Ectopic Pregnancy
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and character. But if you must be without one,
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you live your grief in good fortune
Ectopic Pregnancy
• Definition.
• Incidence. Doubled after ARTs to [2-3%]
• Usually found in the first 6-8 weeks of pregnancy;
but later if not located in the tube.
• Heterotopic pregnancy.
Mortality risks
• Before the 19th century, → exceeded 50%.
• By the end of the 19th century, dropped to
5%.
• Current advances in early detection, improved
to less than 5 in 10,000.
• Remains the leading cause of pregnancy-
related death in the first trimester of
pregnancy.
Strong Risk Factors: 1/2
• previous ectopic pregnancy
• previous tubal sterilization surgery
• intrauterine device (IUD) use
• previous genital infections
• chronic salpingitis
• salpingitis isthmica nodosa
• infertility
• multiple sexual partners
• smoking continue…….
Week Risk Factors: 2/2
• assisted reproductive technology (ART)
• first sexual encounter <18 years
• maternal age >35 years
• tubal reconstruction surgery
Land Marks
* The most common cause of tubal
abnormality associated with ectopic
pregnancy is salpingitis.
• Chromosomal abnormalities do not cause
ectopic pregnancies.
• ? A role for the conceptus.
Incidence/ Sites
Natural Conception ARTs
Overall incidence About 1% 2-3%
Fallopian tube > 95% > 90%
Ovarian &abdominal 1-2% 5%
Cervical 0.15% 1.5%
Cesarean scar 1 in 1800 Unknown
Heterotropic 1 in 30.000 1 in 100
Bilateral fallopian tube ectopic occur in 1 in 200.000
Symptoms
• Vaginal bleeding.
• Nausea and vomiting.
• Pain; lower abdominal, sharp abdominal, iliac
fossa.
• Pain; shoulder, neck, rectal: → diarrhea.
• Pain and bleeding → fainting; rupture ectopic.
Pain
• The onset of the pain may be abrupt or slow.
• The pain may be continuous or intermittent.
• The pain may be dull or sharp.
• The pain may be mild or severe.
• The pain is not crampy.
The classic signs and symptoms:
• Abdominal pain,
• Amenorrhea,
• Vaginal bleeding.
• Hypotension, ± syncope.
Diagnostic Factors
* Common factors mainly are:
– abdominal pain
– amenorrhoea
– vaginal bleeding
– abdominal tenderness
– adnexal tenderness or mass
– blood in vaginal vault
* Uncommon factors mainly are:
• haemodynamic instability, orthostatic hypotension
• cervical motion tenderness
• urge to defecate
• referred shoulder pain
Bleeding: → dissect into the lumen →
endometrium → spotting.
→ some passes into the
peritoneal cavity.
→ most trapped between the serosal
and mucosal layers.
Pathophysiology
Effective transport of embryos in the fallopian tube
requires a delicately regulated complex interaction
between the tubal epithelium, tubal fluid, and
tubal contents. This interaction ultimately
generates a mechanical force, composed of tubal
peristalsis, ciliary motion, and tubal fluid flow, to
drive the embryo towards the uterine cavity. This
process is subject to dysfunction at many different
points that can ultimately manifest as ectopic
pregnancy.
Pathophysiology
• Damage of the tubal cilia by infection, →egg
transport becomes disrupted.
• Formation of pocket like pools that engulf the
fertilized eggs.
• Infection-related scarring and partial blockage
of the Fallopian tubes.
• Bleeding-related scarring and partial blockage
of the Fallopian tubes.
Clinical Presentation
• Acutely ruptured; top surgical emergency.
• Probable ectopic in a symptomatic women.
• Possible ectopic in mild symptomatic women
with pregnancy of unknown location.
Diagnosis
• History. Using the mind judgment.
• Physical examination.
• Ultrasound evaluation; but often the findings are
not conclusive.
• Blood tests; serial β-hCG levels in maternal
serum, CBC.
Diagnosis/1
• Equivocal ultrasound results should be combined with
quantitative beta hCGlevels.
• Diagnostic uterine curettage presence or absence of
intrauterine chorionic villi; The presence of chorionic
villi confirms a failed intrauterine pregnancy
• Clinical judgment; If a patient has a beta hCG level of 1,500
mIU/mL or greater, but the transvaginal USS does not show
an IUS, ectopic pregnancy should be suspected.
• Laparoscopic Role
The Discriminatory Zone
• The range of β-hCG values in which the
ultrasound image can first detect the sign of
intra uterine pregnancy.
• Most centers quote a range of 1500 to 3510
mIU/ml AS the DZ.
