OBSTETRICS II
ECTOPIC PREGNANCY
APMC Textbook of Obstetrics 3rd ed.
Definition: implantation of the blastocyst outside the endometrial
lining of the uterine cavity
- Most common site: OVIDUCT
RISK FACTORS
• Alterations/damage of the normal function of the fallopian tubes
o Ex: obstruction – high risk following surgery of oviducts
(reanastomosis, tuboplasty, or sterilization)
• Previous pelvic inflammatory disease (PID) that results in bilateral
salpingitis (Chlamydia trachomatis – 1 of the primary causes)
• Tubal kinking and narrowing of the lumen from peritubular
adhesions following pelvic infections or surgeries
• appendicitis and endometriosis
• Failed contraception with IUD (tubal sterilization & progesterone-
only minipills increase number of ectopic pregnancy)
Tubal corrective surgery, tubal sterilization,
High risk
previous ectopic pregnancy, IUD, tubal pathology
Moderate Infertility, previous genital infection, multiple
risk partners
Previous pelvic/abdominal surgery, smoking,
Slight risk
douching, intercourse before 18 yrs old
PATHOGENESIS
• Primary types: interstitial/cornual, isthmic, ampullary, fimbrial
o Most common: 1st – ampullary, 2nd – isthmic
• Secondary types: tubo-ovarian, tubo-abdominal, broad ligament
• Fertilized ovum burrows and erode through the tubal mucosa
(muscular layer because submucosa is absent) ! maternal blood
vessels open ! blood pours into spaces in and around the
trophoblast ! expands ! tubal rupture
Progression of ectopic pregnancy:
1. Tubal rupture – spontaneous, but may be caused by trauma
assoc. w/ vigorous pelvic exam or coitus
o On early weeks of 1st trimester – ovum at isthmic segment
o Late ruptures – interstitial segment
• Small tubal rupture ! hemorrhage or small opening for
conceptus extrusion to peritoneal cavity ! hypovolemia
o Small conceptus – usually resorbed after extrusion
o Big conceptus – may remain in cul-de-say for years as an
encapsulated mass or may calcify to a lithopedion
2. Abortion – usually when ovum is in the ampulla
• Disconnection bet. conceptus and tubal wall ! hemorrhage
• Complete placental separation may lead to extrusion to
peritoneal cavity (bleeding may stop; resolution of symptoms)
• If some products remain in oviduct, bleeding persists and
blood will pool in the cul-de-sac
• Hematosalpinx - accumulation of blood in the oviduct
CLINICAL PRESENTATION
" Signs and Symptoms
• Most frequent: pelvic and abdominal pain, amenorrhea and
occasional vaginal bleeding or spotting (abnormal menses)
• Others: GI complaints in later parts of pregnancy, dizziness and
fainting accompanying massive hemorrhage
• Pain following rupture is felt all over the abdomen
• Vital signs (VS) stable before rupture
1. Moderate bleeding: normal VS or slight ↑BP or ↓HR
2. Progressive blood loss: ↓BP or ↑HR
• During pelvic exam, exquisite tenderness is elicited on motion of
the cervix (noted when about to rupture/already ruptured)
• Uterus may be pushed to one side by the ectopic mass or broad
ligament hematoma
" Laboratory Tests
A. Human Chorionic Gonadotropin (hCG) Assay
• Enzyme linked immunoabsorbent assay (ELISA) or serum and
urine – positive at 10 – 20 mIU/mL hCG
• Latex agglutination inhibition slide tests – positive at 500 –
800 mIU/mL hCG levels
B. Progesterone levels (Serum)
• >25 ng/mL = normal pregnancy (97.5% sensitivity)
• <5 ng/mL = ectopic pregnancy/intrauterine fetal demise
• this test is inconclusive because 5 -25 ng/mL is common
• those who undergo Assisted Reproductive Technology (ART)
has higher levels of progesterone
" Procedures
A. Culdocentesis
• Inserting a long, large bore needle (gauge 16-18) through an
adequately exposed posterior vaginal fornix into the pouch of
Douglas and aspirating the contents
• (+) = hemoperitoneum; 85% compatible w/ ectopic preg.
