ECTOPIC PREGNANCY

• Dr. Arvindh Santhosh

• 2nd year Junior Resident - OG
• Madras Medical College
 ECTOPIC PREGNANCY

• Pregnancy implanted outside uterine cavity

• 96% of ectopic occur in fallopian tubes
• Other sites- cervical, cornual/insterstitial,
ovarian, abdominal, caesarean/ hysterotomy
scar
In the fallopian tubes sites :
Ampulla – 70%
Fimbrial - 12%
Isthmus - 11%
Interstitial / cornual - 3%

Hysterotomy / LSCS scar-1 / 2000

ABDOMINAL-1/5000
OVARIAN-1/7000
CERVICAL-LESS THAN 1%
• Incidence – 2% of all pregnancies

• Increasing in incidence

• Continues to be the leading cause of

pregnancy related maternal deaths
• About 4% of all deaths
 RISK FACTORS
• PID AND OTHER GENITAL INFECTIONS

• INFERTILITY AND RELATED FACTORS

• PREVIOUS ECTOPIC

• TUBAL SURGERIES

• ART

• CONTRACEPTIVES / IUDS

• PROGESTRONE IMPLANTS

• SMOKING, INCREASING AGE , VAGINAL DOUCHING

 DIAGNOSIS

• Symptoms and clinical features

• Typically manifests around 6 to 8 weeks from

LMP
• May lack symptoms when ectopic site other
than tubes
 Symptoms
• Amenorrhea
• Abdominal Pain
• Vaginal Bleeding
• Fainting Attack
• Shoulder Tip Pain

THINK ECTOPIC
8
FEATURES OF RUPTURED ECTOPIC

• Severe or persistent abdominal pain

• Fainting episodes / loss of consciousness

• Abdominal distension

• Vaginal bleeding –no pathognomonic pattern

• Scanty brown discharge to bleeding

• Usually follows amenorrhea

 DIAGNOSTIC EVALUATION

• Confirm pregnancy with UPT and serum hCG

• Once confirmed serial measurement of hCG to

assess doubling
 HETROTROPIC PREGNANCY
• Now commonly seen
• Spontaneous incidence – 1/30000
• Intra uterine pregnancy with extra uterine, usually
follows ART.
• ART incidence – 0.9%
• NO ROLE FOR MEDICAL MANAGEMENT.
• TREATMENT IS BY SURGICAL MEASURES
 • Heterotopic pregnancy. A 30-year-
old woman presented at 6 weeks
with pelvic pain and a positive
pregnancy test.
IU • A, Sagittal scan shows a retroverted
uterus with a normally positioned
6-week gestational sac with yolk
sac.
• B, In the left adnexa, adjacent to

ectopic the left ovary (LO), there is a tubal

ring (arrow) that proved to be an
ectopic sac at laparoscopy
 TVS
• TO LOCATE PREGNANCY TVS IS GOLD STANDARD

• IF hCG is above discriminatory zone and no evidence of

intra uterine pregnancy and symptom suggestive of
pregnancy then Ectopic is suggested.

• hCG can be detected in serum and urine as early as 8 days

after the LH surge - 21-22 Days after LMP.
 TVS in Ectopic

• Diagnose

• Triage patient for management

• Follow up in those with conservative

management
• Evaluate haemodynamic stability and if

haemodynamically unstable, may be

transferred to acute care facility and may need

surgical intervention
• Physical examination

• look for pallor, abdominal tenderness - diffuse or

localized , abdominal distension
• Vaginal examination to confirm presence of vaginal
bleed
• P/V examination for cervical motion tenderness and
extra ovarian adnexal mass.
 FAST ULTRASOUND
• Focused assesment with sonography for trauma
• IF HAEMODYNAMICALLY UNSTABLE FAST done
FOR INTRA PERITONEAL BLEEDING
• Diagnosed as ruptured ectopic in a lady in reproductive
age group unless proved otherwise.
• Complete haemogram /HCT blood grouping and Rh to
be done.
 TVS FINDINGS
• EMPTY UTERINE WINDOW WITH AN ADNEXAL RING SIGN IS THE TYPICAL ULTRA
SOUND FEATURE IN 89% OF CASES
• GESTATIONAL SAC WITH YOLK SAC IS MORE SPECIFIC FOR DIAGNOSIS.
• LIVE EXTRAUTERINE EMBRYO – 100% SPECIFIC
• COMPLEX ADNEXAL MASS – ROUND ECHOGENIC TUBAL RING SEPARATE FROM OVARY
WITH GOOD PERIPHERAL COLOR FLOW.
• RING OF FIRE APPEARANCE
• IN ECTOPIC GESTATION PSEUDO SAC IS FORMED THAT IS MERELY FLUID / BLOOD IN
ENDOETRIAL CAVITY LIKE GESTATIONAL SAC.
• FREE ECHOGENIC FLUID IN PELVIS AND UPPER ABDOMEN.
Empty uterine window with adnexal ring

