ECTOPIC

PREGNANCY

PRSENTED BY
Mr.Ahalya.P
ECTOPIC PREGNANCY

DEFINITION: In ectopic pregnancy, a fertilized

ovum implants in an area other-than the
endometrial lining of the uterus
-It is the implantation of the fertilized ovum outside
the uterine cavity.
*Common site(95 %): the tubes
*Rare site (5%): The ovaries,a rudimentary horn of
bicornuateuterus,broad
ligaments,peritoneum&cervix.
 Isthmic Ampullary
Interstitial and 12% 70%
cornual 2–3%

Ovarian 3%
Fimbrial
Cesarean scar 11%
<1

Abdominal 1% Cervical <1%

Sites of ectopic pregnancies

Risk factors for ectopic pregnancy
History of previous ectopic pregnancy
(IUCD) or sterilization failure
Pelvic inflammatory disease
Chlamydia infection
Early age of intercourse and multiple partners
History of infertility
Previous pelvic surgery
Increased maternal age
Cigarette smoking
Strenuous physical exercise
Types of Ectopic
Implantation site

Extrauterine Uterine
- tubal - cervical
- ovarian - angular
- abdominal - cornual
TUBAL PREGNANCY
The fertilized ovum may lodge in any portion
of the oviduct, giving rise to ampullary,
isthmic, and interstitial tubal pregnancies
In rare instances, the fertilized ovum may
implant in the fimbriated extremity.
The ampulla is the most frequent site,
followed by the isthmus.
Contd….

INCIDENCE:
About 1: 250
Tubal Ectopic
1. Ampulla(64%)

2. Isthmus(25%)

3. Infudibulum(9%)

4. Interstitial(2%)
Tubal Ectopic Etiology
1.Salpingitis and pelvic inflammatory diseases
2.Iatrogenic
Contraceptive failure
Tubal surgery
Intra pelvic adhesions following pelvic
surgery
ART
Others
PATHOGENESIS OF TUBAL
PREGNANCY
Trophoblast develops in the
The uterus enlarges upto 8 Leads to degeneration,fall of
fertilized ovum and invades
weeks size and becomes soft hcG
into the tubal wall

Trophoblast produces hcG The tubal pregnancy does

Separation of uterine
which maintains corpus not usually proceeding
decidua
luteum beyond 8 to 10 weeks

Corpus luteum produces

oestrogen and progesterone Separation of the gestational
Leads to uterine bleeding
which change the secretary sac from the tubal wall
endometrium into decidua
Contd…
Tubal rupture:
-General symptoms: Short period of
amenorrhoea,Usually does not exceed 8 to 10
weeks,pain.Vaginal bleeding
-Abdominal examination
*Lower abdominal tenderness and rigidity especially on
one side may be present
-Vaginal examination:
*Bluish vagina and bluish soft cervix
Contd….
*Uterus is slightly enlarged and soft.
*Marked pain in one iliac fossa on moving the cervix
from side to side
Undisturbed (Unruptured) tubal pregnancy:
Symptoms:
*General symptoms and signs are present.
*Fainting attacks
*Nausea & vomitting
Contd…
Signs:
General examination:
*Anaemia in varying degrees depends on bleeding
*Pulse is usually rapid
*Temperature slightly higher(up to 38 o C)
*Fall blood pressure
Abdominal examination:
*Cullen’s sign- Periumblical bluish discolouration
*Boggy swelling in the cul-de-sac(space in the lower pelvis
below the tubes and ovaries) if pelvic haematocele present
OVARIAN PREGNANCY
Ovarian pregnancy
Ovarian pregnancy is defined as the implantation of the
conceptus on the surface of the ovary or inside the ovary,
away from the fallopian tubes
. The diagnosis of ovarian pregnancy is rarely achieved
pre-operatively; hence most women are treated
surgically as the diagnosis is reached only at operation
OVARIAN PREGNANCY
Spieglberg’s criteria in the dignosis include
-Tube with affected side must be intact
-The gestation sac must be in the position of the ovary
-The gestational sac is connected to the uterus by the
ovarian ligament
-The ovarian tissue must be found on its wall on
histological examination
-The tube on the involved side is intact.
Cont…………
The embedding may occur intra follicular or extra
follicular

