ECTOPIC PREGNANCY

LECTURE NOTES FOR MBBS STUDENTS

NILE UNIVERSITY ABUJA
BY DR MSHELIA MHB

1 mhbmshelia
 DEFINITION / Introduction
 ECTOPIC PREGNANCY:- Refers to
implantation of the fertilized ovum at any
site other than the normal endometrial cavity
Any pregnancy where the fertilized ovum
gets implanted and develops in a site other
than normal uterine cavity.
 It is a significant cause of maternal
morbidity and mortality.
Understanding this is very important so that
the clinician should be very alert to be able
to diagnose and manage appropriately .
2 mhbmshelia
 REVISION
 Ovulation normally occurs on day 14 (+/- 2)
of the menstural cycle (Normal 28 day
cycle). The ovum is picked up by the
fimbrial of the fallopian tube.
 Fertilization occurs in the ampulla and the
zygote is transported through the fallopian
tube into the uterine cavity.
 It takes about 3-4 days to reach the uterine
cavity. By this time it has become a
blastocyst. The blastocyst have adhesive
and corrosive properties so it attaches its
self to the endometrial cells and gets
mhbmshelia
3
implanted.
4 mhbmshelia
 SITES OF ECTOPIC PREGNANCY

Fimbrial 2) Ampullary 3) Isthmic 4) Interstitial 5)Ovarian 6) Cervical

Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligament
) Primary abdominal
 INCIDENCE
 Variable depending on country
 Rising world wide
 Recent evidence indicates that the incidence of ectopic
pregnancy has been rising in many countries
- USA – 5 fold (1 – 2% of all pregnancies, USA)
- UK – 2 fold
- France – 15/1000
- India – 1 in 100 deliveries
- Nigeria – 2-3% of gynecological emergencies
 Recurrence rate – 15% after 1st, 25% after 2 ectopic
pregnancies

6 mhbmshelia
 HISTORY

963 AD – Albucasis first described

Ectopic Pregnancy
1884 -- Robert Lawson Tait of
Birmingham performed the forst
successful Salpingectomy operation
1953 – Stromme – Conservatice surgery
of Salpingostomy
1973 – Shapiro & Adller – Laparoscopic
Salpingectomy
1991 – Young et al – Laparoscopic
Salpingotomy
7 mhbmshelia
 AETIOLOGY - 1

The exact aetiology is not completely

known, but
Any factor that causes delayed
transport of the fertilized ovum
through the fallopian tube favours
implantation in the tubal mucosa,
giving rise to (a tubal) ectopic
pregnancy.
These factors may be Congenital or
8 Acquired.
mhbmshelia
 AETIOLOGY - 2
 CONGENITAL –
 Anatomic abnormalities of the uterus eg rudimentary horn
 Congenital malformations of the fallopian tube
 Tubal Hypolasia, Tortuosity, Congenital diverticuli, Accessory
ostia, Partial stenosis.

 AQUIRED –
 - Inflammatory: PID, Septic Abortion, Puerperal Sepsis,
MTP (Intraluminal adhesion)
- Surgical: Tubal reconstructive surgery, Recanalisation of
tubes. ----any intra abdominal surgery , eg appendectomy,
laparotomy etc
- Neoplastic: Broad ligament myoma, Ovarian tumour.
- Miscellaneous Causes: IUCD, Endometriosis, ART (IVF &
GIFT), Previous ectopic.
 Salpingitis Isthmica Nodosum

9 mhbmshelia
 Note: These factors can be classified into

 High risk factors – tubal surgery, previous

ectopic pregnancy,
tubal sterilization.
 Medium risk factors – history of infertility,
STI, multiple sexual partners
 Low risk factors – previous pelvic/abdominal
surgery.
 Heterotrophic pregnancy: pregnancy in
the uterus coexisting with ectopic
pregnancy. It is very rare but it can occur
hence the importance of appropriate
10 investigations
mhbmshelia
 DIAGNOSIS (1)
Take a good history Look for the following:-
History of infertility and history of any intra
abdominal surgery. History of STI, puerperal or
post abortal infection.
Use of assisted reproductive techniques such as
IVF
& Use of ovulation induction
Altered tubal motility
Progesterone only contraception
Progesterone IUDs
History, through physical examination and
appropriate investigations.

11 mhbmshelia
 CLINICAL PRESENTATION
(GENERAL)
 Ectopic Pregnancy remains asymptotic
until it ruptures when it can present in
two variations – Acute or Chronic
rupture
 SYMPTOMS
- Amenorrhea
- Abdominal Pain
- Syncope
- Vaginal Bleeding
- Pelvic Mass

12 mhbmshelia
 DIAGNOSIS Note:
“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.

