Unit II - Ectopic

2.
2 ECTOPIC PREGNANCY
Reflection ??
• Do you think/know pregnancy might occur out

side the uterus?
Ectopic Pregnancy
• Implantation of fertilized ovum in an area other than

the endometrial lining of the uterus
• More than 95% of extra uterine pregnancies occur in
the fallopian tube
Ectopic…
• increased from 4.5:1000 in 1970 - 19.7:1000 in 1992.

• This may be due to a higher incidence of salpingitis,
an increase in ovulation induction and assisted
reproductive technology, and more tubal
sterilizations
• Its significant cause of maternal morbidity and
mortality, as well as fetal loss.
• It is the leading cause of pregnancy-related death in
the first trimester and accounts for 9% of all
pregnancy-related deaths
Classification & Incidence
• Ectopic pregnancy can be classified as follows

1. Tubal (> 95%)—Includes ampullary (55%), isthmic
(25%), fimbrial (17%), and interstitial (2%).
2. Other (< 5%)—Includes cervical, ovarian, and
abdominal (primary abdominal pregnancies have
been reported, but most abdominal pregnancies are
secondary pregnancies, from tubal abortion or
rupture and subsequent implantation in the bowel).
3. Intraligamentous
Class..
4. Heterotopic pregnancy -- is a rare
complication of pregnancy in which both extra-
uterine (ectopic pregnancy) and
intrauterine pregnancy occur simultaneously.
• combined ectopic pregnancy
5. Bilateral ectopic -- simultaneous Tubal
Ectopic Pregnancy (BTP)
• is the rarest form of ectopic pregnancy
•
Ectopic…
Pathology
• In tubal ectopic pregnancy, implantation typically

occurs in the wall of the tube, in the connective
tissue beneath the serosa.
• There may be little or no decidual reaction and
minimal defense against the permeating trophoblast.
• The trophoblast invades blood vessels, causing local
hemorrhage.
• A hematoma in the subserosal space enlarges as
pregnancy progresses.
Patho…
• Progressive distention of the tube eventually
leads to rupture.
• Vaginal bleeding is of uterine origin and is caused
by endometrial involution and decidual sloughing.
• Atypical changes in the endometrium may be
suggestive of ectopic pregnancy.
• These changes can be seen in normal pregnancy
and in miscarriage and therefore are not
diagnostic of ectopic pregnancy.
Mechanism?
• Generally, The mechanisms responsible
for ectopic implantation are unknown.
• The four main possibilities are
1. an anatomic obstruction to the passage of the zygote,
2. an abnormal conceptus
3. abnormalities in the mechanisms responsible
for tubal motility
4. transperitoneal migration of the zygote (ovum is
transferred to the opposite tube via the peritoneal fluid)
Risk factors for ectopic px
Sign and symptoms
Symptoms
Pain—Pelvic or abdominal pain is present in close to 100% of
cases.
• Pain can be unilateral or bilateral, localized or generalized.
• The presence of shoulder pain is more variable, depending
on the amount of intra-abdominal bleeding.
Bleeding—Abnormal uterine bleeding, usually spotting, occurs
in roughly 75% of cases and represents decidual sloughing.
• A decidua cast is passed in 5–10% of ectopic pregnancies
and may be mistaken for products of conception.
Symptoms…
Amenorrhea—Secondary amenorrhea is variable.
• Approximately half of women with ectopic
pregnancies have some spotting at the time of
their expected menses and thus do not realize
they are pregnant.
Syncope—Dizziness, lightheadedness, and/or
syncope
• represent advanced stages of intra-abdominal
bleeding
Sign and symptoms
On examination, the following signs are important

in the diagnosis of ectopic gestation.
Tenderness—Diffuse or localized abdominal
tenderness is present in over 80% of EP.
• Adnexal and/or cervical motion tenderness is
present in over 75% of cases.
Adnexal mass—A unilateral adnexal mass is
palpated in one-third to one-half of patients.
• Occasionally, a cul-de-sac mass is present.
Sign…
Uterine changes—The uterus may undergo
typical changes of pregnancy,
• including softening and a slight increase in
size.
Hemodynamic instability—
• Vital signs will reflect hemodynamic status of
patients with tubal rupture
• massive intra-abdominal hemorrhage.
Investigation
• B-hCG: The qualitative serum or urine -hCG assay is

positive in virtually 100% of ectopic pregnancies.
• The value of this test is limited, however, because a
positive result does not help to elicit the location of
the pregnancy.
• More helpful is a quantitative -hCG value that, in
conjunction with transvaginal ultrasound, can usually
make the diagnosis.
• hCG level of greater than 6,500 mIU per mL
How to diagnose ectopic px?
Several special procedures are helpful in diagnosing

ectopic pregnancy
1. Ultrasound—Ultrasound is useful in evaluating
ectopic pregnancy by documenting the presence or
absence of an intrauterine pregnancy
2. Laparoscopy—The need for laparoscopy in the
diagnosis of ectopic pregnancy has declined with
the increasing use of ultrasound.
dx…
3. Culdocentesis —
• Culdocentesis, the transvaginal passage of a
needle into the posterior cul-de-sac in order to
determine whether free blood is present in the
abdomen.
• has largely been replaced by transvaginal
ultrasound
4. MRI — useful adjunct to ultrasound in cases
where an unusual ectopic location is suspected.
Differential diagnosis for ectopic pregnancy
GYNECOLOGIC PROBLEMS
• Threatened or incomplete abortion
• Ruptured corpus luteum cyst
• Acute pelvic inflammatory disease
• Adnexal torsion
• Degenerating leiomyoma (especially in pregnancy)
NONGYNECOLOGIC PROBLEMS
• Acute appendicitis
• Pyelonephritis
• Pancreatitis
Emergency Treatment
• Immediate surgery is indicated when the diagnosis

of ectopic pregnancy with hemorrhage is made.
• Blood products should be available because
transfusion is often necessary.
• There is no place for conservative therapy in a
hemodynamically unstable patient.
• Rho (D) immunoglobulin should be given to any Rh-
negative mother with the diagnosis of ectopic
pregnancy because sensitization may occur
Management
TREATMENT of TUBAL PREGNANCY

