ECTOPIC PREGNANCY

ALDILYN J. SARAJAN, MD, MPH

2ND YEAR OB-GYN RESIDENT
ZCMC
 EPIDEMIOLOGY

 1% to 2% of all pregnancies women

 The increased incidence of ectopic pregnancy is

thought to be due to two factors:

 (1) the increased incidence of salpingitis

 (2) improved diagnostic techniques
 MORTALITY

 Most common cause of maternal death in the first

half of pregnancy.
 The major cause is blood loss.

 Most cases of mortality

 70%result from gestations in the tube

 30% were interstitial cornual or abdominal gestations.
 ETIOLOGY

FACTORS CONTRIBUTING TO THE RISK

 Salpingitis
 Hormonal imbalance
 Cigarette smoking
 ETIOLOGY

TUBAL PATHOLOGY LEADING TO ECTOPIC RISK

 Disruption of normal tubal anatomy from infection,

surgery, congenital anomalies, or inflammatory
disease such as endometriosis is a major cause of
ectopic pregnancy.
 ETIOLOGY

TUBAL PATHOLOGY LEADING TO ECTOPIC RISK

 Endometriosis- 2x risk
 Salpingitis Isthmica Nodosa-
 Microscopic presence of tubal epithelium within the
myosalpinx or beneath the tubal serosa
 ETIOLOGY

TUBAL PATHOLOGY LEADING TO ECTOPIC RISK

 Tubal surgery
Rates of ectopic pregnancy
After salpingoplasty or salpingostomy procedures to treat 15% to 25%.
distal tubal disease ranges from
After reversal of sterilization procedures 4%
Previous ectopic 25%
After single dose methotrexate 8%
Salpingectomy 9.8%
Linear salpingostomy 15.4%
 ETIOLOGY

TUBAL PATHOLOGY LEADING TO ECTOPIC RISK

 Diethylstilbestrol Exposure

Rate of ectopic pregnancy

In women who have been exposed to diethylstilbestrol (DES) in 4% to 5%
utero
Exposed to DES whose hysterosalpingograms demonstrated 13%
abnormalities in the uterine cavity
 CONTRACEPTION FAILURE

 Laparoscopic surgery, female tubal sterilization

 10 years after the procedure, the cumulative life table

probability of pregnancy was 1.85%

 if pregnancy occurred after tubal sterilization by

laparoscopic fulguration, the ectopic pregnancy rate
was as high as 50%.
 CONTRACEPTION FAILURE

CONTRACEPTIVE RATE OF ECTOPIC

PREGNANCY
Copper T380 IUD or progestin-only oral 5%
contraceptives-
Progestogen-releasing IUDs 25%
 HORMONAL ALTERATIONS

 Exogenous progesterone administration, if increased

levels of exogenous or endogenous estrogens are
present shortly after the time of ovulation the
incidence of ectopic pregnancy is increased.

 ectopic pregnancy rate is about 1.5% for conceptions that

occur after ovulation has been induced with clomiphene
citrate.
 increased levels of estrogen, as well as of progesterone,
interfere with tubal motility and increase the chance of
ectopic pregnancy.
 HORMONAL ALTERATIONS

 Ectopic occur in about 1% of pregnancies that develop after in

vitro fertilization and embryo transfer.

 The reason for this increased incidence is likely due to one or

more of several factors:

 Increased sex steroid hormone levels

 The presence of proximal tubal disease (although the ratio is
similar in women with normal tubes)
 Flushing an embryo directly into the tube.
 PREVIOUS ABORTION

 Prior induced abortion increases the risk of ectopic

pregnancy, there is probably no major association of
increased risk.
SITES OF ECTOPIC PREGNANCY

 Most ectopic pregnancies occur in the tube.

SITES OF ECTOPIC PREGNANCY

Tubal 97.7%
Abdominal 1.4%
Ovarian or cervical 1%
 SITES OF ECTOPIC PREGNANCY

 Most ectopic pregnancies occur in the tube.

