Presented by :

DR.Shiras Abodijana
 ECTOPIC PREGNANCY

 DEFINITIONS:-
 An ectopic pregnancy is a pregnancy where the fertilized ovum
implanted outside of the endometrial cavity .
 Ectopic pregnancy contributes significantly in maternal
morbidity and mortality .
 INCIDENCE

 Over all incidence of ectopic pregnancy is approximately

11\1000 pregnancies with an estimated 11000 ectopic
pregnancies diagnosis each year.
 In women attending early pregnancy clinics the incidence is 2-
3% .
 In caesarean scar pregnancy the Incidence is 1:2000 .
RISK FACTORS

 There are several risk factors for ectopic pregnancies. However, in

as many as one-third to one-half (Majority ) of cases NO risk factors
can be identified .
 These Risk factors are :-
 IN-vitro fertilization (IVF) .
 pelvic inflammatory disease .
 use of an intrauterine device (IUD).
 Endometriosis .
 Previous pelvic surgery .
 Previous ectopic pregnancy .
 Cigrette Smoking .
 SYMPTOMS

 Up to 10% of those with ectopic pregnancy have no symptoms, and one-

third have no medical signs.
 In many cases the symptoms have low specificity, and can be similar to
those of other genitourinary and gastrointestinal disorders, such as
appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage,
ovarian torsion or urinary tract infection .
 Light vaginal bleeding
 Abdominal pain and pelvic pain
 Amenorrhoea
 Dizziness or weakness
 Upset stomach and vomiting
 Sharp abdominal cramps
 SIGN OF ECTOPIC PREGNANCY

 On examination :
 Abdominal tenderness .
 Adnexal tenderness and or mass .
 Uterus seems to be normal in size or bulky .
 Fever .
SITES (TYPES) OF ECTOPIC
PREGNANCY
 Pathophysiology of ectopic
pregnancy
 When the trophoblast develops in the fertilized ovum and invades
deeply into the tubal wall , Bhcg production maintains the corpus
luteum .
 The corpus luteum produces oestrogen and progesterone which change
the secretory endometrium into decidua , then uterus enlarges up to 8
weeks and becomes soft ( myohyperplasia and hypertrophy ) .
 Endometrium showed histological pattern called arias stella
phenomenon and its hyperplasia of glands with loss of polarity ,
cytoplasmic vacuolization and hyperchromatic nucleus , So all that
leads to absence of chorionic villi .
 Along side arias stella and absence of chorionic villi are the main uterin
changes in ectopic pregnancy .
 Pathophysiology of ectopic
pregnancy
 Because of the tube lack to decidual change , inadequacy of its lumen
, its thin wall and the bleeding from the trophoblast invasion , Ectopic
pregnancy usually does not proceed to more than 10 weeks .
 Then separation of the gestational sac from tubal wall leads to its
degeneration , fall of Bhcg level , regression of corpus luteum and
subsequent drop in the oestrogen and progesterone level .
 Both decidual separation and uterin bleeding call Decidual Cast .
 TUBAL PREGNANCY

 Diagnosis :
 Serum progesterone level is not useful in predicting ectopic
pregnancy
 Serum BHCG level is useful for planning the management of an
ultrasound visualized ectopic pregnancy
 Transvaginal ultrasound is the diagnostic tool of choice for tubal
ectopic pregnancy , identified by visualizing an adnexal mass
that move separate to the ovary .
 TVS has reported sensitivities of 87-99% and specificities of 94-
99.9%
 Cystic adnexal mass is most common finding in around 50-60%
of cases . An empty extra uterine gestational sac presenting
around 20-40% of cases while an extra uterine gestational sac
containing a yolk sac and \or embryonic pole that may or may
not have cardiac activity present 15-20% of cases.
 There is no specific appearance or thickness to support
diagnosis of tubal ectopic pregnancy in up to 20% of cases a
pseudo sac may be seen with the uterine cavity
 Free fluid is often seen on U\S but is not diagnostic of ectopic
pregnancy , has been reported in 28-56% of ectopic
pregnancies.
 MANGMENT
1-SURGICAL MANGMENT :-
 The majority are managed surgically , laparoscopy is preferable to laparotomy.
 In the presence of a healthy contralateral tube salpingectomy should be performed
in preference to salpingotomy , it has been found that the cumulative ongoing
pregnancy rate was 60.7 % after salpingotomy and 56.2% after salpingectomy
persistant trophoblast occurred more frequently in salpingotomy 7%.
 In women with a history of fertility reducing factor , previous ectopic , contralateral
tube damage , previous abdominal surgery , previous PID , salpingotomy should be
considered .
 Repeat ectopic pregnancy occurred in 81% in salpingotomy and 5% in
salpingectomy.
 Studies have reported persistent trophoblast rates of 3.9 – 11% after salpingotomy .
 MANGMENT
2-PHARMACOLOGICAL MANGMENT :-
 Systemic methotrexate may be offered but if should never be
given at the first visit , unless pre diagnosis of ectopic
pregnancy is absolutely clear and viable intrauterine pregnancy
has been excluded
 Methotrexate at dose of 50 mg\m2 IM has been widely used as a
single dose instead of a repeat surgical procedure . Use of
prophylactic methotrexate at time of laparoscopic salpingotomy
also has been reported and when compared with salpingotomy
alone has significant reduction in the rate of persistent
trophoblast (1.9 % versus 14.5%).
PHARMACOLOGICAL MANGMENT