• General condition should be corrected
I. Salpingectomy – removal of FT
• Indications: disturbed tubal pregnancy in a shocked patient.
• Correction of shock is done simultaneously with laparotomy.
II. Conservative management: (preservation of the affected tube).
• Indications: Young patient desiring pregnancy with undisturbed
tubal Pregnancy.
• Disadvantages: recurrence of tubal pregnancy.

Mgt…
The main treatment options are:
• expectant management – your condition is carefully
monitored to see whether treatment is necessary.
• medication – a medicine called methotrexate is used
to stop the pregnancy growing.
• surgery – surgery is used to remove the pregnancy,
usually along with the affected fallopian tube.
Mgt..
• If the ectopic pregnancy cannot
be removed by a laparoscopically, another
surgical procedure called a laparotomy may be
done.
Mgt..
A. Conservative surgery (through laparotomy or laparoscopy).
1. Linear salpingostomy
• Linear incision in the anti-mesenteric border to evacuate the
tube, ensure haemostasis.
• The tube is left open to heal by 2ry intention to avoid stenosis.
2. Linear salpingotomy:
• As salpingostomy but the incision is sutured.

Mgt..
3. Segmental resection and end-to-end anastomosis:
• for pregnancy in the isthmical portion of the tube
• rarely indicated, difficult and predisposes to
obstruction
4. Milking of the tube

• expression through the fimbria for pregnancy near
the fimbria.
Mgt…
B. Non-surgical management (Methotrexate):
• I.M. or intra-tubal (guided by U/S) to destroy the trophoblast.
Indication:
• young patient with undisturbed tubal pregnancy,
• pregnancy sac < 3 cm in diameter,
• serum β-HCG < 15000 miu/ml,
• haemoperitoneum not more than 50 ml with careful follow up
as the tubal pregnancy may rupture even after injection
needing surgical intervention.
• N.B.: In all cases anti-Rh antibodies are given if the patient is Rh
-ve and the husband is Rh +ve
Management of rare ectopic type
Ovarian px – removal of affected ovary

Cervical px
• The fertilized ovum is implanted in the cervix below the
level of the internal os producing a barrel-shaped cervix
and hour-glass uterus.
• It produces painless bleeding after a missed period.
Treatment:
• In a young patient: try ligation of the cervical arteries and
methotrexate.
• Total Hysterectomy
Px in rudimentary horn
• Disturbance of pregnancy is usually late (at
the 4th or 5th month).
• At laparotomy: it is differentiated from
interstitial tubal pregnancy by relation of the
round ligament to the pregnancy sac
• Treatment: excision of the affected horn.
Abdominal extrauterine px
• It is either: primary in the peritoneum or secondary following tubal
rupture.
• The fate of the fetus: Usually dead, it even may be mummified or
calcified.
• If living -- it is mal-developed
Diagnosis -- U/S.
• Treatment: blood should be available and immediate laparotomy
to remove the fetus.
• If the placenta is attached to a vital organ: the cord is ligated short,
the placenta is left for autolysis and we may give methotrexate.
Time of Rupture
• Rupture usually is spontaneous.
• Isthmic pregnancies tend to rupture earliest, at 6 to 8
wk GA, because of the small diameter of this portion
of the tube.
• Ampullary pregnancies rupture -- 8–12 weeks.
• Interstitial pregnancies -- 12–16 weeks, as the
myometrium allows more room to grow than the
tubal wall.
Time of Rupture
• Interstitial rupture is quite dangerous because its
proximity to uterine and ovarian vessels can result in
massive hemorrhage.
• After rupture, the conceptus may be resorbed or
remain as a mass in the abdominal cavity.
• Rarely, if not damaged during rupture, it may implant
elsewhere in the abdominal cavity and continue to
grow
Prevention
• Prevention of STD by early detecting and rx may
avoid tubal damage with subsequent EP.
• Other risk factors for ectopic pregnancy are
more difficult to control.
• Early diagnosis of unruptured tubal pregnancy
by maintaining a high index of suspicion and
liberal use of -hCG titers, ultrasound, and
laparoscopy will minimize potential problems of
hemorrhage, infertility, and extensive surgery
Summary
• What is ectopic pregnancy?
• Classification?
• Sign and symptoms?
• Diagnosis?
• management.?
THANK YOU !!!

Unit II - Ectopic

Uploaded by

Copyright:

Available Formats

Unit II - Ectopic

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Unit II - Ectopic

Uploaded by

Copyright:

Available Formats

2.

• Do you think/know pregnancy might occur out

• Implantation of fertilized ovum in an area other than

• increased from 4.5:1000 in 1970 - 19.7:1000 in 1992.

• Ectopic pregnancy can be classified as follows

• In tubal ectopic pregnancy, implantation typically

On examination, the following signs are important

• B-hCG: The qualitative serum or urine -hCG assay is

Several special procedures are helpful in diagnosing

• Immediate surgery is indicated when the diagnosis

TREATMENT of TUBAL PREGNANCY

4. Milking of the tube

Ovarian px – removal of affected ovary

You might also like