Ectopic pregnancy

Prepared by:

Dr. Gehanath Baral

MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
13th & 16th April,2007

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• Definition:- Implantation of fertilized ovum
anywhere outside the normal uterine cavity.
• Types:-
– Extrauterine:
• Tubal-97% (Ampulla-55%, Isthmus-25%, Interstitial-
20%,Infundibulum-18%)
• Ovarian-0.5%,
• Abdominal-1%
– Uterine-1.5%: Angular, Cornual, cervical
• Incidence:1:100

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 Causes
1. PID  loss of cilia, mucosal adhesion, peritubal
adhesion
2. Post surgical intrapelvic adhesion
3. Tubal surgery
4. Past ectopic pregnancy
5. ART
6. Tubal anomaly
7. IUCD/Defective tuboligation/Progestin only pills
8. Endometriosis

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 Pathology
1. Implantation in between mucosal fold

2. Less decidualisation,less muscle hypertrophy,more

stretching,blood vessels eroded

3. Intramuscular implantation

4. Pseudocapsularis by fibrin,epithelium,few muscles

5. Bleeding in between pseudocapsularis and ovum

6. Distention and thinning of tube

7. Decidual changes without chorionic villi in uterus

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 Mode of termination
1. Tubal mole:
– Complete absorption
– Abortion Pelvic hematocele
2. Tubal abortion
– CompletePelvic hematocele
– IncompleteDiffuse intraperitoneal hemorrhage
3. Tubal rupture
– Roof Diffuse intraperitoneal hemorrhage
– FloorIntraligameatary hematoma
4. Tubal perforation
– Roof20 abd.pregnancy
– Floor20intraligamentary pregnancy

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Mode of termination

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Ruptured tubal ectopic: Symptoms

1. Amenorrhoea

2. Abdominal pain:
– Tubal distention
– Colic
– Peritoneal irritation

3. P/V bleeding

4. Syncopal attack

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Ruptured tubal ectopic: Signs
1. Pallor and perspiring
2. Shock:
– Low BP
– High feeble pulse
– Cold extremity
3. P/A: Lower abd. Tenderness
4. P/V:
– Pale vaginal mucosa
– Bulky uterus
– Tenderness on fornix
– Cx excitation
– Bleeding

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Fate or tubal rupture

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 Unruptured tubal ectopic
1. Delayed period or spotting
2. Lower abd. Discomfort or colic
3. P/V:
– Uterus smaller than the period of amenorrhoea
– Forniceal mass:
• Pulsatile
• Round
• Separate from uterus
• Tender
4. Tests:
– TVS
– Radioimmunoassay of beta-hCG
– Laparoscopy

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 Chronic (old) ectopic: Symptoms
1. Amenorrhoea
2. Lower abd pain: AcuteDull/Colicky
3. P/V bleeding
4. Frequency and Dysuria
5. Tenesmus
6. Fever from infection of pelvic bleed

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 Chronic (old) ectopic: Signs
1. General:
– Sick looking
– Anemic
– Febrile
– Persistent tachycardia
2. P/A:
– Lower abd. Tenderness and guarding
– Irregular tender abd. Mass
3. P/V:
– Pale vaginal mucosa
– Tender buggy mass in pelvis attached to uterus
– Cx excitation

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 D/D:
1. Acute appendicitis

2. Peptic ulcer perforation

3. Torsion of ovarian cyst

4. Ruptured corpus luteal cyst or

Chocolate cyst

5. PID

6. Incomplete abortion
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 Investigation
Non-invasive procedures:

1. Blood: Hb, Grouping, TC, DC, ESR

2. USG:
– Empty uterus
– Adnexal mass of gestation
3. Beta-hCG:
– Low level
– Doubling time >2days
4. USG & beta-hCG
– -ve TVS & hCG>1500IU/L
– -ve TAS & hCG>6000IU/L
5. Serum progesteron
– <5ng/mlectopic or abnormal
– Normal>25ng/ml
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 Investigation

Invasive procedure:

• Culdocentesis

• Laparoscopy

• Laparotomy

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Management ruptured tubal ectopic