13 mhbmshelia
 DIAGNOSIS (1)
In recent years, in spite 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 %.
14 mhbmshelia
 DIAGNOSIS
Diagnosis could be difficult before it ruptures so high
index of clinical suspicion in a patient with risk factors
is necessary
 History:-
 Physical examinations
 Investigations
 General investigations(FBC, urinalisis, E/U/Cr, G&X-
match blood, USS, β HCG etc.
Normal pregnancy, β HCG doubles every 48 to 72
hours
In EP, the increase is less and mean levels are lower.
However, a single HCG value not used to diagnose or
monitor EP, but serial assays.

15 mhbmshelia
 METHODS OF EARLY
DIAGNOSIS
Ultrasound 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.
16 mhbmshelia
 METHODS OF EARLY
DIAGNOSIS
Ultrasound features of ectopic pregnancy
after 5 weeks can be any of the
following:
2. Poorly defined tubal ring possibly
containing echogenic structure and POD
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
mhbmshelia
17
cavity is cold in respect to blood flow
 METHODS OF EARLY
DIAGNOSIS
TVS can visualise a gestational sac as early as 4 – 5
weeks from LMP.
During this time, the lowest serum β HCG is 2000
IU/L.
When β 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 β HCG does
not double in 48 hours ectopic pregnancy will be
confirmed.
The discreminatory zone of bHCG; 1500 to 1800
mIU/mL with TVS, 6000 to 6500 mIU/Ml with
abdominal scan
When not sure, the gold standard of diagnosis is to
do laparoscopy.
18 mhbmshelia
 MANAGEMENT (general)
Depends on the stage of the disease and
the condition of the patient at diagnosis.
Options:
- Surgery – Laparotomy / Laparoscopy
- Medical – Administration of Trophotoxics
at the site or systemically
- Expectant - Observation

19 mhbmshelia
 SURGICAL TREATMENT OF
ECTOPIC PREGNANCY
Carried out either by Laparotomy /
Laparoscopy
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 out the tube

20 mhbmshelia
 Acute (ruptured ectopic)
SYMPTOMS
Classic triad
Abdominal pain
Amenorrhoea
Vaginal bleeding

Other features
Dizziness or weakness
Syncope
Vomiting
Other features of pregnancy
Lavatory sign
21 mhbmshelia
 MANAGEMENT OF ACUTE ECTOPIC
PREGNANCY
 Hospitalisation
Resuscitation:
- Treatment of shock using wide bore
canula, set up IVF (N/S) take blood for
investigations.
- Analgesics
- Blood transfusion
 Surgery laparotomy

22 mhbmshelia
 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.
Blood Transfusion: Auto-
transfusion.
23 mhbmshelia
 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 prelvic
abcess
Salpingo-oophorectomy

24 mhbmshelia
 MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS:
Surgical
Surgically Administered Medical (SAM)
treatment
Medical treatment
Expectant management

25 mhbmshelia
 EXPECTANT TREATMENT
Identification criteria (Ylostalo et al,
1993):
- Falling level of serum β HCG at 2
day intervals - No sign of intrauterine
pregnancy
- Diameter of ectopic pregnancy <4
cm
- No sign of rupture or of acute
bleeding by TVS
If any deviation from the above
26 mhbmshelia
criteria occurs, then emergency
MEDICAL TREATMENT WITH
METHOTREXATE
Advantages:
- Minimal hospitalisation. Usually
outpatient treatment: Reduces cost.
- 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
 SURGICAL TREATMENT OF
UNRUPTURED ECTOPIC PREGNANCY
Surgical
Carried out either by Laparotomy /
Laparoscopy
 The procedures are:
-Salpingectomy / - Conservative Surgery
(in cases of infertility & desire for
pregnancy)
• Linear salpingostomy
• Linear salpingotomy
• Segmental resection and anastomosis
• Milking out the tube

28 mhbmshelia
 SAM TREATMENT
 Aim: Trophoblastic destruction but avoiding
the 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 (Feichtinger et al, 1989)

- With Falloposcopic control (Kiss et al, 1993)