SITE OF TUBAL PREGNANCY

Ampullary 70% to 81%
• distal and middle
third of the tube.
Isthmus 12%
Fimbriae 5% to 11%
Interstitial 2%

A true cornual pregnancy is one located in the

rudimentary horn of a bicornuate uterus, and this
occurrence is quite rare.
SITES OF ECTOPIC PREGNANCY

 About 1 in 200 ectopic pregnancies are true ovarian pregnancies

that fulfill the four criteria originally described by Spiegelburg:

 1. The tube and fimbria must be intact and separate from the ovary.
 2. The gestational sac must occupy the normal position of the ovary.
 3. The sac must be connected to the uterus by the ovarian ligament.
 4. Ovarian tissue should be demonstrable in the walls of the sac.
SITES OF ECTOPIC PREGNANCY

 The hemorrhagic mass (ovarian ectopic)

 Should be located adjacent to the corpus luteum, never within
it.

 Associated with profuse hemorrhage,

 81% of reported to have a hemoperitoneum greater than 500 ml.

 Successfully treated by ovarian resection and not

oophorectomy.
SITES OF ECTOPIC PREGNANCY

 Most abdominal pregnancies

occur secondary to tubal
abortion with secondary
implantation in the peritoneal
cavity
 On rare occasions a primary
abdominal pregnancy may occur.
SITES OF ECTOPIC PREGNANCY

Abdominal pregnancy
 The following three criteria originally set forth by Studdiford
must be present:

 (1) the tubes and ovaries must be normal, with no evidence of

recent or past injury
 (2) there must be no evidence of a uteroplacental fistula
 (3) the pregnancy must be related only to the peritoneal surface
and early enough in gestation to eliminate the possibility of
secondary implantation after primary tubal nidation
SITES OF ECTOPIC PREGNANCY

Abdominal pregnancy

 Prognosis for fetal survival is poor, (11%).

 Laparotomy with removal of the fetus
 adjunctive option is to administer methotrexate
SITES OF ECTOPIC PREGNANCY

Abdominal pregnancy

 Prognosis for fetal survival is poor, (11%).

 Laparotomy with removal of the fetus
 adjunctive option is to administer methotrexate
 SITES OF ECTOPIC PREGNANCY

Cervical pregnancy
 Four pathologic criteria for the
diagnosis by Rubin and colleagues
are:
 (1) Cervical glands must be present
opposite the placental attachment
 (2) the attachment of the placenta to
the cervix must be intimate
 (3) the placenta must be below the
entrance of the uterine vessels or
below the peritoneal reflection of the
antero-posterior surface of the uterus
 (4) fetal elements must not be present
in the corpus uteri
SITES OF ECTOPIC PREGNANCY

Cervical pregnancy
 Clinical findings:

 Uterine bleeding after amenorrhea without cramping

pain
 A softened cervix that is disproportionately enlarged,
complete confinement and firm attachment of the
products of conception to the endocervix
 Closed internal os
SITES OF ECTOPIC PREGNANCY

Cervical pregnancy
 Treatment:

 Systemic methotrexate
 Angiographic uterine artery embolization evacuation of
the pregnancy
 performed trans-cervically with minimal blood loss
 Transvaginal ultrasound-guided injections of potassium
chloride directly into the gestational sac
SITES OF ECTOPIC PREGNANCY

 Uncommon form of ectopic gestation is

combinedintrauterine and extrauterine (heterotopic)
pregnancy (94% tubal and 6% ovarian)

 Heterotopic pregnancy
 a rare occurrence with an incidence between 1 in 16,000
or 1 in 30,000 pregnancies
SITES OF ECTOPIC PREGNANCY

 Chronic ectopic pregnancy

 occurs when the intraperitoneal hemorrhage associated
with tubal abortion or rupture is relatively minor and
ceases spontaneously, but the ectopic gestation neither
resolves completely nor implants and continues to
develop as an abdominal pregnancy.
SITES OF ECTOPIC PREGNANCY