1. Resuscitation

2. Laparotomy &
removal of blood/
autotransfusion

3. Salpingectomy

4. Hysterectomy: if
interstitial ectopic

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Interstitial ectopic

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Salpingectomy

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Linear salpingectomy

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Management of old ectopic

1. Resuscitation

2. Laparotomy

3. Removal of blood clot

4. Salpingectomy

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 Unruptured tubal ectopic

• Expectant: For spont.resoluton

– Falling hCG
– Ectopic<4cm
– No evidence of bleeding/rupture
• Medical:
• Surgical:
1. Linear salpingostomy: Incision left open
2. Linear salpingotomy: Incision closed
3. Segmental resection
4. Removal from fimbrial end
5. Salpingectomy

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 Medical treatment
• Drugs:
1. Methotrexate
2. HCl
3. PGF2alfa • Methotrexate: 1mg/kg /day day
1,3,5,7
4. Hyperosmolar glucose +
5. Actinomycin • Folinic acid: 0.1mg/kg/day dai
• Indication: 2,4,6,8
– Stable pt./ Can be
followed up
– Sac<4cm without cardiac • Weekly beta-hCG testing untill
activity hCG<10mIU/ml
– hCG not >10,000mIU/ml
– No internal bleeding

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 Abdominal pregnancy
• Primary:rare

1. Both tubes and ovaries normal without evidence of recent

pregnancy
2. Absence of uteroplacental fistula
3. Presence of pregnancy on peritoneal surface

• Secondary=1:3000

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 20 Abdominal Pregnancy

Tubal wall perforation

Escape of gestation sac intact into the pelvic cavity

Placenta attached to the other structures

New vascular access from the host tissue

20 amniotic sac formed by fibrin deposition all around

Intestine, Omentum and other structures get attached to 20

sac
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 C/F
1. Pain and bleeding
2. Exaggerated pregnancy symptoms

3. Uterine contour not well defined

4. No Braxton Hick’s contraction
5. Easily felt fetal parts
6. Persistent malpresentation

7. P/V: Cx not softened, Abd.mass and uterus difficult to

separate

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 Diagnostic suspicion

• Repeated failure of induction in IUFD

• No contraction on oxytocin induction

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Fate of 20 Abdominal Pregnancy
1. Complete absorption

2. Massive intraperitoneal bleeding

3. Fistula formation to Contiguous organs

4. Lithopedion formation

5. Rarely reaches to term

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 Complication
1. Profuse abd.bleeding

2. Fetal death

3. Increased malformation

4. Increased NND

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 Test: USG

1. No uterine wall around the fetus

2. Fetal parts in close proximity to maternal abd. wall

3. Persistent attitude and malpresentation

4. Visualization of uterus separate to the fetus

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 Test: X-ray abdomen

1. High position of fetus without outline of uterine

shadow

2. Superimposed gas shadow on the fetal skeleton

3. Superimposed maternal and fetal spine

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 Management:

Laparotomy

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 Ovarian ectopic…
Spiegelberg’s criteria

1. Intact tube On the side of ectopic

2. Gestation sac in ovary

3. Gestation sac connected to uterus by ovarian ligament

4. Ovarian tissue on the wall of sac on histopathology

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…Ovarian ectopic
• Type:
– Intrafollicular
– Extrafollicular

• Presentation: Rupture

• T/T:
– Salpingo-oophorectomy
– Ovarian resection

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 Cervical ectopic
• Defn: Implantation at or
below the internal os

• Presentation:
1. Painless bleeding

2. Distended Cx

3. Continuous bleeding even

after evacuation or spont.
abortion

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Cx ectopic: Diagnostic criteria

1. H/O: Amenorrhoea followed by painless bleeding

2. O/E:
– Soft enlarged Cx
– Conceptus firmly attached and confined to endocervix
– Closed internal os and partially opened external os
3. USG:
– Pregnancy in Cx canal
– Empty uterine cavity
4. Villi inside Cx stroma on histopathology

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 Treatment

1. Medical: Methotrexate

2. Surgical:
– Hysterectomy
– Intracervical plugging

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