Management:
 Rupture is the fate
Salpingo oophorectomy - definite treatment
Ovarian resection – Diagnosis is made early
ABDOMINAL PREGNANCY
TYPES
 Primary
 Secondary
PRIMARY ABDOMINAL PREGNANCY
Implantation of the fertilized ovum on the peri
ostium is rare and the existence is questionable.
SECONDARY ABDOMINAL PREGNANCY
The primary site being tube, ovary or even the uterus,
the conceptus escapes out through the uterine scar.
 CRITERIA FOR DIAGNOSIS OF
PRIMARY ABDOMINAL PREGNANCY
History
Both the tubes and ovaries are normal without
evidence of recent injury.
Absence of utero placental fistula
Presence of pregnancy related symptoms
Abdominal examination
*Unusual tranverse or oblique lie
*Fetal parts are felt very superficial with no uterine
muscle wall around
Contd…
Vaginal examination:
*The uterus is soft, about 8weeks and separate from the
fetus
*No presenting part in the pelvis
 SECONDARY ABDOMINAL
PREGNANCY
SYMPTOMS
H/of tubal pregnancy during early months
Pain on lower abdomen and vaginal bleeding
Minor ailments of pregnancy are exagerated
SIGNS IN ADVANCED PREGNANCY
Even in massaging Braxton Hick contractions are
absent
Fetal parts are felt easily
Abnormal high position of fetus
IMAGING STUDIES
Sonography
MRI
Xray examination
DIAGNOSIS
 Repeated failure of induction for IUD
 During induction by oxytocin uterine contraction
could not be excited
 MANAGEMENT
Treatment of abdominal pregnancy is surgical. In
advanced abdominal pregnancies accompanied by
normal fetal development diagnosed in the late second
trimester termination of pregnancy may be delayed for a
few weeks until the fetus reaches viability.
At surgery the gestational sac should be opened carefully
avoiding disruption of the placenta. The fetus should be
removed, the cord cut short and the placenta should be left
in situ .
Laparotomy
CORNUAL PREGNANCY
Pregnancy occurring in rudimentary horn of a bi
cornuate uterus
 Increasing Ectopic Pregnancy Rates
A number of reasons at least partially explain the
increased rate of ectopic pregnancies in the United
States and many European countries. Some of these
include:
1. Increasing prevalence of sexually transmitted
infections, especially those caused by Chlamydia
trachomatis
2. Identification through earlier diagnosis of some
ectopic
pregnancies otherwise destined to resorb spontaneously
3. Popularity of contraception that predisposes
pregnancy failures to be ectopic
4. Tubal sterilization techniques that with
contraceptive failure increase the likelihood of
ectopic pregnancy
5. Assisted reproductive technology
6. Tubal surgery, including salpingotomy for
tubal pregnancy and tuboplasty for infertility .
Mortality
According to the World Health Organization (2007),
ectopic pregnancy is responsible for almost 5 percent of
maternal deaths in developed countries.
Clinical presentation
1-subacute clinical picture of
A -abdominal pain &vaginal bleeding in early pregnancy.
Vaginal bleeding is usually dark red, indicative old blood
B- abdominal/ pelvic pain may be localized to the iliac fossa.
C- shoulder tip pain indicative of free blood in the abdominal cavity
D- dizziness (anemia)
Bimanual examination can reveal tenderness in the fornices and
there may be cervical excitation
2- Acute clinical presentation due to rupture ectopic pregnancy
with massive intraperitoneal bleeding. They can present with
signs of hypovolaemic shock & acute abdomen
Investigation
The following are useful investigation for the diagnosis of
ectopic pregnancy
1- observations :Bp, pulse ,temperature
2- laboratory investigations:
Hemoglobin. blood group(prepare blood for cross match) & B-
HCG
A B-HCG level of less than 5mIU/ml, is considered negative
for pregnancy& any thing above 25 mIU/ml is considered
positive for pregnancy
In 85% of pregnancy the B-HCG levels almost double every 48
hours in normally developing intrauterine pregnancy
In ectopic pregnancy the rise in B-HCG is suboptimal,. However
multiple readings are required for comparison purposes.
Transvaginal ultrasound scan (TVS)
An intrauterine gestational sac should be visualized at 4.5 weeks
Gestation.the corresponding B-HCG at that gestation is around
1500 mIU/ml.By the time a gestational sac with fetal heart
pulsation is detcted (at around 5 weeks gestation)B-HCGlevel
should be around 3000 mIU/ml
Thus , if there were discrepancy betwween B-HCG cocentration
and that seen on ultrasound scan(e.g.a highB-HCG with no
intruterine pregnancy on ultrasound scan), the differential
diagnosis of an ectopic pregnancy must be made.
Identification of an intrauterine pregnancy(gestational sac,
yolk sac, and fetal pole) on TVS effectively excludes the
possibility of ectopic pregnancy in most patients except in
those patients with rare heterotopic pregnancy.
The presence of free fluid during TVS is suggestive of a
ruptured ectopic pregnancy
Laparoscopy: this can be used to diagnose and treat ectopic
pregnancy
Culdocentesis
This simple technique was used commonly in the past to
identify hemo peritoneum. The cervix is pulled toward the
symphysis with a tenaculum, and a long 16- or 18-gauge
needle is inserted through the posterior vaginal fornix into
the cul-de-sac. If present, fluid can be aspirated, however,
failure to do so is interpreted only as unsatisfactory entry into
the cul-de-sac and does not exclude an ectopic pregnancy,
either ruptured or unruptured. Fluid containing fragments of
old clots, or bloody fluid that does not clot, is compatible
with the diagnosis of hemoperitoneum resulting from an
ectopic pregnancy. If the blood subsequently clots, it may
have been obtained from an adjacent blood vessel rather
than from a bleeding ectopic pregnancy.
Ultrasound
With the advent of diagnostic ultrasound and the
increasing use of conservative treatment, the diagnosis
of ectopic pregnancy is increasingly made without the
help of surgery.