 Cesarean scar ectopic pregnancy

 The gestational sac is located in the previous cesarean scar
and is surrounded by myometrium and connective tissue
 It is believed that the mechanism for implantation is due to
the migration of the embryo through a small defect in the
previous incision site or a microscopic fistula within the scar.
 Adenomyosis, in vitro fertilization, previous dilation and
curettage, and manual removal of the placenta are also
reported as risk factors.
 HISTOPATHOLOGY

 After implanting on the

mucosa of the endosalpinx,
the trophoblast invaded the
lamina propria and then the
muscularis of the tube and
grew mainly between the
lumen of the tube and its
peritoneal covering.
 HISTOPATHOLOGY

 Hemoperitoneum
 advanced ruptured ectopic pregnancy other than that
which is cervical in origin
 a combination of clotted and unclotted blood in the
peritoneal cavity.
 unclotted blood does not clot on removal from the
peritoneal cavity because it originates from lysis of
blood that has previously coagulated.
 HISTOPATHOLOGY

 Inflammatory cells are nearly always seen.

 plasma cells, lymphocytes, and histiocytes.
 The presence of chorionic villi
 frequently degenerated or hyalinized,
 nucleated red cells
 established the diagnosis of ectopic pregnancy.
 Decidual reaction in the tube is uncommon.
 HISTOPATHOLOGY

 The secretory cells of the

endometrial glands become
hypertrophied with
hyperchromatism, pleomorphism,
and increased mitotic activity,
knowb as Arias- Stella Reaction
 SYMPTOMS

 Abdominal pain
 Absence of menses
 Irregular vaginal bleeding
 SIGNS

 Abdominal tenderness
 Adnexal tenderness
 Tachycardia and hypotension
 can occur after rupture if blood loss is profuse
 DIFFERENTIAL DIAGNOSIS

 Salpingitis
 Threatened or incomplete abortion
 Ruptured corpus luteum
 Appendicitis
 Dysfunctional uterine bleeding
 Adnexal torsion,
 Degenerative uterine leiomyoma
 Endometriosis.
 PROCEDURES USED FOR THE DIAGNOSTIC
EVALUATION OF THE ASYMPTOMATIC OR MILDLY
SYMPTOMATIC WOMAN

 Human Chorionic Gonadotropin

 85% of women with ectopic pregnancy have serum HCG levels
lower than those seen in normal pregnancy at a similar
gestational age.
 “discriminatory zone”
 defined as the serum HCG level above which a gestational sac
should be visualized by TVUS if an (IUP) is present.
 level of 1500 to 2000 mIU/mL is used.
 When an IUP is not seen on TVUS at the set discriminatory zone, an
abnormal pregnancy is diagnosed, and an ectopic pregnancy needs
to be ruled out.
 PROCEDURES USED FOR THE DIAGNOSTIC
EVALUATION OF THE ASYMPTOMATIC OR MILDLY
SYMPTOMATIC WOMAN

 Progesterone
 lower in an ectopic pregnancy, IUP at or above 10ng/mL

 Ultrasonography
 the key to the diagnosis is TVUS
 the length of GS
 by 5 1/2 weeks from LMP an IU sac
 visualization of a yolk sac at 5.5 weeks, a fetal pole by 6 weeks
cardiac activityat 6.5 weeks.
 An abnormal pregnancy is likely if there is absence of a fetal
pole with a gestational sac of 2 cm and if no cardiac activity is
noted with a crown-rump length of >0.5 cm.
PROCEDURES USED FOR THE DIAGNOSTIC EVALUATION
OF THE ASYMPTOMATIC OR MILDLY SYMPTOMATIC
WOMAN

 Ultrasonography
 Detection of a complex or cystic
adnexal mass (often called an
echogenic “bagel” sign) or
visualization of an embryo fetal pole in
the adnexa

