UNUSUAL ECTOPIC

PREGNANCIES
Presentan : Dr. Abdul Bari
Moderator : Dr. H. Azhari, SpOG(K)

 Ectopic pregnancy is defined as the abnormal implantation and growth of a

conception outside the uterine cavity.
Under normal physiologic conditions, a fertilized ovum migrates from the ampulla of
the fallopian tube to implant on the wall of the endometrium.
However, if the conception fails to reachits normal position within the endometrial
cavity, an ectopic pregnancy occurs.
Early diagnosis is critical to initiate treatment before rupture with possible
hemoperitoneum and resultant hypovolemic shock.

The rates of ectopic pregnancy have dramatically increased

over the past several decades
Most ectopic pregnancies are detected in women older than 35
years and those of non white ethnicities.
Risk factors for the development of ectopic pregnancy are
predominantly due to abnormal fallopian tube function

 These risk factors include

a history of ectopic pregnancy,
a history of tubal surgery (ie, tubal ligation),
sexually transmitted disease or
pelvic inflammatory disease,
endometriosis,
smoking,
progesterone- only contraceptives,
and artificial reproductive technology (in vitro fertilization [IVF]).

 Early signs and symptoms of ectopic pregnancy :

missed menstrual periods,
vaginal bleeding,
abdominal/back pain,
nausea, and
breast tenderness.

Nonspecific physical examination findings :

cervical motion tenderness,
a palpable adnexal mass, and
uterine bleeding

 Transvaginal sonography of the pelvis remains the primary imaging technique in the
evaluation of ectopi c pregnancy.
Various transvaginal sonographic criteria :
including visualization of a live extrauterine pregnancy,
an extrauterine gestational sac containing a yolk sac or embryo,
an empty tubal ring, and
a noncystic adnexal mass

A more recent study in the obstetrics literature by Condous et al showed transvaginal

sonography to have a 91% sensitivity and 100% specificity as well as a 94% positive
predictive value and100% negative predictive value in the diagnosis of ectopic pregnancy.

 Approximately 95% to 97% of all ectopic pregnancies occur within the fallopian tube.
The most common location for a tubal ectopic pregnancy :
the ampulla (70%),
isthmus (12%) and
the fimbria (11%).

However, ectopic pregnancies can also implant outside the fallopian tube:
the abdomen,
cervix,
ovary,
cesarean delivery scar,
or interstitial/ intramural segment of the fallopian tube.

Abdominal Pregnancy
Abdominal pregnancy is defined as implantation
in the peritoneal cavity, exclusive of tubal,
ovarian, or intraligamentary pregnancy (Figure
1).
The risk factors for abdominal pregnancy are
similar to risks described for other ectopic
pregnancies with the exception of cocaine use,
which is exclusively associated with abdominal
pregnancy

 Primary abdominal pregnancy is defined as direct peritoneal implantation of the

fertilized ovum andis diagnosed by the Studdiford criteria
normal fallopian tubes and ovaries;
absence of a uteroperitoneal fistula; and
attachment exclusively to a peritoneal surface early enough to eliminate the possibility of a
secondary gestation.

Secondary abdominal pregnancy is defined as reimplantation of a ruptured

extrauterine pregnancy, most commonly tubal, in the peritoneal cavity.

 Sonographic features that can suggest abdominal pregancy diagnosis :

empty uterus adjacent to the bladder,
absence of a myometrium around the fetus,
a poorly visualized placenta,
an unusual fetal lie, and
relative oligohydramnios.

Magnetic resonance imaging can help delineate maternal and fetal anatomy and
determine the exact position of the placenta for preoperative planning.

 In early gestation when an embryo is present, laparotomy is preferred, although

laparoscopic surgical intervention remains an option in low-risk
Isolated or adjunctive treatments with methotrexate and preoperative embolization
of the placenta have also been
Regardless of the treatment of choice, precise preoperative planning using available
imaging tools is crucial to prevent complications and reduce mortality.

Cervical Pregnancy
Cervical pregnancy
implantation of the
pregnancy in the endocervical
canal below the level of the
internal os (Figure 2)
The risk factors, including
intrauterine adhesions,
cesarean deliveries, fibroids,
and previous therapeutic
abortions, have all been
associated with cervical.

 Specific sonographic guidelines have been established to assist the radiologist and
clinician in making an accurate diagnosis. These guidelines include the following:
an echo-free uterine cavity;
decidual transformation of the endometrium with a dense echo structure;
an hourglass uterine shape;
a ballooned cervical canal;
a gestational sac in the endocervix;
placental tissue in the cervical canal;
a closed internal os

Additionally, it is crucial to differentiate between a cervical pregnancy and cervical

abortion, in which an aborted intrauterine pregnancy is passing through the cervical
canal (Figure 3).

