ECTOPIC PREGNANCY

By Amielia Mazwa Rafidah

Obstetric and Gynecology
Department

Definition

An ectopic pregnancy is a gestation that

implants outside of the endometrial
cavity.
@
defined as pregnancy occurring outside
the endometrial lining of the uterus
It represents a serious hazard to a
womans health and reproductive
potential, requiring prompt recognition
and early aggressive intervention.

SITES

95% occur in the tubes: the commonest site is the Ampulla

(85%), followed by the Isthmus.
The uterus:

The Ovary
Broad Ligament
Abdominal:

I. Intramural.
II. Angular
III. Cervical
IV. Rudimentary Horn

I. Primary: first implantation occurs in a peritoneal surface.

II. Secondary: original implantation occurs first in the tube-ostia,
aborted subsequently then reimplanted into a peritoneal surface.

Multiple Ectopic: may occur:

Involving both tubes

Combined intra- & extra-uterine pregnancy

Epidemiology

Since the early 1970s, the incidence of

ectopic pregnancy has tripled, and
currently this condition represents the
fourth leading cause of maternal
mortality overall (4%) and the most
common cause of maternal mortality in
the first trimester.
The overall incidence of ectopic
pregnancy is estimated to be at least one
in every 200 pregnancies.

Etiology

Probably as many as 50% of cases result

from alteration of tubal transport
mechanisms secondary to damage to the
ciliated surface of the endosalpinx
caused by infections such as Chlamydia
and gonorrhea.

Others are the result of intrinsic

abnormalities of the fertilized ovum and
possibly transmigration of the oocyte to
the contralateral tube, with resulting
delays in passage.

Evolution

Tubal pregnancies rapidly invade the

mucosa, feeding from the tubal vessels,
which become enlarged and engorged.
The segment of the affected tube is
distended as the pregnancy grows.
Possible outcomes of such abnormal
gestations are as follows:

The pregnancy is unable to survive owing

to its poor blood supply, thus resulting in
a tubal abortion and resorption , or it is
expelled from the fimbriated end into the
abdominal cavity.

The pregnancy continues to grow until

the overdistended tube ruptures, which
resulting profuse intraperitoneal
bleeding.

In rare instances, a tubal pregnancy will

be expelled from the tube and seed onto
sites in the abdominal cavity (e.g. the
omentum, the small/large bowel, or the
parietal peritoneum), and gives rise to a
viable abdominal pregnancy

High risk factors

High risk factors can be summarized as
follows:
A history of tubal infection (ectopic rate
of 1:24, as opposed to 1:200 in non
infected patients)
Prior ectopic pregnancy (15% to 50%
increase in incidence of ectopic gestation
in subsequent pregnancies)
History of tubal sterilization within the
past 1 to 2 years (higher incidence if
cauterization was used)

History of tubal reconstructive surgery

(tuboplasty or end-to-end reanastomosis
for sterilization reversal)
Pregnancy with an IUD in place or a
history of IUD use.
Infertility.
More than one therapeutic abortion
(controversial)
Pregnancy resulting from failed postcoital
contraception (probably associated with
abnormal tubal transport)

Symptoms and Clinical

Diagnosis

The classic symptom triad

amenorrhea,
vaginal

bleeding,
abdominal pain

normal pregnancy findings like breast

tenderness, nausea and urinary
frequency are also found.

Abdominal pain, usually in the lower

abdomen in early cases, or generalized in
ruptured ectopics with a hemoperitoneum.
Amenorrhea or a history of an abnormal last
menstrual period is found in 75% to 90% of
ectopic pregnancies.
Vaginal bleeding, from spotting to the
equivalent of a menstrual period, results
from a low human chorionic gonadotropin
(hCG) production by the ectopic trophoblast
and is seen in 50% to 80% of patients.

Making the diagnosis of an acutely

ruptured ectopic pregnancy is fairly
straightforward.
The patient presents with symptoms of
increasing abdominal pain, abdominal
distention, and hypovolemia.
The entire abdomen is acutely tender
with guarding and rebound tenderness

Physical examination

in patients with an unruptured ectopic pregnancy

may be extremely variable.
90% have abdominal tenderness, but
only 45% have positive rebound tenderness, and
only 50 % have an adnexal mass on pelvic examination.

In half the cases, the mass is contralateral to the

ectopic pregnancy and represents the corpus
luteum.
20%present with bilateral adnexal masses owing
to the presence of a contralateral coupus luteum
cyst. The uterus is soft and either of normal size
or slightly enlarged.

Differential Diagnosis

Many gynecologic and nongynecologic

disorders have symptoms in common with
ectopic pregnancy.
Gynecologic disorders to be considered
include :
Threatened or incomplete abortion
A ruptured corpus luteum cyst
Acute pelvic inflammatory disease with fever,
abdominal pain, leukocytosis, and, at times, adnexal
masses.
Adnexal torsion
Degenerating leiomyoma (common in pregnancy)

The key to the successful management of

ectopic pregnancy is early diagnosis.
Although the number of new cases has
increased threefold, fewer are arriving at
the hospital ruptured, with the patient
already in hemorrhagic shock.
This decrease is evidence that a high
index of suspicion and vigorous efforts at
early diagnosis are effective.

