Bellington Vwalika
ECTOPIC PREGNANCY
DEFINITION
Any pregnancy where the fertilised
ovum gets implanted & develops in a site
other than normal uterine cavity.
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INCIDENCE
>1 in 100
Recent evidencepregnancies.
indicates that the incidence of ectopic
pregnancy has been rising in many countries.
USA-5 fold
UK-2 fold
France 15/1000 pregnancies
India-1in100 deliveries
Recurrence rate - 15% after 1st, 25% after 2 ectopics
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HISTORY
Ectopic pregnancy was first described in 963 Ad
by Albucasis.
1884 -- Robert Lawson Tait of Birmingham
prformed the first successful Salpingectomy
operation
1953 -- Stromme – Conservative surgery of
Salpingostomy
1973 -- Shapiro & Adller – Laparoscopic
Salpingectomy
1991 -- Young et al – Laparoscopic Salpingotomy
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AETIOLOGY
Any factor that causes delayed transport of the
fertilised ovum through the.
Fallopian tube favours implantation in the tubal
mucosa itself thus giving rise to a tubal ectopic
pregnancy.
These factors may be Congenital or Acquired.
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AETIOLOGY
CONGENITAL - Tubal Hypoplasia , Tortuosity ,
Congenital diverticuli , Accessory ostia , Partial
stenosis
ACQUIRED -
Inflammatory: PID, Septic Abortion, Puerperal Sepsis,
MTP (lntraluminal adhesion)
Surgical: Tubal reconstructive surgery, Recanalisation of
tubes
Neoplastic: Broad ligament myoma, Ovarian tumour
Miscellaneous Causes: IUCD , Endometriosis, ART (IVF
& & GIFT), Previous ectopic
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SITES OF ECTOPIC PREGNANCY
Ampulla (>85%) Abdomen (< 2%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Cervix (< 2%)
1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian
6)Cervical 7)Cornual-Rudimentary horn 8)Secondary
abdominal 9)Broad ligament 10)Primary abdominal
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CLINICAL PRESENTATION
Ectopic Pregnancy remains asymptotic until it
ruptures when it can present in two variations - Acute
&. Chronic
SYMPTOMS-
Amenorrhea
Abdominal Pain
Syncope
Vaginal Bleeding
Pelvic Mass
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DIAGNOSIS
“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 colours in
darkness, illumination clearly identifies it.”
--Mc. Fadyen - 1981
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DIAGNOSIS
In recent years, inspite of an increase in the incidence
of ectopic pregnancy there has been a fall in the case
fatality rate.
This is due to the widespread introduction of
diagnostic tests and an increased awareness of the
serious nature of this disease.
This has resulted in early diagnosis and effective
treatment.
Now the rate of tubal rupture is as low as 20%.
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METHODS OF EARLY DIAGNOSIS
Immunoassay utilising monoclonal antibodies to
beta HCG
Ultrasound scanning – Abdominal & Vaginal
including Colour Doppler
Laparoscopy
Serum progesterone estimation not helpful
A combination of these methods may have to
be employed.
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METHODS OF EARLY DIAGNOSIS
At 4-5 weeks-
TVS can visualise a gestational sac as early as 4-5
weeks from LMP.
During this time the lowest serum beta HCG is
2000 IU/Lt.
When beta HCG level is greater than this and
there is an empty uterine cavity on TVS, ectopic
pregnancy can be suspected.
In such a situation, when the value of beta HCG
does not double in 48 hours ectopic pregnancy
will be confirmed.
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METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5
weeks can be any of the following-
1. Demonstration of the gestational sac with or
without a live embryo (Begel’s sign) - The GS
appears as an intact well defined tubal ring by 6
weeks when it measures 5 mm in diameter.
Afterwards it can be seen as a complete
sonolucent sac with the yolk sac and the
embryonic pole with or without heart activity
inside.
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METHODS OF EARLY DIAGNOSIS
The USG features of ectopic pregnancy after 5
weeks can be any of the following-
2. Poorly defined tubal ring possibly containing
echogenic structure and POD typically
containing fluid or blood.
3. Ruptured ectopic with fluid in the POD and an
empty uterus.
4. In Colour Doppler, the vascular colour in a
characteristic placental shape, the so-called fire
pattern, can be seen outside the uterine cavity
while the uterine cavity is cold in respect to
blood flow
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MANAGEMENT
Depends on the stage of the disease and the condition
of the patient at diagnosis.
Options-
Surgery – Laparoscopy / Laparotomy
Medical – Administration of drugs at the site /
systemically
Expectant – Observation
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MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
Hospitalisation
Resuscitation -
Treatment of shock
Lie flat with the leg end raised
Analgesics
Blood transfusion
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MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
Culdocentesis: -
Most Helpful in Emergent Situations to Confirm
Diagnosis
Highly Specific if performed and Interpreted
Correctly: - Presence of Free-Flowing, NON-Clotting
Blood
Negative Tap Inconclusive
Remains Controversial
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MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
Laparotomy should be done at the
earliest.
