Ectopic Pregnancy

Zakaria Sanad , MD
Professor,Obstetrics and Gynecology
Department
Faculty of Medicine , Menoufiya University , Egypt
 Ectopic Pregnancy ( Eccyesis )

 Pregnancy implanted outside the endometrial lining

of the normal uterine cavity
 Incidence : 1.5 – 2 % of all pregnancies
 Incidence increased from 0.5 % ( 1970 ) to 2 %
( 2000 ) due to increased PID,ART, and tubal surgery
 Morbidity and mortality decreased dramatically due
to earlier diagnosis ( U/S and hCG )
 Still the leading cause of death in 1st trimester
( 5 – 10 % of pregnancy deaths )
 Classification ( Location )

 Tubal : > 95 %
 Other : < 5 % ( cervical, ovarian,
cesarean scar, rudimentary horn,
abdominal )
 Heterotopic ( combined IU and
ectopic ) : Spontaneous 1/30,000
ART 1/100 – 1/500
Risk factors
 Tubal ( PID,tubal surgery, endometriosis,
leiomyoma,anomalies )
 Assisted Reproductive Technology
(ART) : 2 – 8 % due to medications, high
E/P levels, damaged tubes, number of
embryos, placement )
 Others ( smoking, douching, recurrence )
 Contraceptive failure : IUD ( 5-10% )
Pathology and Fate
 Tubal implantation is abnormal :
+The tube is less distensible
+ The intra-arterial pressure is high
+ Decidual reaction is minimal
+ Trophoblast is more invasive
 Timing of rupture :
= Isthmic ( 6-8 weeks )
= Ampullary ( 8-12 weeks )
= Interstitial / Cornual ( 12-16 weeks )
 Rupture may lead to severe IP hge ….
shock …. Death
 Rupture into tubal lumen .. tubal abortion
 Re-implantation on omentum, intestine or
mesentery …. 2ry abdominal pregnancy
 Sometimes, the dead embryo may be
mummified or calcified
 Blood collects in the Douglas pouch, broad
ligament, around fimbria , even under the
diaphragm
 Spontaneous resolution may occur in 30%
due to early embryonic death and
resorption
Clinical Findings
 No specific symptoms or signs are
pathognomonic – many disorders can
present similarly
 Normal preg, threatened,or incomplete
abortion, ovarian cyst rupture, ovarian
torsion, gastroenteritis or appendicitis
can all be confused with EP
 Early diagnosis is crucial, high index of
suspicion should be maintained ( early
pregnancy with bleeding and/or pain )
Symptoms
 Pelvic or abdominal pain :
+ almost 100 % of cases
+unilateral or bilateral
+ localized or generalized
+ sub-diaphragmatic or shoulder pain is
suggestive of intra-abdominal bleeding
+ caused by tubal distension, contraction,
abortion or rupture / phrenic nerve ++
 Abnormal uterine bleeding :
+ in 75 % of cases
+ due to decidual sloughing of the endom
( lack of progesterone )
+ usually intermittent light spotting
+ however may be heavier
+ a decidual cast may be passed in 5-10%
+ pathologic ex : decidua without ch villi
 2ry amenorrhea is variable :
+ about half of women with EP have some
bleeding at the time of expected menses
and may not realize they are pregnant
 Syncope, dizziness, lightheadedness
may occur initially and should raise
suspicion of intra-abdominal bleeding
( rupture or abortion )
 Signs
 Pelvic/abdominal tenderness :
+ diffuse or localized
+ in the majority of cases
 Adnexal and/or cervical motion tenderness
is also a common finding
 Adnexal mass :

+ A unilateral adnexal mass in 1/3 – ½

+ more often unilateral adnexal fullness
+ Occasionally, a cul-de-sac mass is noted
 Uterine changes of pregnancy :
+ Softening and a slight increase in size
( effect of E and P )
 Hemodynamic instability :

+ Vital signs reflect hemodynamic

status of patients with tubal rupture
and intra-abdominal bleeding
Laboratory Findings
 Hematocrit :
+ is important initial test to assess the
hemodynamic status and reflect the amount
of intra-abdominal bleeding
 B-hCG :

