ECTOPIC PREGNANCY
Dr.Najwa.B.Eljabu
Arab & Libyan Board
Msc reproductive and Maternal sciences
Glasgow University
DEFINITION
Ectopic pregnancy is implantation occurring outside the
uterine cavity.
Either implanted outside the uterus (fallopian tube, ovary
and abdominal cavity) or in abnormal position within the
uterus (cornua, cervix).
Combined tubal and uterine (Heterotopic) pregnancies are
uncommon)
It is a major cause of maternal mortality in the first
trimester.
OVERVIEW
Incidence Increasing (16/1000 Pregnancies in UK)
95-98% tubal
50% ampulla
20% isthmus
12% fimbrial
10% interstitial
Mortality Decreasing With Better Detection
Surgical and Medical Treatment Available
Recurrence Rate ~ 10-15%
RISK FACTORS
Maternal age
Number of sexual partners
Cigarette smoking
Previous Ectopic Pregnancy
PID (Gonorrhea, Chlamydia)
Tubal Surgery or pelvic surgery
Infertility and infertility treatment
ICUD
IVF
SITES
Ampulla (50%)
Isthmus (20%)
Cornua (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)
Simultaneous intrauterine and ectopic pregnancies
(heterotopics) occur in 1/3000 to 1/30000 pregnancies
SYMPTOMS
Amenorrhea (typically 6-8 weeks)
Abdominal Pain
Vaginal Bleeding (small amount)
Syncope
Pelvic Mass
Shoulder tip pain
15% of the cases present acutely with abdominal pain,
amenorrhea and haemodynamic compromise
In most cases the history will be more chronic
Arias-stella reaction
EVALUATION AND DIAGNOSIS
History and Physical Exam
Blood investigations (CBC, blood group)
Serial Quantitative HCG
Ultrasound
Laparoscopy
EVALUATION AND DIAGNOSIS
Clinical:
O/E: look for signs of intra-peritoneal hemorrhage
Abdominal tenderness(95%)
Peritonism
Abdominal distension
Pain on movement of the cervix (cervical excitation
(50%)
Adnexal mass (63%)
Cervix ----closed
SERIAL B-HCG
HCG Levels Double Every 48 Hrs
66% Rise / 48 Hrs Consistent With Ectopic
Single Determination Not Helpful
Best If Done Within Same Laboratory
At HCG of 1000 IU/L gestational sac of an
intrauterine pregnancy should be detected by US
ULTRASOUND
May or May Not Be Helpful
Discriminatory Zone:
TV: 1500-2000 mIU/ml
TA: 6500 mIU/ml
+IUP: Generally Excludes Ectopic
Free fluids in POD
Adnexal mass
TREATMENT
Observation
Laparoscopy
Laparotomy
Medical
MTX
Hyperosmolar Glucose
PG
OBSERVATION
Many Tubal Pregnancies Abort
Needs simple follow up
Criteria for selection of patients
Serial HCG levels and US
MANAGEMENT OF ACUTE
HEMORRHAGE
- Urgent hospital assessment
- Resuscitation
- Intravenous access and two large cannula
- Start IVF (colloid)
- Send for blood group, CBC and cross match
- Serum BHCG
- Transfer to theater
- Anti D should be given to all RH negative
women
LAPAROSCOPY
Allows Diagnosis and Treatment
Lower post op morbidity and quicker recovery
Salpingotomy
Salpingectomy (Total / Partial)
Cornual Resection
Minimally Invasive, Unlike Laparotomy
Few Contraindications: Unstable Patient
(Possibly)
MINI-LAPAROTOMY
Salpingectomy
Salpingotomy
Needed in acute intra-peritoneal
haemorrhage-------for immediate ligation of
the bleeding point
MEDICAL TREATMENT
Suitable patients are:
Haemodynamically stable
serum BHCG less than 10000IU/L
no extrauterine fetal heart by US
compliant patient
METHOTREXATE
Toxic to Trophoblast Cells
Minimal Side Effects
May Preserve Fertility in Cases of Cervical
Pregnancy
Requires Compliant Patient, Time
Pain Not Uncommon
BHCG May Rise Initially
PERSISTENT TROPHOBLAST
Most Often after Salpingostomy
Laparoscopic
Minilap
Most Easily Treated With MTX
OUTCOMES
15% Repeat Ectopic Rate
60-70% intra-uterine pregnancy after single
ectopic
SUMMARY
Ectopic Pregnancy is a Common, Treatable
Problem
Sensitive Assays Allow Early Detection
Surgical and Medical Options Exist
Ruptured Ectopics should be Unusual with
Compliant Patients and Appropriate Medical
Care
THANKS