Empty uterus

Adnexal ring with YS

Ring of fire
• B, Sagittal transvaginal scan
• shows a large pseudogestational sac with echogenic
debris. Note the acute angle at the lower end,
uncommon in a gestational sac.
• Pseudogestational sac. A, Coronal transvaginal scan of a 33-year-old
woman (G2P1) at 8 weeks with pelvic pain. There is a rounded intrauterine
sac filled with low-level echoes. No yolk sac or embryo is seen. There is a
single echogenic ring around the fluid (arrow). This is a fluid-filled
endometrial canal, a decidual cast, or pseudogestational sac.
 HCG DISCRIMINATORY ZONE
• SERUM HCG ABOVE WHICH GESTATIONAL
SAC SHOULD BE VISUALISED BY TVS IF
INTRAUTERINE PREGNANCY is PRESENT

• D zone 2000 IU/litre - in most institutions.

Setting D zone at 3100 IU/L minimizes the risk of
interfering with a viable IUP with a relative risk of
delaying diagnosis.
• If HCG is between 2000 – 3510, patient stable
follow up with a close surveillance and repeat tvs.
• HCG concentration increases atleast 66% every
48 hrs in 85% viable iup
• Only 15% viable iup had a rate of rise less than
this level.
• Slowest rise is more than 35 % only.
• Current protocol is to measure HCG every 48 hrs.

• But more practical approach is to measure every

72 hrs.
• In this HCG rise more than 35% in 48 hrs and
doubles in 72 hrs then do a tvs when hcg reaches
3500 when intra uterine or ectopic can be
diagnosed.
• LACK OF NORMAL RISE OF HCG ACROSS 3
MEASUREMENTS is CONSISTENT WITH
ABNORMAL PREGNANCY EITHER ECTOPIC /
IUP THAT WILL ULTIMATELY ABORT
• HCG above 2000 wihtout visualisation of iup / extra
uterine pathology may represent multiple gestation
since there is no proven discriminatory level for
multiple pregnancy.
 PREGNANCY OF UNKNOWN LOCATION

• In absence of definite usg finding of IUP or

histopathology findings impossible to
differentiate ectopic and an early failed Iu
pregnancy.
INTERSTITIAL ECTOPIC
• Color flow Doppler ultrasound
• shows increased vascularity around the sac with
high-velocity flow.
• At laparoscopy, ectopic site can be seen bulging the isthmic portion
• of the tube (arrow). It was successfully removed by salpingostomy.
• Postoperative specimen of the wedge resection
• and removal of the left cornua.
 Cornual pregnancy
• Pregnancy located in the rudimentary horn of a bicornuate uterus.

• Usg criteria:

• Visualisation of single interestitial portion of fallopian tube in the main

uterine body.

• Gestational sac completely surrounded by myometrial mantle.

• GS mobile and separate from uterus.

• A vascular pedicle adjoining the GS to the unicornuate uterus.

 Management of Cervical Pregnancy

• Methotrexate

• Ligation of descending branch of uterine artery.

• Uterine artery embolisation

• Cervical cerclage

• If Bleeding Persist
Foley’s bulb Tamponade or Cervical Packing
• Hysterectomy Last Resort

