Ectopic Pregnancy and
Pregnancy of Unknown
Location
Definition:
Ectopic Pregnancy:
Pregnancy which the developing blastocyst becomes implanted at a site other than
the endometrium of the uterine cavity
Pregnancy of Unknown Location:
Woman with positive pregnancy test but no intrauterine or extrauterine pregnancy
can be seen with TVS
Ectopic Pregnancy
Epidemiology:
1-2% of pregnancy
Anatomical Location:
Risk Factors
Tubal pathology:
Disruption of normal tubes either:
Anatomically
Physiologically
Example: PID, Previous tubal surgery
Previous Ectopic Pregnancy
Clinical Presentation:
History: Typically present at 6-8 weeks if
Triad of: LMP
Lower Abdominal Pain During this time the gestational sac
is large enough to cause distention
of the tube leading to the pain
May present with or without tubal
PV Bleeding Amenorrhea rupture→ life threatening leading
Other symptoms: to haemorrhagic shock
Breast tenderness
Nausea and vomiting
Dizziness and fainting
Shoulder tip pain
Rectal pressure or pain on
defaecation
Clinical Presentation:
Physical Examination:
Common Signs:
Pelvic tenderness
Adnexal tenderness
Abdominal tenderness
Other reported signs:
Cervical tenderness
Peritonitis
Features of intrabdominal haemorrhage→ shoulder tip pain, fullness of pouch of
Douglas
Shock and collapse
Differential Diagnosis
Miscarriage
Physiological (Implantation Bleeding)
Cervical, vaginal or uterine pathology
Subchorionic haematoma
Gestational trophoblastic disease
Diagnostic Evaluation
Patient present to us either stable or unstable
Stabilise the patient first→ Scan for any intraperitoneal haemorrhage
Diagnostic Evaluation of Ectopic Pregnancy
Serum BhCG
TVS/TAS
UPT
Diagnostic Evaluation
1st confirm patient is pregnant:
- UPT positive
2nd- TVS
TVS finding:
Intrauterine Pregnancy
Gestational sac seen intrauterine (± FH)
Ectopic Pregnancy
Gestational sac with yolk sac and embryo seen extrauterine (± FH)
Inconclusive-- > correlate with Beta HCG
Not able to visualise any gestational sac (Pregnancy of Unknown location)
Diagnosis of tubal pregnancy
According to NICE Guideline:
Sign indicating of tubal pregnancy
Adnexal mass with yolk sac/ fetal pole
High probability of tubal pregnancy (correlate with Beta HCG before confirm
dx)
Empty gestational sac (tubal ring sign)
Inhomogeneous adnexal mass
Possible of tubal pregnancy (correlate with Beta HCG before confirm dx)
Empty uterus
Collection of fluid in uterus
Diagnostic Evaluation
3rd Serum Beta HCG
Assess trophoblastic proliferation → normal, abnormal or declining in trend
Take serum HCG 2 times 48 hours apart → monitor the trend
3 conclusion:
Intrauterine pregnancy
Increase of > 63%
Re-scan the patient in 2 weeks to confirm IUP, if >1500IU rescan earlier
Abnormal pregnancy
Either > less than 63% or < less than 50%
Re assess the patient again to confirm the dx
Failing pregnancy
Decrease > 50%
Repeat UPT 2/52- if negative → no further mx
If positive- review patient
Management of Ectopic Pregnancy
Expectant
Medical
Surgical
Management of Ectopic Pregnancy
Expectant
Clinically stable and pain free
Tubal pregnancy measuring 35mm with no heartbeat
Serum beta hCG <1000
And able to return follow up
Repeat beta HCG level on D2,D4 and D7 after original test
If reduce by 15% every test, then repeat weekly until negative
If not reassess and KIV medical/surgical management after d/w
specialist
Management of Ectopic Pregnancy
Medical
Systemic methotrexate:
Single-dose protocol
Two- dose protocol
Multiple dose protocol
Criteria:
No significant pain
Unruptured tubal ectopic pregnancy, <35mm, no heartbeat
HCG <1500. If 1500-5000( methotrexate can still be considered, offer choice of surgical mx)
No intrauterine pregnancy
Able to return for follow up
Repeat serum HCG on D4 and D7 and then weekly until negative
*ensure patient has no liver, renal or haematologic issue prior to methotrexate*
Methotrexate Therapy
Single Dose Protocol:
50mg/m2 BSA IM x1
Repeat HCG at D4 and D7
If reduce by more than 15% Repeat weekly until undetectable
If reduce less than 15% start 2nd dose of methotrexate
Two- Dose Protocol
Similar to single dose, but regardless of D4 serum beta HCG reduce or not, give 2nd dose
Ensure patient Haemato, Renal and liver has no issues.
Make sure patient does not have contraindication for methotrexate
Make sure patient is on contraception for at least 3 months post methotrexate and
started on folic acid prior to next pregnancy
Management of Ectopic Pregnancy
Surgical
If patient is not able to come for follow up, not indicated for medical or
expectant.
Unstable, ruptured ectopic, haemoperitoneum
Open vs Laparoscopic
Laparoscopic whenever possible
Salphingectomy vs Salphingotomy
Salphingectomy → reduce risk of recurrence, less likely of retained
trophoblast
3 weeks post op to take UPT→ if positive for TCA
If infertility (contralateral tube defect)→ consider salphingostomy
Take serum hCG at D7 after surgery then weekly until negative
Take Home Message
Ectopic Pregnancy= Pregnancy outside of uterus, 95% tubal pregnancy
PUL= UPT positive→ scan not able to determine where is pregnancy
Most feared complication→ rupture→ haemoperitoneum and haemodynamically compromised
Clinical Presentation: Triad of PV bleed, abdominal pain, ammenorhea
Assessment:
1.UPT
2. TVS→ confirm either IUP/Extrauterine Pregnancy/ Pregnancy of Unknown Location
3. Correlate with Beta HCG Level
Management:
Expectant vs Medical vs Surgical
Haemodynamically unstable→ Surgical Management
Unable to follow up → Surgical management