B. Ultrasound or Sonogram
• Transvaginal ultrasound – imaging technique of choice in early
pregnancy
• Findings: complex adnexal mass separate from the ovary,
echogenic fluid in the cul-de-sac
• (+) ectopic = Empty uterine cavity w/ 1,500 mIU/mL β-hCG
C. Laparoscopy (gold standard for dx)
• Favored over laparotomy because of the fast recovery time
and associated low morbidity
DIAGNOSIS
• When patient is hemodynamically stable, a pregnancy test
followed by a transvaginal ultrasound is warranted
• β-hCG > 1,000-2000 mIU/mL (discriminatory level)= normal
intrauterine pregnancy is visualized
• aspiration of non-clotting blood on culdocentesis when pregnancy
test is (+) suggest ectopic pregnancy
• Pregnancy of unknown location (PUL): (+) pregnancy, hCG levels
above discriminatory level, empty uterine cavity, no adnexal mass
on pelvic sonogram
1. Early pregnancy failure (abortion)
2. Early intrauterine pregnancy without definite identification
3. Ectopic pregnancy
• Normal mean doubling time of β-hCG = 48 hrs
o If initial titer < discriminatory level, repeat assay every 2 days
o If titre doesn’t double on follow-up and repeat TVS reveals an
empty uterine cavity ! unlikely intrauterine pregnancy ! do
dilatation and curettage
- Absent products of conception = ectopic pregnancy
- Present products of conception = failed pregnancy/abortion
• Shock Index (SI): ratio of heart rate to systolic blood pressure
(HR/SBP); can easily identify ruptured ectopic gestations
o Normal = 0.5 – 0.7
o Ruptured ectopic pregnancy = >0.85
o Index value increases in px w/ low baseline hgb levels
• Most sensitive predictors of ruptured tubal gestation:
o Abdominal pain
o Low hemoglobin
o Large amount of echogenic fluid in the pouch of Douglas
TREATMENT
" Medical Treatment
• Methotrexate – folic acid antagonist for proliferating trophoblast
o Regimen: single dose 50 mg/m2 IM (higher rate of persistent
ectopic pregnancy) or variable dose
o Single-dose IM MTX: β-hCG rises for the first 4 days, resolves
in 27 days; salpingostomy β-hCG level resolves after 20 days
o Indications:
- Pregnancy is < 6 wks
- Tubal mass is <3.5 cm
- Non-viable fetus
- Serum β-hCG < 15,000 mIU/mL
o Contraindications:
- Active intra-abdominal bleeding
- Breastfeeding
- Immunodeficiency & blood dyscrasia
- Alcoholism
- Peptic ulcer disease
- Liver or renal disease
- Active pulmonary disease
o To assess efficacy and safety, test for:
- Baseline serum β-hCG titre
- Normal hemoglobin
- Hematocrit & platelet levels
- Normal liver & renal function
o Falling β-hCG levels over a 6 wk period = successful
o Initial β-hCG of 10,000 IU/mL ! causes failures
o To counter side-effects = citrovorum factor (IV/IM/oral)
o Avoid coitus, alcohol, and taking folic acid or prenatal vitamins
" Surgical Management
• Can be conservative (laparoscopy) or radical (laparotomy)
 • Conservative surgery is reserved for the patient who desires
future fertility and is hemodynamically stable
o Salpingostomy, salpingotomy, partial salpingectomy,
segmental resection with or without reanastomosis
• Laparoscopy – modern tx for ectopic pregnancy
o Advantages over laparotomy: preserves pelvic function, less
morbidity and faster recovery time
• Ectopy in distal third of oviduct = salpingostomy/salpingotomy
• Ectopy at isthmic portion = segmental resection
• Salpingostomy – linear incision on the antimesenteric side of the
involved oviduct where conceptus is removed; incision left to heal
• Salpingotomy – incision is closed with fine sutures
• Salpingectomy – excision of the oviduct from its uterine
attachment; done is oviduct is damaged beyond salvage
PERSISTENT ECTOPIC PREGNANCY
• Complication of conservative management; may lead to rupture
• Occurs with incomplete removal of the products of conception
• 14-day mean time rupture
• Rare when β-hCG < 50% of preoperative value
• “Separation pain” – experienced several days after MTX therapy;
mild and self-limiting, relieved by non-narcotic analgesics
• Px with severe pain: monitored with serial hct, serum β-hCG and
transvaginal sonogram
• Factors that may increase risk of persistent ectopy:
1. small pregnancies (<2 cm)
2. early therapy (before 42 menstrual days)
3. β-hCG serum levels exceeding 3,000 mIU/mL
4. Implantation medial to the salpingostomy site
• Tx: MTX or surgery
PROGNOSIS
• Subsequent conception rate = 60% (the rest = infertile)
• After initial ectopy, 1 of 3-4 conceptions will be ectopic
• Modifying factors: age, parity, history of infertility, diseased
contralateral oviduct, rupture or unruptured state & IUD use
• Higher fertility rate: parous px < 30 yrs old, high parity (>3 births)
and with unruptured ectopic pregnancies
• Lower fertility rate: 1st pregnancy ectopy, w/ hx of infertility, w/
hx of salpingitis, diseased contralateral oviduct, & ruptured ectopy
• Conservative tx of unruptured ectopic pregnancy = high incidence
of subsequent fertility
OTHER TYPES OF ECTOPIC PREGNANCY
A. Heterotropic Pregnancy
• Ectopic pregnancy that exists w/ a normal intrauterine pregnancy
• Assisted reproductive technology (ART) – contributes to incidence
Ex: ovulation induction, IVF, embryo transfer (ET)
• Suspicion of its presence is heightened by:
1. following ART
2. absent vaginal bleeding w/ signs & symptoms of ectopic preg.