 Endovaginal color Doppler flow

imaging, it is possible to establish the
diagnosis of ectopic pregnancy with
greater sensitivity and specificity than
with ordinary endovaginal
sonography.
PROCEDURES USED FOR THE DIAGNOSTIC EVALUATION OF
THE ASYMPTOMATIC OR MILDLY SYMPTOMATIC WOMAN

 Dilation and Curettage

 Serum HCG levels are more than 1500 miu/ml
 The gestational age exceeds 38 days
 The serum progesterone level is less than 5 ng/ml and no
intrauterine gestational sac is seen with vaginal
ultrasonography,
 A curettage of the endometrial cavity (by D&C) with histologic
examination of the tissue removed, by frozen section if
desired, can be undertaken to determine if any gestational
tissue is present.
PROCEDURES USED FOR THE DIAGNOSTIC EVALUATION OF
THE ASYMPTOMATIC OR MILDLY SYMPTOMATIC WOMAN

 They involve the use of vaginal probe pelvic

ultrasonography, measurements of serial quantitative HCG
and single serum progesterone levels, and uterine curettage

 The rate of increase (measuring serum progesterone levels

at 4, 5, and 6 weeks’ gestational age), and performing serial
ultrasonography beginning 3 weeks after ovulation will help
to establish the diagnosis of ectopic pregnancy before tubal
rupture.
PROCEDURES USED FOR THE DIAGNOSTIC EVALUATION OF
THE ASYMPTOMATIC OR MILDLY SYMPTOMATIC WOMAN
DIAGNOSTIC EVALUATION OF WOMEN
WITH SUSPECTED ECTOPIC PREGNANCY

 A sensitive qualitative pregnancy test and TVS

 diagnostic aids necessary to establish the diagnosis.

 Culdocentesis- if TVS is not available.

 If HCG is present and peritoneal fluid is seen

sonographically
 it is most likely that an ectopic pregnancy is present, and
laparoscopy should be performed.
MANAGEMENT

MEDICAL THERAPY
 MANAGEMENT

MEDICAL THERAPY

single-dose regimen success rate of 88.1% (86 to 90).

multiple- dose regimen was significantly more successful: (89% to 96%).
MANAGEMENT

MEDICAL THERAPY
 MANAGEMENT

MEDICAL THERAPY
 1 and 4 days after treatment- transient
rise in HCG level between.
 Between 4 and 7 days after
methotrexate
 HCG levels should fall at least 15%.
 If no decrease or there is less than a 15% in
each subsequent week
 an additional dose of methotrexate should
be given for a maximum of three doses.
 If after three doses of methotrexate HCG
levels do not decline by 15% weekly, a
surgical procedure should be performed.
 MANAGEMENT

MEDICAL THERAPY

 Serum progesterone levels fall more

after methotrexate

 a progesterone level of less than 1.5 ng/

mL -an excellent predictor.

 Between 3 and 7 days after initiating

therapy, severe pelvic pain lasting up to
12 hours frequently occurs.
 MANAGEMENT

SURGICAL THERAPY
 Tubal Pregnancy
 Laparoscopy is the procedure of choice for ruptured
ectopic pregnancy as well as for cases when medical
therapy (methotrexate) is contraindicated or refused.

 Laparoscopy
 when an accurate diagnosis cannot be made.
 MANAGEMENT

SURGICAL THERAPY
 Tubal Pregnancy
 Conservative treatment (i.e., preserving the tube and
not performing a salpingectomy) for an unruptured
ectopic pregnancy

 method of choice for women who desire future fertility.