 Success rates of single dose range 65-95% with 3-27% of

women requiring a second dose
 Predictors of success:
-Initial serum BHCG
-ultrasound appearance of the ectopic pregnancy
-pretreatment changes in in serum BHCG level
-decrease in BHCG level from day 1 to day 4 after methotrexate
PHARMACOLOGICAL
MANGMENT
#During treatment women should be advised to avoid alcohol
and folate containing vitamins
CHARACTRISTIC OF GOOD CONDIELATE :
-Hemodynamic stability
-Low serum BHCG , ideally less than 15000 iu\l, but can be up to
5000iu\l
-No fetal cardiac activity on U\S
-Exclusion of intrauterine pregnancy
-Willingness to attend for follow up
-No known sensitivity to methotrexate.
 MANGMENT
3- EXPECTANT MANAGEMENT :-
 It’s a reasonable option for appropriately selected and
counseled women with success rate range (57-100%)
 Selection criteria :
 Clinical stability
 No abdominal pain
 No evidence of haemopertoneum on scan
 An ectopic pregnancy measuring less than 30mm with no
evidence of embryonic cardiac activity
 Serum BHCG level less than 1500 iu\l
 Women’s consent
 CERVICAL PREGNANCY

 Diagnosis:
 A single serum BHCG carried out at the time of U\S diagnosis is
useful in deciding management options . A serum BHCG level
greater than 10000 iu\l is associated with decreased chance of
successful methotreaxate treatment
 MANAGEMENT

Early accurate diagnosis is the key factor in conservative

management . GA less than 12 wks , absence of fetal cardiac
activity and lower serum BHCG level are associated with more
successful rate

Other options:
Dilatation and curettage , systemic methotrexate , local
injection with potassium chloride or methotrexate .
 Caesarean scar pregnancy

 Diagnosis
 No biochemical investigations are needed routinely . Serum BHCG level
may be useful as baseline if conservative treatment is contemplated ,
bat it dose not have a role in the diagnosis of caesarean scar pregnancy
 Imaging :
 Clinician’s should be a wear that U\S is the primary diagnostic modality
using TVS supplemented by transabdominal imaging if required
 MRI can be used as second line investigation if diagnosis is equivocal
and there is local expertise in MRI diagnosis of C\S scar pregnancy.
 Diagnostic criteria on TVS:
 1- empty uterine cavity
 2- gestation sac or solid mass on trophoblast located anteriorly
at the level of internal oss embedded at the site of the previous
lower uterine segment C\S scar .
 3- thin or absent layer of myometrium between the gestational
sac and the bladder
 4- evidence of prominent trophoblastic placental circulation on
Doppler scan
 5- empty endocervical canal
Management

 Primary medical treatment consist of using methotrexate by

local injection into the gestational sac under U\S guidance or
systemically by IM injection , local injection more effective
means of terminating pregnancy .
 Disadvantage : trophoblast remains in situ , risk of hemorrhage .
 Surgical treatment consist of either evacuation of pregnancy
( using suction or hysteroscopy resection ) or excision of the
pregnancy as open laproscopic or transvaginal procedure .
 Expectant management suitable for women with small nonviable
scar pregnancies, may be considered if pregnancy is partially
implanted into the uterine cavity .
Management of second trimester scar pregnancy challenging with
high risk of maternal morbidity and hysterectomy in these cases
risk of surgical intervention must be balanced with the risk of
allowing the pregnancy to continue arm to reach potential viable
gestational age.
INTERSTITIAL PREGNANCY

 Diagnosis :biochemical :
 Single serum BHCG should be carried out at diagnosis to help with
management . In some cases a repeat serum BHCG in 48 hr may be
deciding further management
 Imaging :
 Incidence varies between 1-6.3%
 U\S scan criteria
 -Empty uterine cavity
 -Product’s of conception GS located laterally in the intestinal part of
the tube end and surrounding by less than 5 mm of myometrium in all
imaging planes .
 -Presence of interstitial line sign , which have sensitivity 80% and
specificity98%.
 Sonographic finding in two dimension can be further
confirmed using three dimension , if available to avoid miss
diagnosis with early intrauterine or angular pregnancy .

 Supplementation MRI can also be helpful in the diagnosis .