 Treatment options :
Tamponade for short-term stabilization with cervical packing or a Foley balloon
uterine artery embolization to control or reduce hemorrhage,
trophoblast excision by dilation and curettage
hysteroscopic resection,
hysterectomy.

Systemic chemotherapy, such as intramuscular methotrexate injection, is an

alternative option

Cesarean Scar Ectopic Pregnancy

Cesarean scar pregnancy is
implantation of a pregnancy in the
scar from a previous cesarean
delivery.
The gestational sac is completely
surrounded by myometrium and
fibrous tissue of the cesarean
delivery scar and is distinctly
separate from the endometrial
cavity (Figure 4).

 Risk factors associated with cesarean scar pregnancy :

a history of multiple cesarean deliveries,
placental disease,
ectopic pregnancy,
breech cesarean delivery

Symtomps :
painless first trimester bleeding,
vaginal bleeding with mild abdominal pain or isolated abdominal pain
severe pain or profuse bleeding is of concern for rupture.

Treatments :
as conservative as local methotrexate injection and
as extreme as complete hysterectomy

Heterotopic Pregnancy
Heterotopic pregnancy is defined as the
simultaneous development of extrauterine and
intrauterine gestations (Figure 5).
The risk factors :
history of ectopic pregnancy,
history of pelvic surgery,
congenital or acquired uterine cavity abnormalities

 Clinical findings :
Abdominal pain,
an enlarged uterus,
an adnexal mass,
and peritoneal irritation

A heterotopic pregnancy can clinically be differentiated from an ectopic pregnancy

by lack of vaginal bleeding, as an intact intrauterine gestation is present

Interstitial Ectopic Pregnancy

Interstitial pregnancy is another rare type of
ectopic pregnancy in which the blastocyst
implants in the interstitial portion of the fallopian
tube (Figure 6).
The interstitial portion of the tube is located at the
junction of the fallopian tube and the uterus.
The term interstitial is often interchangeably used
with cornual pregnancy.
An angular pregnancy, which is a similar but
separate entity, is described as implantation in the
lateral uterine angle just medial to the interstitial

 Risk factor for interstitial pregnancy :

IVF.
Uterine anomalies,
prior salpingectomy,
ovulation induction,
Previous ectopic pregnancy,
history of sexually transmitted disease.

 The most reliable imaging finding is the interstitial line sign, which describes an
echogenic line extending from the border of the intramural gestation to the corneal
region of the uterine cavity.
If the echogenic line sign is not present, the combination of the latter 2 findings
along with an empty uterine cavity are useful for diagnosing interstitial pregnancy,
with an approximate sensitivity of 40% and a specificity of 90%.
Conservative treatment options :
laparoscopic cornual evacuation or resection,
local injection of vasoconstrictors,
local and/or systemic administration of methotrexate

Ovarian Pregnancy
Ovarian pregnancy is another uncommon
type of ectopic pregnancy (Figure 7).
Risk factors :
intrauterine device use,
assisted reproductive technology such as IVF,
endometriosis,
pelvic inflammatory disease,
prior surgery

 The 4 classic anatomic and histologic Spielberg criteria include the following:
the fallopian tube should be intact and separate from the ovary;
The gestational sac should occupy the normal position in the ovarian pelvis;
the gestation should be connected to the uterus by the ovarian ligament;
ovarian tissue must be present in the specimen connected to the gestational

Ovarian gestations are mostly treated :

surgically with oophorectomy or wedge
conservative medical management, particularly with systemic methotrexate administration
75 or even
laparoscopic injection of methotrexate into the sac

Conclusions
The overall rate of ectopic pregnancy continues to rise.
Early recognition of the signs and symptoms of ectopic
pregnancy is paramount to achieving positive patient
outcomes.
Despite the substantial increase in incidence, ectopic
pregnancy remains a challenging diagnosis in the emergency
department setting.
Therefore, skilled sonographic evaluation of the pelvis in a
patient with a suspicion for ectopic pregnancy is invaluable.

Transvaginal sonography plays a vital role in the detection of

these unusual types of ectopic pregnancy.
Sonographic features such as an echo-free uterine cavity and
the interstitial line sign can help the physician in the diagnosis
of these rare forms.
Knowledge of these imaging characteristics can facilitate the
difficult diagnosis of ectopic pregnancy and prompt
appropriate management.

Thank You