Diagnosis/2
Clinical examinations are not diagnostic;
* Up to 30% of patients with ectopic
pregnancies have no vaginal bleeding,
* About 10% have a palpable adnexal mass,
* Up to 10% have negative pelvic examinations.
* No combination of physical examination
findings can reliably exclude ectopic
pregnancy
* Combined transvaginal ultrasonography and
serial quantitative beta-hCG measurements
are approximately 96 percent sensitive and 97
percent specific for diagnosing ectopic
pregnancy.
* Transvaginal ultrasonography followed by
quantitative beta-hCG testing is the
optimal and most cost-effective strategy
for diagnosing ectopic pregnancy.
Diagnostic approach
• Step one: Confirm pregnancy and ectopic
pregnancy symptoms
• Step two: Evaluate hemodynamic stability
• Step three: Assess pregnancy location
• Step four: Follow with hCG and ultrasound to
confirm or exclude ectopic pregnancy
• Step five: plan of management
Signs of a ruptured fallopian tube ectopic
• Sudden, severe, sharp pain,
• Feeling faint and dizzy,
• Feeling or being sick,
• Diarrhea.
• Shoulder tip pain,
• The dangerous of rupturing the large artery
runs on the outside of each Fallopian tube.
Differential Diagnosis
Only 50% of patients with an ectopic pregnancy
present with the classic triad of amenorrhea, pain,
and vaginal bleeding.
• Appendicitis.
• Salpingitis.
• Ruptured corpus luteum cyst or ovarian follicle.
• Spontaneous abortion or threatened abortion.
• Ovarian torsion.
• Urinary tract disease.
Differential Diagnosis
A study by Huchon et al found that the following
4 symptoms independently contributed to the
diagnosis of tubal rupture:
• Vomiting during pain,
• Diffuse abdominal pain,
• Acute pain for longer than 30 minutes,
• Flashing pain,
The sensitivity was 93% in the presence of 1 or more of these
items
Treatment Options
• Observation; resolve on their own without the
need for any intervention.
• Laparoscopy; for diagnosis and management.
• Laparotomy; urgent surgery due to life-
threatening bleeding.
• Medication; under certain circumstances.
Expectant Management
• General health appears to be stable,
• Pain levels are considered to be acceptable,
• An ultrasound scan shows a small ectopic pregnancy
with no worrying bleeding into the abdomen.
• Initial β-hCG titers below 200 mIU/mL.?? 1000
mIU/mL.
• The level of β-hCG titers decreasing.
• Able and welling to comply with close fellow up.
• The lady prefer expectant management than
methotrexate therapy.
Emergency surgery
• Hemodynamically unstable
• Signs or symptoms of impending or ongoing rupture of ectopic
• Indications for a concurrent surgical procedure, which may
include:
• •Desire for sterilization
• •Planned in vitro fertilization for future pregnancy with known
hydrosalpinx
• Heterotopic pregnancy with coexisting viable intrauterine
pregnancy
• Contraindications to MTX therapy
• Failed MTX therapy
Surgery: Laparotomy vs. Laparoscopy
Applied for both options; salpingectomy or
salpingostomy
• If suspicion that the fallopian tube has ruptured,
emergency surgery.
• If the fallopian tube has not ruptured,
laparoscopic surgery may be all that is needed to
remove the embryo and repair the damage.
• Salpingostomy is preferred because it is a
conservative surgical option
Medical
Methotrexate
Antimetabolite chemotherapeutic agent that
binds to the enzyme dihydrofolate reductase,
which is involved in the synthesis of purine
nucleotides. This interferes with
deoxyribonucleic acid (DNA) synthesis and
disrupts cell multiplication.
Treatment with methotrexate is an attractive
option when the pregnancy is located on the
cervix or ovary or in the interstitial or the
cornual portion of the tube or the scar of
cesarean section.
Establishing the diagnosis 1/3
By one of the following criteria:
• Abnormal doubling rate of the (β-hCG) level
less than 5000 & USS identification of a GS
outside of the uterus.
• Abnormal doubling rate of the β-hCG level, an
empty uterus, and menstrual aspiration with
no chorionic villi.
Establishing the diagnosis 2/3
• The patient must be haemodynamically
stable, with no signs or symptoms of active
bleeding or haemoperitoneum.
• The patient must be reliable, compliant, and
able to return for follow-up care.
• The size of the GS should not exceed 4cm at
its greatest dimension.