39
CAESEREAN SCAR PREGNANCY
• Empty uterine cavity and cervix
• Implantation into deficient scar with a
gestational sac partially or completely located
within the myometrial mantle.
• Thin or absent myometrial layer between GS
and Bladder
• Sustained peri-trophoblastic flow on color
doppler.
CAESEREAN SCAR PREGNANCY
CAESEREAN SCAR PREGNANCY
ABDOMINAL pregnancy
○ Potential sites for Abdominal
pregnancy
○ the omentum
○ pelvic sidewall
○ broad ligament
○ posterior cul-de-sac
○ abdominal organs (eg, spleen, bowel,
liver) large pelvic vessels
○ diaphragm
○ uterine serosa .
CHRONIC ECTOPIC PREGNANCY
• PREGNANCY DOES NOT COMPLETELY RESORB DURING EXPECTANT
MANAGEMENT.
• PERSISTENCE OF CHORIONIC VILLI WITH BLEEDING INTO TUBAL
WALL AND DISTORTS IT BUT DOESN’T RUPTURE.
• SYMPTOMS: LOWER ABDOMINAL PAIN , VAGINAL BLEEDING,
AMENORRHEA.
• MAY FORM PELVIC MASS.
• BETA hCG LEVEL MAYBE LOW OR ABSENT.
• DIAGNOSIS BY USG.
• TREATMENT-SURGICAL REMOVAL.
 MANAGEMENT OF ECTOPIC PREGNANCY

• MEDICAL

• SURGICAL

• EXPECTANT

• Anti D Prophylaxis to Rh D -ve women.

 INDICATION FOR EXPECTANT
MANAGEMENT
• Asymptomatic patient

• Should be informed about the clinical implication like risk

of rupture
• Ready access to medical facility and follow up

• Transvaginal scan should not show an extra uterine gs or

demonstrable mass suspicious of ectopic.
• Serum hcg below 200 miu/l and decreasing across 2
consecutive measurement by more than 10%.
• IF HCG NOT REACHING UNDECTABLE

LEVEL WITHIN 10 WEEKS OFFER

METHOTREXATE.
 PHARMACOLOGICAL THERAPY
WITH MTX – MOST PREFERRED
SELECTION CRITERIA

Haemodynamically stable

NO CI FOR MTX

SERUM BETA HCG < 5000 MIU/L

No fetal cardiac activity on TVS

Willing and able to comply with post treatment follow up with

access to emergency medical service.

ECTOPIC MASS < 3- 4 CM

Comply with post treatment and follow up.

 CONTRA INDICATION
• Intra uterine pregnancy

• Ruptured ectopic

• Abnormalities in haemotological / renal parameters

• Immune deficient.

• Fetal cardiac activity

• Active pulmonary disease.

• Hyper sensitivity

• Breast feeding
• Single dose administration of MTX 1MG/KG IM
Approxi.15-20% women will require a second dose
• HCG Estimation done on 4 and 7th day should show
a decrease of 15%.
• If not observed second dose is given.

Increase in HCG from day 1 to day4 seen due to

continued production HCG by syncytiotrophoblast
despite cessation of production by cyto trophoblast.
• After 7th day then weekly HCG is checked

• If there is <15% reduction then a third dose is

given.
• Still not reducing adequately laparoscopic
salpingostomy / salpingectomy .
• Use of 2 dose MTX regimen on day 0 and day
4 has been proposed with 89 % success.
• Multiple dose MTX therapy for interstitial /
cervical pregnancy.
• Serum hCG checked on day 4 and 7 and
followed up.
• Multiple dose regimen on day 1 , 3, 5 and 7
and folinic acid on 2, 4, 6 and 8 days .
• Reassure patients that there is no effect on
ovarian reserve after treatment with
methotrexate.
• Can try pregnancy 3 months after treatment.
 SURGICAL TREATMENT
• 2 choices of surgical approach

• salpingectomy and salpingostomy

• Emergency surgery indications

– 1. Haemodynamically unstable

– 2. Signs and symptoms of impending or ongoing rupture.

– 3. Concurrent surgical procedures needed like desire for

sterilisation , removel hydrosalpinx or with hetrotropic
pregancy
 PERSISTENT ECTOPIC
• After salpingostomy for 4- 15 % cases persistent ectopic
occur.
• Usually 50% reduction of beta hcg occurs by day 1 after
surgery. THEN DAY 4th.
• No cases of persistent ectopic seen when post op HCG on
day1 fell >76%
• If not certain about the completeness of removal of products
a single dose of mtx given prophylactically post op.
 Fertility after tubal ectopic
• Prior fertility most important factor

• PRIOR TUBAL DAMAGE DECREASE RATE OF future PREGNANCY

• Women who had an IUD at the time of ectopic appear to have better
fertility
• 93% of spontaneous pregnancy after surgical treatment occur in the first 18
months following the procedure.
• If not conceiving after 12 -18 months other tube may be damaged should
be referred for IVF.
• Recurrent ectopic occurs in 50 %

• Recurrence rate increases to 30 % following 2 ectopics.