- Hysteroscopic control (Goldenberg et al,
1992)
- Hysterosalpingographic control (Risquez et al,
29
1990)
mhbmshelia
 MEDICAL
Methotrexate 1mg/kg body weight
Patient should
Be haemodynamically stable
No severe or persisting abdominal pain
Un-ruptured adnexal mass less than 4cm
No cardiac activity if seen by scan
HCG does not exceed 5000 IU/L
Ability to follow up multiple times
Normal baseline liver and renal function
test results
30 mhbmshelia
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 Methotrexate
IM in a single dose of 50mg/m2 without
Folinic acid. If serum HCG does not fall
to 15% within 4 – 7 days, then a second
dose of Methotrexate is given and
resolution is confirmed by HCG
estimation
MEDICAL TREATMENT WITH
METHOTREXATE
Advantages:
- Minimal hospitalisation. Usually
outpatient treatment: Reduces cost.
- 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
 CONTRAINDICATIONS TO
METHOTREXATE THERAPY
Intrauterine pregnancy
Immunodeficiency
Moderate to severe anaemia, leukopenia or
thrombocytopenia
Breastfeeding
Evidence of tubal rupture
Clinically important hepatic or renal
dysfunction

33 mhbmshelia
 SALPINGECTOMY Vs
SALPINGOSTOMY/SALPINGOTOMY
The choice of surgical treatment does
not influence the post treatment fertily,
but prior history of infertility is
associated with a marked reduction in
fertility after treatment
Making the choice: Chapron et al (1993)
have described a scoring system, based
on the patient's previous gynaecological
history and the appearance of the pelvic
organs, to deicde between
salpingostomy / salpingotomy and
salpingectomy.
34 mhbmshelia
 SALPINGECTOMY Vs
SALPINGOSTOMY/SALPINGOTOMY
Fertility reducing factor
Score
• Antecedent one Ectopic pregnancy
2
• Antecedent each further Ectopic pregnancy
1
• Antecedent adhesiolysis
1
• Antecedent Tubal micro surgery
2
• Solitary tube
2
• Antecedent Salpingitis
35 1
mhbmshelia
 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 piece meal
or in a tissue removal bag.

36 mhbmshelia
 LAPAROSCOPIC
SALPINGOTOMY
To reduce blood loss, first 10 – 40 IU of
Vasopressin diluted in 10 ml of normal saline is
injected into the mesosalpinx.
Then the tube is opened through an
anitmesenteric longitudinal incision over the
tubal pregnancy by a
- Co2 laser (Paulson, 1992)
- Argon laser (Keckstein et al; 1992)
- Laparoscopic scissors snd ablating the
bleeding points with bipolar diathermy.
- Fine diathermy knife (Lundorff, 1992)
37 mhbmshelia
 LAPAROSCOPIC
SALPINGOTOMY
The tubal pregnancy is then
evacuated by suction irrigation.
Hemostasis of the
trophoblastic bed is ensured.
The tubal incision is left open.

38 mhbmshelia
 PERSISTENT ECTOPIC PREGNANCY
(PEP)
This is a complication of salpingotomy /
salpingostomy when residual trophoblastic
continues to survive because of incomplete
evacuation of the ectopic pregnancy.
Diagnosis is made because of a raised
postoperative serum β HCG
If untreated, can cause life threatening
hemorrhage
TREATMENT is by:
- Reoperation and futher evacuation /
Salpingectomy
39 - Administration of IM / oral Methotrexate
mhbmshelia

2
 PROGNOSIS
Important cause of first trimester maternal
mortality
Early diagnosis key to good outcome

After 1 EP
50 – 80% chance of Intrauterine gestation
10 – 25% chance of EP

40 mhbmshelia
 DIFFERENTIAL DIAGNOSIS
Salpingitis
Abortion
Appendicitis
Torsion/ rupture of ovarian cyst
Rupture of corpus luteum

41 mhbmshelia
 Advance abdominal
pregnancy
Abdominal pregnancy very rare. Incidence
is 1 in 25000 -1 in 30000 pregnancies
Primary:- common with the use of ovulation
induction drugs
Secondary following tubal ectopic that got
seeded on to the intra peritoneal structures
Advanced;- when pregnancy reached 20
weeks or more with signs that is either
living or have lived in the mothers
peritoneal cavity.
Associated with high MM and NNM
42  High congenital anomalies.
mhbmshelia
 Special investigations for
diagnosis
USS
MRI
CT SCAN
NB
PLAIN X-RAY

43 mhbmshelia
 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 councelling of
patients is mandatory.
 Ruptured ectopics should be unususal with
compliant patients and appropriate medical
care.

44 mhbmshelia
Thank you for listening

45 mhbmshelia