+ a qualitative urine or serum h-CG test is

+ve in virtually 100 % of EPs
+ however, does not differentiate IU from
EP
+ more helpful is quantitative hCG with
TV ultrasound
+ if ultrasound is nondiagnostic ( early
EP, early normal pregnancy, or early
failed pregnancy ), serial hCG values can
be followed
+ B-hCG level should rise at least 53 %
over 48 h in normal pregnancy
+ inappropriate rise, plateau, or decline of
hCG indicate abnormal pregnancy with a
sensitivity of 99 % ( abortion or ectopic )
+ Of note, 1/3 of EP show a normal rise
 Serum progesterone : may help
+ independent of hCG levels
+ < 5 ng/ml in 100% of abnormal pregnancy
( abortion or EP )
+ > 20 ng/ml indicate normal IU pregnancy
+ 5 – 20 ng/ml values are equivocal
Diagnostic Tests
 TV ultrasound : is essential
+ Initial TV U/S can visualize an IU
pregnancy or a definite EP
+ If neither is seen, this is a pregnancy of
unknown location
+ 25 – 50 % of women with EP initially
present in this manner
+ IU pregnancy may not be seen because
the G sac has not yet developed or has
collapsed
+ likewise, early EP may be too small to be
detected by U/S
+ When a diagnosis cannot be made, serial
hCG and U/S are followed until an EP, IU
pregnancy, or early pregnancy failure is
confirmed
+ TV U/S should detect IU pregnancy when
hCG value is within or above the
discriminatory zone ( 1500-2000 mIU/ml )
+ If hCG is above the D Zone and U/S is
nondiagnostic, EP or early abnomal
pregnancy is likely
 A normal IU sac :
+ Regular and well-defined
+ Sonolucent area having a double ring
 In EP, a pseudogestational sac may be
present ( central, irregular, no double ring )
due to fluid/blood in the cavity due to decidual
sloughing
 A complex adnexal mass with empty uterus
raises the suspicion of EP especially if hCG is
above the D zone
 A gestational sac with yolk sac or embryo w c
pulsations within the adnexa confirms EP
 Rupture … anechoic or echogenic fluid in DP
 Laparoscopy :
+ was used for diagnosis in the past
+ in current medicine, U/S replaced it
+ U/S is equally accurate, cost-effective
and non-invasive
+ in surgical tt , laparoscopy is the gold
standard assuming the patient is hemo-
dynamically stable
 D & C : can be used to confirm or
exclude IU pregnancy
 Usually used when an early ectopic or
abnormal IU pregnancy is suspected
 Should not be used if pregnancy is
desired ( removal )
 Chorionic villi on pathologic ex = IU preg
 Decidua only = EP is highly likely
 Laparotomy : Immediate surgery is
indicated in hemodynamically unstable
patient with a presumed EP for rapid
access to control intra-abdominal he
 Laparotomy is also indicated in stable
patients when laparoscopy does not allow
adequate visualization or if too difficult
due to scar tissue of previous operations
 Culdocentesis : the vaginal passage of a
needle into the Douglas pouch was used to
confirm hemoperitoneum
 This technique has now been replaced by
TV U/S and is rarely performed in modern
medicine
 Magnetic Resonance Imaging
( MRI ) : is a useful adjunct to U/S in EP
of unusual location ( cervical, cesarean
scar, interstitial ) in which methotrexate
therapy is preferred
Methotrexate
 Antimetabolite folic acid antagonist
 Binds dihydrofolate reductase,blocking

DHF … THF active form of folic acid …

arrested DNA, RNA, protein synthesis
 90% resolution rate

 Bone marrow, GIT, pulmonary damage

 Hepatotoxic, nephrotoxic, teratogen, breast

milk
Patient Selection

 Asymptomatic, motivated, compliant

 Early unruptured ectopic
 B-hCG < 5000 mIU/ml
 Gestational sac < 3.5 cm
 No cardiac activity
 No contraindication
 Other types of ectopic
B- Salpingostomy

 Small unruptured ectopic

 10-15 mm linear incision on
antimesenteric border
 Extruded POC are removed or flushed
 Bleeding points are coagulated
 Incision left to heal by 2ry intention
 Monitoring by B-hCG
 NB- Salpingotomy is rarely done
Cesarean scar pregnancy
 Implantation within myometrium of prior C/S
scar
 1/2000 normal pregnancies
 Increased with C/S delivery rate
 Present early with pain and bleeding
 TVUS or MRI
 Hysterectomy, Methotrexate, conservative
surgery + Embolization or Foley balloon
catheter
Type 1 , Endogenous
) On-the-scar (

Type 2 , Exogenous

) In-the-niche (

Kaelin Agten et al, 2017

Early CSP ( GS + YS )