• Take into account that great love and great
achievements involve great risk
• Lost time is never found again
• Nobody can make you feel inferior without
your permission
• It is the province of knowledge to speak, and
it is the privilege of wisdom to listen
• If you talk to a man in a language he
understands, that goes to his head. If you talk
to him in his language, that goes to his heart.
Establishing the diagnosis 3/3
• Absence of fetal cardiac activity on USS findings - The
presence of fetal cardiac activity is a relative
contraindication.
• No evidence of tubal rupture - Evidence of tubal
rupture is an absolute contraindication.
• β-hCG level less than 5000 mIU/mL - Higher levels
are a relative contraindication.
• Evidence of hepatic or renal compromise is a
contraindication to methotrexate therapy.
Contraindications to Medical Therapy
• A β-hCG level of greater than 5,000 mIU/mL,
• Fetal cardiac activity,
• Free fluid in the cul-de-sac
• "There is an inverse association between β-
hCG levels and successful medical
management of an ectopic pregnancy".
Adverse Drug Effects
• Nausea
• Vomiting
• Stomatitis
• Diarrhea
• Gastric distress
• Dizziness
Treatment Effects
• An increase in abdominal pain (occurring in up
to two thirds of patients),
• An increase in β-HCG levels during the first 1-3
days of treatment, and
• Vaginal bleeding or spotting.
• Increased abdominal pain is believed to be
caused by the separation of the pregnancy
from the implanted site.
Day 1:
• Level of β-hCG,
• CBC,
• Liver function,
• kidney function tests.
• Blood type, Rh status,
Day 1
Methotrexate (50 mg/m2) is administered by IM
injection.
Advise patients not to take vitamins with folic
acid until complete resolution of the ectopic
pregnancy.
Day 4
• The patient returns for measurement of her β-
hCG level.
• The level may be higher than the
pretreatment level.
• The day-4 hCG level is the baseline level
against which subsequent levels are
measured.
Day 7
• Draw β-hCG curve, perform a complete blood
count.
• If the β-hCG level has dropped 15% or more
since day 4, obtain weekly β-hCG levels until
they have reached the negative level for the
lab.
• If the weekly levels plateau or increase, a
second course of methotrexate may be
administered.
• If the β-hCG level has not dropped at least
15% from the day-4 level, →↓
• Administer a second IM dose of methotrexate
(50 mg/m2) on day 7, and
• Observe the patient similarly.
• If no drop has occurred by day 14, surgical
therapy is indicated.
If the patient develops increasing abdominal
pain after methotrexate therapy, repeat a
transvaginal ultrasonographic scan to evaluate
for possible rupture.
Conception/ Recurrence
• Approximately 30%of women treated for
ectopic pregnancy later have difficulty
conceiving.
• The overall conception rate is approximately
75% regardless of treatment.
• Rates of recurrent ectopic pregnancy are
between 5 and 20%.
• The risk increases to 30%in women who have
had two consecutive ectopic pregnancies.
Ectopic Pregnancy Facts
• An ectopic pregnancy is a pregnancy located
outside the inner lining of the uterus.
• Risk factors for ectopic pregnancy include
previous ectopic pregnancies and conditions
(surgery, infection) that disrupt the normal
anatomy of the Fallopian tubes.
• Hormonal imbalances or abnormal development
of the fertilized egg also might play a role.
• An ectopic pregnancy can't proceed normally.
The fertilized egg can't survive. Continue….
• Early treatment of an ectopic pregnancy can help
preserve the chance for future healthy pregnancies.
• The major health risk of an ectopic pregnancy is
internal bleeding.
• Diagnosis of ectopic pregnancy is usually established by
proper history, physical exam, blood hormone tests,
pelvic ultrasound, and on top thinking of it.
• Treatment options for ectopic pregnancy include
conservative approach, surgery and medical.
continue…..
• Obviously, the clinical challenge is to avoid tubal rupture by
making a correct and timely diagnosis, thereby optimizing
fertility prospects.
• There is no difference in the reproductive outcome after
treatment of EP by laparotomy versus laparoscopy.
Salpingostomy is associated with higher subsequent IUP and
recurrent EP rates compared with salpingectomy.
• Methotrexate is a viable alternative to laparoscopic
salpingostomy for a selected group of patients.
• All Rh-negative, unsensitized women who have EP should
receive anti-D immunoglobulin.
• Avoid pregnancy for at least 3 months to permit the tube
normalize and the methotrexate completely eliminated.
“Education is not the learning of facts, but
The training of the mind to think”.
Albert Einstein
Great minds discuss ideas; average minds
discuss events; small minds discuss people
Our greatest fear should not be of failure… but
of succeeding at things in life that don’t really
matter