 MANAGEMENT

The conservative surgical techniques used include:

Salpingotomy The tubal incision is closed primarily but
is unnecessary and has worse
subsequent pregnancy rates

Salpingostomy The tubal incision is allowed to close by

secondary intention
Best results of conservative
management

Fimbrial Traumatizes the endosalpinx

evacuation

Partial Segmental resection of the portion of

salpingectomy the tube containing the ectopic
pregnancy
 MANAGEMENT

SURGICAL THERAPY
 Interstitial Pregnancy
 Laparoscopic cornuotomy using a temporary tourniquet
suture and diluted vasopressin injection can be effective
for these cases
 safe and effective with the advantage of preserving
reproductive function compared with cornual resection
 Subsequent intrauterine pregnancies after previous
cornual ectopic pregnancy should be delivered by C-
section.
 MANAGEMENT

SURGICAL THERAPY
 Ovarian Pregnancy
 Treated by laparoscopic surgical excision
 Alternatives include:
 ovarian wedge resection
 unilateral salpingo-oophorectomy
 should be avoided and does not improve the subsequent
pregnancy rate or lower the risk of recurrence.
 MANAGEMENT

SURGICAL THERAPY
 Abdominal Pregnancy
 Surgical and interventional radiology and endovascular
surgery must be considered for assistance.

 Cervical Pregnancy
 Evacuation with dilatation and curettage or vacuum
aspiration after methotrexate treatment
 MANAGEMENT

SURGICAL THERAPY
 Cesarean Scar Pregnancy

 Evacuation with dilatation and curettage or vacuum

aspiration under trans-abdominal ultrasound guidance

 Hysteroscopy coupled with curettage followed by uterine

artery embolization is also an alternative surgical approach
for these cases
 MANAGEMENT

 PERSISTENT ECTOPIC PREGNANCY

PERSISTENT ECTOPIC PREGNANCY
After linear salpingostomy 5%

After fimbrial expression or tubal abortion 12% to 15%

Preoperative HCG levels are greater than 3000 miu/ml, 22% to 42%.
HCG level is above 1000 miu/ ml 7 days after surgery or is PEP is nearly
more than 15% of the original level always present
 MANAGEMENT

 PERSISTENT ECTOPIC PREGNANCY

 Measured both HCG and progesterone levels
preoperatively and every 3 days after conservative tubal
surgery for an unruptured ectopic gestation

 If a day 9 serum HCG level is more than 10% of the initial

level or a day 9 serum progesterone level is higher than
1.5 ng/ mL, PEP is presumed.
 MANAGEMENT

PERSISTENT ECTOPIC PREGNANCY

 Medical Treatment
 MTX
 Surgical Treatment
 salpingectomy, salpingostomy,
 Expectant Management
 The lower the initial HCG level, the greater the success
with spontaneous resolution.
 DIAGNOSIS IN WOMEN WITH
A HISTORY OF INFERTILITY

 In women with a history of infertility, the diagnosis of ectopic

pregnancy has been subjected to a risk-scoring assessment
 PROGNOSIS FOR SUBSEQUENT
FERTILITY

 If a woman wishes to conceive after having an ectopic

pregnancy, three possibilities exist:

 She may remain infertile

 She may conceive and have an intrauterine gestation (with A viable
birth or spontaneous abortion)
 She may conceive and have an ectopic gestation

 conception rate in women following all ectopic pregnancies is

about 60%, with the other 40% remaining infertile.
 PROGNOSIS FOR SUBSEQUENT
FERTILITY
Factors for subsequent Higher Lower
fertility
Age Higher in parous women
younger than age 30.
Parity high parity (more than three First pregnancy: 35%
births) : 80%
History of infertility With history of infertility
evidence of With salpingitis
contralateral tubal Contralateral salpingitis
disease

the ectopic pregnancy Unruptured: 82%. Ruptured: 65%

is ruptured or intact
IUD normal rates of subsequent fertility and no increased risk of a
subsequent ectopic pregnancy
PROGNOSIS FOR SUBSEQUENT
FERTILITY

 Risk factors for a repeat ectopic pregnancy were:

 Ectopic pregnancy as the first pregnancy,
 Age younger than 25
 Evidence of tubal infection,
 History of infertility
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