Ectopic Pregnancy

DEFINITION
Customarily it is called extrauterine
pregnancy.

It refers to the implantation of fertilized

ovum on any tissue other than the
mucous membrane lining the body of
uterine cavity.
 Classification
•fallopian tube (1.ampulla 2. isthmus 3.infundibulum 4.interstitial)
termed as tubal pregnancy
95 percent of all ectopic pregnancy
the ampulla is the commonest site
the scale is 60%.
•cervix
•ovary
•abdominal cavity
•broad ligament
 INCIDENCE
•In China the incidence is about 1 case to
56~93 mature intrauterine pregnancy.
•In Britain is 1 case to 150.
•In some countries where pelvic infection
is common, the incidence is much higher.
It is 1 in 28.
 ETIOLOGY
1.Chronic salpingitis
2.Developmental or functional
abnormalities of the tube
3.Use of intrauterine contraceptive devices
(IUD)
4.Previous operation on the tube
5.Pelvic endometriosis
6.Transmigration of ovum
 PATHOLOGY
1.Termination of the
tubal pregnancy

2.Uterus
Termination of the tubal pregnancy
the tube has no decidua and the muscular wall of the
tube is thin, so the embryo is not suitable to be
growing in tube. (three layer: serosa, muscle, and
mucosa)
A tubal pregnancy may terminate in follow ways:
(1) Tubal abortion
(2) Rupture of tubal pregnancy
(3) Abdominal pregnancy
isthums rupture occurs early at about 6 weeks
ampulla rupture at 8~12 weeks
interstitial rupture at 3~4 months
 Uterus
•It is slight enlargement and softening.
•Endometrium is altered to become a
decidue.
• If embryo dies, endometrium may be
passed (or is shed in fragments), it is called
“decidual cast”. The patients have some
external bleeding.
 CLINICAL FEATURE
Amenorrhea
Abdominal pain
Symptoms Vaginal bleeding
Syncope
Shock
General condition
Signs Abdominal examination
Pelvic examination
 Amenorrhea
•Usually patients have a menopause about
6~8 weeks except interstitial pregnancy.

•The absence of missed menstrual period

by no means rules out tubal pregnancy.

•A history of amenorrhea is not obtained in

20 percent of cases.
 Abdominal pain
•Severe pain is due to sudden rupture of tube.
•In the presence of hemoperitoneum, pain
from diaphragmatic irritation may be
experienced.

•Appreciable blood in the peritoneal cavity

may lead to a degree of peritoneal irritation
and varying degrees of discomfort.
 Vaginal bleeding
•Slight dark brownish bleeding
may be intermittent or continuous.
•Decidual cast may be expelled in
some cases.
 Syncope and shock
•This occurs due to abdominal pain and
severe bleeding.
•Profuse intraperitoneal heamorrhage
and severe pain will result in sudden
shock and collapse of the woman.
 General condition
•Skin is pallor.
•Pulse is rapid.
•Blood pressure is low when shock
occurs.

•The temperature may be normal or even

low after acutehemorrhage. When
temperature up to 38℃, it perhaps
related to hemoperitoneam. Higher
Abdominal examination
Signs of abdominal palpation:
(when tubal rupture occurs)
• shifting dullness is positive
• extremely tender and distention
• pelvic mass (soft ,elastic, or firm )
 Pelvic examination
---speculum & bimanual examination
•Vagina: the posterior fornix bulge because
of blood in the cul-de-sac
•Cervix: marked pain on motion
•Uterus: slight enlargement and softening
•Adnexa: A tender, boggy mass may be felt
on one side of the uterus
•In existence of interstitial pregnancy, the
uterine size corresponds to the gestational
age, but is asymmetrical. The feature of
rupture looks like rupture of uterus.
 DIAGNOSIS
•It based on history, symptoms, signs
and supplementary examination.

•The classic trail of amenorrhea,

vaginal bleeding and pain occurs in
only 25% of cases.
 DIAGNOSIS
There are five common supplementary
examinations:
Culdocentesis
Pregnancy test
Sonography
Laparoscopy
Endomentrial curettage
 Culdocentesis
It is used to diagnose the presence of
hemoperitoneum.
As the cervix is pulled toward the symphysis
with a tenaculum, a long 18-gauge needle is
inserted through the posterior vaginal fornix
into the cul-de-sac. Fluid can be aspirated. If
fluid is dark blood and contain small clots or
blood is non-coagulable, the diagnosis may be
confirmed.
 Pregnancy test
Three methods for testing human
chorionic gonadotropin ( hCG, secreting
by the trophoblastic cells ) :
agglutination inhibition assays
(older method)
enzyme-linked immunosorbent assay
(ELISA)
radioimmunoassay
(RIA)
 Pregnancy test
Pregnancy tests based on hCG are
often misleading (false-positive and
false-negative)
Specific radioimmunoassays for beta
subunit of hCG (β-hCG) will minimize
the likelihood of false-negative tests.
 Sonography
•The effect of B-ultrasonic examination is
less than HCG determination in early
diagnosis. But it is significant in making a
diagnosis of interstitial diagnosis.

•It is useful in distinguishing ectopic from

early intra-uterine pregnancy in which a
gestational ring can be dectected .
 Laparoscopy
•It is more time-consuming but more
reliable.
•It is very useful in the management of
patients suspected to having an ectopic
pregnancy.
•It more recently has been used for
operative management.
 Endometrial
curettage
It’s only decidua without
chrorionic villi.
 DIFFERENTIAL
DIAGNOSIS
Tubal pregnancy differentiates with:
•abortion of intrauterine pregnancy
•acute appendicitis
•rupture of luteum or follicular cyst
•salpingitis
 MANAGEMENT
•Surgical treatment.

•Therapy of combining traditional

Chinese medicines and western
medicine.
 Surgical treatment
•It is the major therapy of tubal pregnancy.
•Once diagnosis is made, immediate
laparotomy is required. Salpingectomy will
permit.
•In interstitial ectopic pregnancy, either before
or after rupture, operation is required.
•Conservative surgical treatment is done in
young woman who wants to labor another
baby.
•Take blood transfusion when patient is in
 Therapy of combining traditional
Chinese medicines and western medicine

Methotrexate is effective in
the management of gestational
trophoblastic disease and may
have a place in the treatment
of selected cases of ectopic
pregnancy.