-hCG testing

Human chorionic gonadotropin is

consisting of two linked subunits, and
-hCG is secreted by both the
cytotrophoblast and the
syncytiotrophoblast and has the sole
function of supporting the corpus luteum.
Abnormal -hCG could not provide
information on the location of the
pregnancy.
Ultrasonography must be used to locate
the gestation.

Ultrasonography

its application to the diagnosis of ectopic

pregnancy, alone and in combination with
hCG testing, is now the standard of care.
Transvaginal ultrasonography has allowed
the detection of an intrauterine
gestational sac at as early as 5 weeks of
amenorrhea (2 mm diameter).

If the sac is not visualized at the uterine

cavity, special attention is needed to
differentiate between a true sac and a
pseudosac, which is a ring-like structure
produced on ultrasound by a prominent
decidual echo.
Evidence of hemoperitoneum may be
inferred by the sonographic description of
free fluid in the cul-de-sac.

Culdocentesis

Culdocentesis is the technique by which a

needle, attached to a syringe, is inserted
transvaginally through the posterior vaginal
fornix into the pouch of Douglas to detect any
fluid within the peritoneal cavity
Although the procedure is simple, inexpensive,
and rapid, it is quite uncomfortable for the
patient and is of limited use in an unruptured
ectopic pregnancy.
It is unnecessary when the diagnosis is
obvious and has a high false-negative rate.

Technique for
culdocentesis

Management

Emergency treatment
Surgical treatment
Laparotomy
laparoscopy

Medical treatment
Expectant management

Emergency treatment

Immediate surgery is indicated when the

diagnosis of ectopic pregnancy with
hemorrhage is made.
Transfusion with whole blood or an
appropriate blood component therapy as
soon possible is indicated when the
patient is in shock.

Surgical treatment

Rapid entry into the abdomen should be

accomplished, as control of hemorrhage can
be lifesaving.
Careful, fast exploration of the abdominal
cavity should be done at once.
Remove products of conception, clots, and
free blood.
At operation the damaged tube is usually
removed.
This procedure is the most common for
ectopic pregnancy.

The type of procedure performed by either

laparoscopy or laparotomy will be dictated
by local findings at the time of surgery and
the desire of the woman for future fertility.
In patients who with to conserve fertility, a
linear salpingostomy is the treatment of
choice in unruptured ampullary
pregnancies.
In ampullary pregnancies that have already
ruptured, a segmantal resection or partial
salpingectomy can be offered, which implies
the removal of only the affected segment of
tube, leaving the rest intact.

Medical treatment

Unruptured ectopic pregnancy can be

treated with Methotrexate (MTX).

Indications

no contraidications to MTX
type of unruptured or abortion
unruptued mass <4 cm at its greastest
dimension
-hCG level <2000mIU/ml
without signs of hemoperitoneum

MTX Containdications

ABSOLUTE

Breast feeding.
Immunodeficiency
Alcoholism or related Hepatic Cirrhosis.
MTX sensitivity.
Active pulmonary disease.
Peptic Ulcer disease.
Hepatic, Renal or Hematologic dysfunction.

RELATIVE

Gestational Age >3.5 cm,

Embryonic HR present.

Expectant management

As many as 80% of ectopic pregnancies

with hCG levels of 1000mIU/ml or less will
not rupture spontaneously or bleed
profusely but will undergo spontaneous
resolution.
Expectant management is generally
reserved for reliable, relatively
asymptomatic patients in whom the hCG
titers are <200mIU/ml and delining.

Treatment of Uncommon Types

of Ectopic Pregnancies

Ectopic pregnancy and tubal pregnancy

are terms used interchangeably because
other sites of ectopic implantation are
rare.
A pregnancy can implant on the surface
of the ovary.
The treatment is aimed at removing the
pregnancy and sacrificing as little as
possible of the ovarian tissue.

Cervical pregnancy usually presents with

profuse vaginal bleeding, and attempts at
removal of the pregnancy are often
unsuccessful.
Hysterectomy is frequently indicated and
is usually quite difficult.
In more recent years, methotrexate have
been used to manage cervical pregnancy.

References

http://en.wikipedia.org/wiki/Ectopic_pregnancy
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/
http://www.google.com/imgres?q=ectopic+pregnancy
American College of Obstetricians and Gynecologists.
Management of recurrent and early pregnancy loss. ACOG
Practice Bulletin No. 24. Obstet Gynecol . 2001; 97 (2).
American College of Obstetricians and Gynecologists. Medical
management of abortion.
ACOG Practice Bulletin No. 67. Obstet Gynecol . 2005;106
(4):871-882.
American College of Obstetricians and Gynecologists. Medical
Management of tubal pregnancy.
ACOG Practice Bulletin No. 3. Obstet Gynecol . 1998;92(6):1-7.

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