Salpingectomy is the definitive
treatment.
No benefit from removing Ovary along with the tube
If blood is not available, auto-
transfusion can be done.
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MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
INVESTIGATIONS-
Laboratory/Chemical test –
Serial quantitative beta HCG level by RIA
Serum progesterone level (<5 mg/ml in ectopic
pregnancy)
Low levels of Trophoblastic proteins such as SPI
and PAPP-, Placental protein 14 & 12
USG- usually haematocele is found
Laparoscopy
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MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
TREATMENT – ALWAYS SURGICAL
Salpingectomy of the offending tube
If pelvic haematocele is infected, posterior.
colpotomy is to be done to drain the pelvic
abscess
Salpingo-oophorectomy
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MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
SURGICAL-
SURGICALLY ADMINISTERED MEDICAL (SAM)
TREATMENT
MEDICAL TREATMENT
EXPECTANT MANAGEMENT
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SURGICAL TREATMENT OF ECTOPIC
PREGNANCY
Carried out either by Laparoscopy / Laparotomy.
The procedures are: -
Salpingectomy / Cornual resection / Excision
Conservative surgery (in cases of Infertility & desire for
pregnancy)
Linear salpingostomy
Linear salpingotomy
Segmental resection and anastomosis
Milking of the tube
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SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
All tubal pregnancies can be treated by partial
or total Salpingectomy
Salpingostomy / Salpingotomy is only
indicated when:
1. The patient desires to conserve her fertility
2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 5Cm. In size
5. Contralateral tube is absent or damaged
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SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
The choice of surgical treatment does not
influence the post treatment fertility, but prior
history of infertility is associated with a marked
reduction in fertility after treatment
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LAPAROSCOPIC SALPINGECTOMY
It is carried out by laparoscopic scissors
and diathermy or Endo-loop.
After passing a loop of No.1 catgut over
the ectopic pregnancy the stitch is
tightened and then the tubal pregnancy
is cut distal to the loop stitch.
The excised tissue is removed by piece
meal or in a tissue removal bag.
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Medical TREATMENT
Aim- trophoblastic destruction without systemic side
effects
Technique- Injection of trophotoxic substance into the
ectopic pregnancy sac or into the affected tube by-
Laparoscopy or
Ultrasonographically guided
Transabdominal (Porreco, 1992)
Transvaginal (Feichtingar, 1987)
With Falloposcopic control (Kiss, 1993)
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Medical TREATMENT
Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2α (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
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Criteria for medical treatment
Unruptured ectopic pregnancy
hCG < 5000 IU/l
Adnexal mass ≤3.5 cm diameter
No fetal heart in adnexae
Normal FBC, LFT, RFT
Fluid less than 50ml in peritoneum
MEDICAL TREATMENT WITH
METHOTREXATE
Ectopic pregnancy size should be < 3.5 cm.
Can be given IV/IM/Oral, usually along with Folinic acid
Recent concept is to give Methtrexate IM in a single dose
of 50mg/m2 without Folinic acid. If serum HCG does
not fall to 15% with in 4-7 days, then a second dose of
Methtrexate is given and resolution confirmed by HCG
estimation
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MEDICAL TREATMENT WITH
METHOTREXATE
Advantages –
Minimal Hospitalisation.Usually outdoor treatment
Quick recovery
90% success if cases are properly selected
Disadvantages-
Side effects like GI & Skin
Monitoring is essential- Total blood count, LFT & serum
HCG once weekly till it becomes negative
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EXPECTANT TREATMENT
Tubal Pregnancies are known to Abort / Resolve
Befor the advent of salpingectomy in 1884, ectopic
pregnancies were being treated expectantly with 70%
mortality.
Today only selected cases are managed expectantly,
screened and identified by high resolution ultrasound
scanner and monitored by serial serum HCG assay
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EXPECTANT TREATMENT
Identification criteria (Ylostalo et al , 1993)-
Diameter of ectopic pregnancy <4 Cm.
No sign of intrauterine pregnancy
No sign of rupture by TVS
No sign of acute bleeding by TVS
Falling level of serum HCG at 2 day intervals
If any deviation from the above criteria occurs, then
emergency treatment is necessary.
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EXPECTANT TREATMENT
Spontaneous resolution occurs in 72%,while 28% will
need laparoscopic salpingostomy
In spontaneous resolution, it may take 4-67 days
(mean 20 days) for the serum HCG to return to non
pregnant level.
The percentage fall in serum HCG by day 7 is a better
indicator than the percentage fall by day 2.
Warning: - Tubal pregnancies have been known to
rupture even when Serum HCG levels are low.
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SUMMARY - KEY POINTS
Incidence of ectopic pregnancy is rising while
maternal mortality from it is falling.
Early diagnosis is the key to less invasive
treatment.
The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
The trend is towards conservative treatment.
Careful monitoring and proper counselling of
patients is mandatory.
Ruptured ectopics should be unusual with
compliant patients and appropriate medical care.
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