 MANAGEMENT

 Conservative :
 Nonsurgical approach is acceptable option for stable interstitial
pregnancies
 Only suitable for women with lower significantly falling BHCG level
in whom the addition of methotrexate may not improve the outcome
 Pharmacological :
 Using methotrexate has been shown to be effective although there
is insufficient evidence to recommend local or systemic approach .
 Surgical :
 By laparoscopic corrival resection or salpingotomy alternative
surgical techniques include hysteroscopy resection under
laparoscopic U\S guidance .
 CORNUAL PREGNANCY

Diagnosis : biochemical :
Single serum BHCG should be carried out at diagnosis to help
with management , a repeat in 48 hr may be useful in deciding
management
Imaging :
U\S criteria
- Visualization of a single intestinal portion of fallopian tube in
the main uterine body .
- GS product seen mobile and separate form uterus and
completely surrounded by myometrium .
- A vascular pedicle adjoin the GS to the unicorn ate uterus .
 MAMAGEMENT

 There are several reported cases of methotrexate and

potassium chlorides injection prior to later laparoscopic
rudimentary horn excision
 OVARIAN PREGNANCY

 Diagnosis :biochemical :
 Single serum BHCG should be carried out at diagnosis to help
with management . In some cases a repeat serum BHCG in 48
hr may be deciding further management .
 Imaging :
 There are no agreed criteria for U\S diagnosis empty uterus and
wide echogenic ring with internal an echoic area on the ovary ,
yolk sac or embryo seen less commonly suggestive of ovarian
ectopic pregnancy .
 As it is difficult to distinguish ovarian pregnancy from corpus
luteal cysts, tubal pregnancy , second corpus luteum, ovarian
germ cell tumors and other ovarian pathologies diagnosis
usually confirmed , surgically and histologically .
 MANAGEMENT

 Definitive surgical treatment is preferred if laparoscopy is

required to make the diagnosis of ovarian ectopic pregnancy
 Systemic methotrexate can be used to treat it when the risk
of surgery in high or post operative in the presence of
persistently raised BHCG level .
 ABDOMINAL PREGNANCY

 Diagnosis : biochemical :
 High index of suspicion is based upon elevated serum BHCG level in
combination with ultrasound findings
 Imaging:
 U\S criteria :
 -absent of intrauterine GS
 -absent of both an evident dilated tube and complex adnexal mass.
 -gestational cavity surrounded by peritoneum .
 - wide mobility similar to fluctuation of the sac , particularly evident
with pressure of the TVS probe to word the posterior cul-de-sac .
 MRI can be useful diagnostic adjunct in adverse abdominal pregnancy
and can help to plan surgical approach .
 MANAGEMENT

 Laparoscopic removal is an option for treatment of early

abdominal pregnancy .
 Possible alternative treatment methods would be systemic
methotrexate with U\S guided feticide .
 Advanced abdominal pregnancy should be managed by
laparotomy .
 HETEROTOPIC PREGNACY

Diagnosis : biochemical :
Serum BHCG level is of limited value in diagnosing heterotopic
pregnancy
Imaging :
It should be considered in all women presenting after assisted
reproductive technologies , women with an intrauterine
pregnancy complaining of persistent pelvic pain and women
with persistently raised BHCG level following miscarriage or
termination of pregnancy .
 MANAGEMENT

The intrauterine pregnancy must be considered in the

management plan
Methotrexate should only be considered if the intrauterine one
is non viable or if the woman dose not wish to continue with the
pregnancy
Local injection of potassium chloride or hyperosmolar glucose
with aspiration of the sac contents is an option for clinically
stable women.
Surgical removal of the ectopic pregnancy is the method of
choice for haemodinamically stable women.
Expectant management is an option in heterotopic where the U\
S finding are of a nonviable pregnancy.
 ROLE OF ANTI D PROPHYLAXIS

 Offer anti D prophylaxis as per national protocol to all RHD –

negative women who have surgical removal of ectopic
pregnancy or where bleeding is repeated or heavy , with
abdominal pain .
 SUPPORT AND COUNSELLING

 Women should be advised, whenever possible , of the

advantage and disadvantage associated with each approach
used for the treatment of ectopic pregnancy , and should
participate fully in the selection of the most appropriate
treatment .
 Women should be made aware of how to access support
groups, such as the ectopic pregnancy trust , or local
bereavement counselling services.
 Muscle relaxation training may be of use to women
undergoing treatment for ectopic pregnancy with
methotrexate
 It’s recommended that women treated with methotrexate
wait at least 3 months before trying to conceive again
 FERTILITY EFFECT

 In the absence of sub fertility or tubal pathology , women should be

advised that there is no difference in the rate of fertility , the risk of future
tubal ectopic pregnancy or tubal patency rates between the different
management methods.
 Women with a previous history of sub fertility should be advised tat
treatment of their tubal ectopic pregnancy with expectant or medical
management is associated with improved reproductive outcomes compared
with radical surgery.
 Women receiving methotrexate for the management of tubal ectopic
pregnancy can be advised that there is no effect ovarian reserve .
 Women undergoing treatment with UAE and systemic methotrexate for non
tubal ectopic pregnancies can be advised that live births have been
reported in subsequent pregnancies.
 Women undergoing laparoscopic management of ovarian pregnancies can
be advised that their future fertility prospect are good.