Gestational sac
with a live
embryo
and a yolk sac
Uterus
In women with ectopic pregnancies bleeding within the
uterine cavity may resemble an early intrauterine
pregnancy (‘pseudosac’).
The presence of free fluid in the pouch of Douglas is a
frequent finding in women with normal intrauterine
pregnancies and it should not be used to diagnose an
ectopic. However, the presence of blood clots is
important and is a common finding in ruptured
ectopics
In women with intrauterine pregnancy on the scan a
possibility of heterotopic pregnancy should be excluded.
This is particularly the case in women who conceived
after stimulation of ovulation orIVF (in vitro
fertilization).
Serum Progesterone. A single progesterone measurement
can be used to establish with high reliability that there is a
normally developing pregnancy. A value exceeding 25
ng/mL excludes ectopic pregnancy with 92.5-percent
sensitivity .
Conversely, values below 5 ng/mL are found in only 0.3
percent of normal pregnancies . Thus, values 5 ng/mL
suggest either an intrauterine pregnancy with a dead fetus
or an ectopic pregnancy. Because in most ectopic
pregnancies, progesterone levels range between 10 and 25
ng/mL, the clinical utility is limited
Novel Serum Markers. A number of
preliminary studies have
been done to evaluate novel markers to detect ectopic
pregnancy. These include vascular endothelial growth
factor (VEGF), cancer antigen 125 (CA125), creatine
kinase, fetal fibronectin, and mass spectrometry-based
proteomics None of these are in current clinical use.
Differential diagnosis
The diagnosis is from any other acute abdominal
catastrophe such as rupture of a viscus or acute
peritonitis. The clinical picture is so typical that in
most cases diagnosis presents no difficulty. Other
diagnoses which may confuse are:
• inevitable miscarriage;
• bleeding with an ovarian cyst;
• pelvic appendicitis;
• acute salpingitis.
Management
Expectant management
Conservative management
Salpingectomy
Medical Management
Medical Management with Methotrexate
This folic acid antagonist is highly effective
against rapidly proliferating trophoblast, and it
has been used for more than 40 years to treat
gestational trophoblastic disease
Selection criteria for conservative management
of ectopic pregnancy
1. Minimal clinical symptoms
2. Certain ultrasound diagnosis of ectopic
3. No evidence of embryonic cardiac activity
4. Size <5 cm
5. No evidence of haematoperitoneum on
ultrasound scan
6. Low serum hCG (methotrexate <3000 IU/l;
expectant
7. <1500 IU/l)
The following are reasonable indications for
methotrexate use
1-cornual pregnancy
2-Persistant trophoblastic disorders
3- patient with one fallopian tube and fertility
desired .
4-patient who refuse surgery or whom surgery is
risky
5-treatment of ectopic pregnancy where
trophoblast is adherent to bowel or blood vessel
Contrindications of medical treatment
1- chronic liver, renal or haematological disordes
2- active infection
3-immunodeficency
4- breast feeding
Side effect of methotrexate
nausea.vomiting ,stomatitis, cojuctivitis, GI upset,
photosensitive skin reaction and Abdominal pain
Advise the women to take contraception for three months
after methotreate. It is also important to avoid alcohol &
exposure to sunlight during treatment
SURGICAL MANAGEMENT
Salpingostomy.
This procedure is used to remove a small
pregnancy that is usually less than 2 cm in
length and located in the distal third of the
fallopian tube .
A 10- to 15- mm linear incision is made
with unipolar needle cautery on the
antimesenteric border over the pregnancy.
Linear salpingostomy for ectopic
pregnancy
Salpingotomy. Seldom performed
today, salpingotomy is essentially the
same procedure as salpingostomy
except that the incision is closed with
delayed-absorbable suture.
Segmental resection
Fimbrial expression
Salpingectomy.
Tubal resection may be used for both
ruptured and unruptured ectopic
pregnancies. It is done in
Affected tube is damaged
Contralateral tube normal
Future fertility is not desired
Nursing management
Diagnosis:
1.Fear related to risk of mortality and possible treatment
alternatives.
2.Pain related to abdominal bleeding Secondary to tubal
rupture /surgical treatment
3.Potential to complications such as hemorrhage caused
by ectopic rupture
4.Fluid volume deficit related to vaginal bleeding