3. persistent or rising hCG titres after D&C for spontaneous
abortion
4. Uterine size is bigger than AOG
5. Visualization of more than one corpus luteum
6. Presence of intra and extra uterine pregnancies on ultrasound
• Tx: surgical approach (preserve normal intrauterine gestation)
B. Cervical Pregnancy
• Blastocyst implants within the endocervical canal and proceeds to
grow and develop in the fibrous cervical wall
• Pathogenesis: rapid ovum transport or delayed ovum maturation
predisposes it to implant in the endocervical canal
• Cervix: dilated and is disproportionately enlarged compared to
uterus, bluish/purplish in color, & distended/edematous
• Rarely grows beyond 20 wks
• Sonologic criteria:
o Placenta and entire chorionic sac w/ a live pregnancy is below
the internal os
o Cervical canal is dilated and barrel shaped
o Empty uterus
• MRI to confirm diagnosis
• Factors to consider for management: desire of the px for children
and her hemodynamic status
• Hysterectomy is reserved for px with:
o Completed family
o Intractable hemorrhage
o 2nd or 3rd trimester pregnancy
o no consent for blood transfusion
• Conservative therapeutic options (1 or a combination of the ff):
1. systemic MTX and sulprostone
2. intra-amnionic injection of MTX, KCl and hyperosmolar glucose
3. local injection of vasopressin, MTX and PG
4. Tamponade
5. cervical and uterine artery embolization or ligation
6. cerclage
7. curettage
C. Interstitial Pregnancy
• Relatively rare; conceptus is implanted in the interstitial segment
of the fallopian tube that is embedded in the uterine cornu
• anatomy of this area allows greater accommodation w/c accounts
for its difficult early dx, late onset of symptoms and occasional
reports of term interstitial pregnancies
• ↑ vascularity = ↑ risk of traumatic rupture and hemorrhagic shock
• sometimes called “cornual pregnancy” (embeds and develops in a
horn of a bicornuate uterus)
• traditional tx: laparotomy w/ salpingectomy plus cornual resection
or sometimes hysterectomy
• may also be treated with MTX
D. Ovarian Pregnancy
• Rare; risk factors, symptoms & PE findings same as tubal preg.
• IUD is associated with high proportion of cases
• Can be primary or secondary
• Diagnostic criteria for primary type (established during surgery):
1. the tube including the fimbria ovarica is intact
2. gestational sac is in the normal anatomic location of the ovary
3. the sac is connected to the uterus by the ovarian ligament
4. definitive ovarian tissue is histologically seen in the wall
• Secondary type: fertilization occurs in the oviduct w/ subsequent
tubal abortion and final ovarian attachment and growth
• Rupture at an early stage – common course
• Transvaginal ultrasound – helpful in early detection
• Classic management = laparotomy
o Ovarian wedge resection ! small involved area
o Ovariectomy ! large involved area
• Resection or laser ablation = preferred treatment
• MTX also effective for unruptured state
E. Abdominal Pregnancy
• 1% of all ectopic pregnancies; rare variant ! omental pregnancy
• Primary abdominal pregnancy – first and only nidation of the
peritoneal surface; criteria for diagnosis:
o Tubes appear normal with no evidence of recent or past injury
o No uterine fistula or evidence of uterine rupture
o Pregnancy is exclusively attached to the peritoneal surfaces
and is early enough to eliminate the possibility of secondary
implantation following primary tubal nidation
• Secondary abdominal pregnancy – more common; pregnancies
occur following tubal abortion or early tubal/uterine rupture with
subsequent implantation and growth in peritoneal surfaces
• Symptoms:
o Abnormal uterine bleeding
o Abdominal pain following a period of amenorrhea
o Discomfort, nausea, vomiting, diarrhea or constipation
o Painful fetal movements are felt late in pregnancy
• Abnormal fetal positions are common; cervix is displaced &
uneffaced; uterus is separate from the pregnancy mass
• Diagnosis
o Early unexplained anemia (tubal rupture/abortion)
o Elevated serum α-fetoprotein are sometimes noted
o MRI (after suspicious ultrasound findings)
o Computed axial tomography scan – if radiation isn’t a concern
• Preoperative preparations:
o Blood components
o Infusion IV systems capable of rapid delivery of large volumes
o Transcatheter embolization of major feeder vessels (if feasible)
• Leaving placenta behind ! safer course of action (placental
separation may lead to life-threatening hemorrhage)
o Consequences: adhesions, infection with abscess, intestinal
obstruction, wound dehiscence, partial urethral obstruction
with reversible hydronephrosis and persistent preeclampsia
o Resorption of placenta monitored w/ ultrasound & β-hCG
F. Pregnancy in a previous cesarean scar
• Rarest type
• Product of conception lies outside the uterine cavity surrounded
by the myometrium and the fibrous tissue of the previous
cesarean section scar
• Important risk factor: performance of CS when the lower uterine
segment is poorly developed
• Symptoms vary from scanty vaginal bleeding to hemorrhage
• Sonography helps in dx:
o Uterine and cervical cavities are empty
o Development of the gestational sac in the anterior part of the
uterine isthmus
o Attachment of gestational sac to the scar
o Absence of healthy myometrium between the urinary bladder
wall and gestational sac
• MTX has best results if 6-8 wks, sac <2 cm, no cardiac activity
• Other tx modalities:
o Laparoscopic excision of gestational sac followed by repair of
lower uterine segment; uterine artery embolization; suction
curettage with ultrasound guide