpingostomy
• Previous laparoscopically
proven PID
• Current IUCD users- 7
times more likely to have
ectopic pregncany
• Abortion- induced
abortion are risk factors
• Salpingitis Isthmica
nodosa- diverticulum
• Assiated conception
• Smoking- risk increases
with number of
cigarettes smoked per
day
• Diethylstilboestrol (DES)
 Most common sites
• Fallopian tube
Ampullary Segment - 80%
Isthmic segment
- 12% Fimbrial end
- 2% Interstitial and
cornual - 2%
• Abdominal -1.4%
• Ovarian -0.2%
• Cervical -0.2%
 Mode of termination
Complete absorption
1. Tubal mole Complete
Abortion Pelvic haematocele
Incomplete

Complete Pelvic Haematocele

2. Tubal abortion
Incomplete Diffuse intraperitoneal haemorrhage

Roof Diffuse intraperitoneal haemorrhage

3. Tubal rupture
Floor Intraligamentary haemotoma

Roof Secondary abdominal pregnancy

4. Tubal perforation
Floor Secondary intraligamentary pregnancy

5. Continuation of pregnancy - rarest

Mode of termination of tubal abortion
 Natural progression
• Unruptured tubal pregnancy- may be
missed/local enlargement with discolored,
dark red or purple look
• Tubal rupture
• Spontaneous involution
• Complete tubal abortion
• Incomplete tubal abortion
• Tubal blood or carneous mole
 Time of rupture
• Isthmic implantation – narrow and
less distensible part/ ruptures at 6-8
weeks and is dramatic
• Ampullary implantation– wider
segment/ 80%/ ruptures at 8-12
weeks
• Interstitial implantation– surrounded
by myometrium/Ruptures at 12-14
weeks/ severe intra abdominal
hemorrhage
 Histological changes
• Early stage- Myometrium responds to hormones in
an usual way – uterus becomes soft and enlarged
• The endometrial glands demonstrate atypical
histological changes – Arias Stella phenomenon-
hyperplasia of glandular cells, closely packed
glands with evidence of hyper secretion, large
irregular hyper chromatic nuclei, cytoplasmic
vacuolation and loss of polarity
• Arias Stella phenomenon and absence of
chorionic villi from endometrial curetting – strong
suspicion for ectopic pregnancy
• Endometrial stroma – converted to decidual tissue
containing large polyhedral cells with
hyperchromatic nuclei.
 Diagnosis
• Diagnostic challenge
• ‘Think ectopic first’- women of reproductive age
presenting with triad of abdominal pain, irregular
vaginal bleeding and amenorrhoea.
• Abdominal pain –Generalised/Localised, Unilateral
or bilateral/ Radiating to the shoulder
• Amenorrhea and abnormal uterine bleeding-
occurs in 75% of the cases.
1/3rd does not remember the LMP.
Bleeding is light, recurrent
and results from detachment of uterine decidua
• If a patient who is few weeks pregnant and
complaints of much pain and little vaginal bleeding
has ectopic pregnancy
 Symptoms and Signs
• Abdominal pain 99% Generalised -44%
Unilateral - 33%
Radiating to the shoulder –
22%
• Abnormal uterine bleeding - 74%
• Amenorrhoea <2 weeks - 68%
• Syncope -37%
• Adnexal tenderness - 96%
• Unilateral adnexal mass -54%
• Uterine cast passed vaginally -7%
 Physical examination
• Assessment of vital signs
• Depending on the rate and amount of blood loss –
slight pallor to haemodynamic shock
• Examination of abdomen and pelvis
• Generalised and localised abdominal tenderness
• Occasionally guarding and rebound tenderness
• Cullen’s sign-Bluish discoloration of the skin
around umbilicus
• Pelvic examination- negative to the presence of a
large, fixed, soft and tender mass
 Clinical presentation
• Acute-
consequence of rupture of ectopic
gestation, intraperitoneal he and
haemodynamic shock.
Pale, hypotensive and tachycardic.
Shoulder pain and urge to defaecate.
Generalised, severe abdominal tenderness
• Subacute-
When the process of tubal rupture or
abortion is gradual
 Further investigations
• Serum βhcg- detected at the time of blastocyst
implantation i.e. 6-7 days after conception/ During
first six weeks it increases exponentially (>6000-
10,000iu/l)/ After this the rise is slower and not
constant
• Single βhcg measurement- if negative rules out
ectopic pregnancy
• Serial βhcg measurement- If βhcg level increases
by<66% over 48hours – ectopic pregnancy
• Urinary βhcg- detected 2 days after serum βhcg
• Schwangerschafts protein 1,HPL, Pregnancy
associated plasma protein A (PAPP-A)
 Ultrasonography
• Transvaginal better/Doppler USG/3D USG
• An empty uterus-28%
• An empty uterus and an adnexal mass -35%
• An intrauterine or psudogestational sac- 25%
• Pseudogestational sac-double ring or double
decidual sac sign (DDSS)/Appearance of the
yolk sac within the gestational sac
• An empty uterus and an ectopic gestational
sac-12%
• Free fluid in POD- 25%
 Further investigations
• Laparoscopy
• Culdocentesis
 Differential diagnosis

• Ruptured corpus luteal cyst

• Threatened or incomplete
abortion
• PID
• Degeneration of fibroid
 Treatment
• Surgical –
Laparotomy
Salpingotomy
Salpingectomy
Salpingooophrectomy
• Medical-
 Scheme of management of tubal ectopic pregnancy
• Detailed history, evaluation of high risk factors and examination
• Serum  hCG
• Ultrasound Scan (Transvaginal preferred)

BE ECTOPIC MINDED

• Some clinical features • Some clinical features • Strong clinical features

•  hCG – negative •  hCG - +ve •  hCG - +ve

Repeat  hCG in 1 week USS – empty uterine cavvity • Patient in shock

with adnexal mass

Patient is stable haemodynamically Resuscitation and laparotomy

- ve + ve
Conservative (some prefer to
Perform laparoscopy) Laparoscopy Ruptured tubal ectopic pregnancy

Unruptured tubal ectopic pregnancy Salpingectomy

(Laparoscopy or Laparotomy)
Contnu……
Contnu……

Eonservative Extirpative

Salpingectomy

Medical (Laparoscopy/USS guidance) Surgical

Direct Local Systemic Milking Salpingostomy Salpingotomy Segmental resection

of the tube
• MTX
• Pot. Chloride • MTX
• PGS
• Hyperosmolar • RU 486
Glucose

 hCG follow up
USS = Ultra Sound Scan MTX = Methotrexate PGS = Prostaglandins
 Reproductive outcome

• Salpingectomy-

I U Pregnancy rate -49.3%

Recurrent ectopic
pregnancy rate -10%
• Conservative surgery -
I U Pregnancy rate
-53%
Recurrent ectopic pregnancy rate -14%
 Non tubal ectopic pregnancy
• Cervical pregnancy
• Ovarian pregnancy- classic
criteria of spiegelberg (1878)-
gestational sac must occupy a
portion of the ovary
Gestational sac must be connected with the uterus by ovarian
ligament
Ovarian tissue must be identified in the wall of the sac

The fallopian tube on the side of ectopic must be intact

• Abdominal Pregnancy
• Interstitial pregnancy
• Interligamentous pregnancy
• Heterotopic pregnancy
• Cornual pregnancy