Ectopic pregnancy

Definition
Ectopic pregnancy is defined as implantation of a
conceptus outside the normal uterine cavity.

Serious hazard to a woman’s health and reproductive

potential, requiring prompt recognition & early
aggressive intervention
Normal implantation
• Ovulation ovum picked up by fimbria swept by ciliary
• action towards ampulla. fertilization.

Zygote cleavage division in (3 -4 days). morula (8-32 cell

stage). embryo to uterine cavity for up to 72 hours. D6
enters uterus. implantation- uterine cavity in normal
positioned pregnancy .
• hCG detected in mother’s serum 1 week after implantation, level
doubles every 36-48 hours
Ectopic implantation
Delay or obstruction of the passage of fertilized egg down the fallopian
tube to the uterus. implantation in tube or ovary or peritoneal
cavity. ectopic pregnancy

hCG fails to raise dramatically

1-2 % of total pregnancy
Recurrence rate–15% after 1st, 25% after 2 ectopics
Increasing incidence
4th leading cause of maternal mortality overall (4%)
most common cause of maternal mortality I trimester
Types:
1. Tubal(95-98%)
2. Non tubal(2-5%)
3. Heterotropic(1/1000)
Among several factors that help explain the incidence of ectopic
pregnancies are:
(1) greater sexually transmitted disease prevalence,
(2) diagnostic tools with improved sensitivity,
(3) tubal factor infertility,
(4) delayed childbearing and accompanied use of assisted reproductive
technology,
(5) increased intrauterine device (IUD) use and tubal sterilization, which
predispose to ectopic pregnancy if the method fails
tubal disease; pelvic infection, such as Chlamydia infection, has been
estimated to account for 40 per cent of all ectopic pregnancies;
Congenital: long narrow tube, diverticulae , accessory ostia.
Traumatic: operation on the tube –salpingoplasty ,tubal reversal
following ligation.
Inflammatory: Chronic salpingitis
Neoplastic: Narrowing of the tube by a fibroid or a broad ligament tumor.
Functional: As tubal spasm or antiperistaltic contractions.
Endometriosis in the tube. encourages embedding of the fertilized ovum.
 Up to half of women with ectopic pregnancy will have no identifiable risk
factors.
• PID 7 fold risk after acute pelvic infection
• Tubal corrective surgery
• Tubal sterilization
• Previous EP
• In utero DES exposure
• IUD 4 times risk- increased, protection against IU pregnancy, increased
incidence of PID
• Documented tubal pathology
Infertility
Previous genital infection
Multiple partners
Previous pelvic or abdominal surgery
Smoking
Intercourse before 18 years
≥ 3 prior spontaneous miscarriages
Age ≥ 40 years
 fate of ectopic pregnancy
1. Tubal mole:
sac is surrounded by blood clot & retained chronic ectopic pregnancy/
involution
2. Tubal abortion:
Separation of sac. expulsion into peritoneal cavity through ostium.
Rarely, reimplantation of conceptus occurs in another abdominal structure
secondary abdominal pregnancy

3. Tubal rupture:
Rupture in anti-mesenteric border profuse bleeding
intraperitoneal haemorrhage.
• The classic symptom triad of ectopic pregnancy is amenorrhea
followed by vaginal bleeding and ipsilateral abdominal pain.
• However, as women seek care earlier, the ability to diagnose
ectopic pregnancy before rupture even before the onset of
symptoms is not unusual.
Of other symptoms, pregnancy discomforts
such as breast tenderness, nausea, and
urinary frequency may accompany more
ominous findings. These include shoulder
pain worsened by inspiration, which is
caused by phrenic nerve irritation from
subdiaphragmatic blood, or vasomotor
disturbances such as vertigo and syncope
from hemorrhagic hypovolemia
 ABDOMINAL
PAIN
Most common

ECTOPIC
ABNORMAL
VAGINAL
AMENORRHOEA
BLEEDING
75%
70%
Apart from classical triad pt presents with
Features of shock
Abdominal tenderness, guarding, BS decreased/absent
Minimal bleeding
Uterus bulky, fornix tender full , adnexal mass, cervical motion
tenderness ”JUMPING SIGN”
Bimanual examination should be very gentle with facilities for
immediate surgical intervention if needed
H/O acute attack of pain from which she has recovered
O/E-ill looking without any features of shock
irregular mass, tenderness
vaginal mucosa pale
uterus may be normal/bulky, ill defined mass may be felt through fornix
 Difficult to diagnose and high degree of clinical suspicion is needed,
sometimes diagnosed accidentally during laparoscopy/laparotomy
Delayed periods, spotting with lower abdominal discomfort
tenderness in lower abdomen
Uterus normal size, small tender mass may be felt in the fornix
DIFFERENTIAL
DIAGNOSIS
(1) NON GYNECOLOGICAL
Appendicitis (Perforated)

Acute Pancreatities
Myocardial Infarct
Pelvic Abcess
Splenic Rupture

Perforated Gastric or Duodenal Ulcer

 (2) GYNAECOLOGICAL
Rupture of
Septic Follicle or Degenerating
Abortion Corpus Luteum leiomyoma
Cyst

Threatened Acute pelvic Retroverted

inflammatory Gravid
Abortion disease Uterus

Pyosalpinx Twisted
Pelvic Abcess Ovarian Cyst
Symptoms of ectopic pregnancy can mimic multiple entities. Early
pregnancy complications such as threatened or missed abortion or
hemorrhagic corpus luteum cyst may be difficult to differentiate.
Moreover, approximately 20 percent of women with normal
pregnancies have early bleeding. Several disorders not related to
pregnancy can also mimic ectopic pregnancy. In general, a positive test
or β -hCG usually excludes these other diagnoses. However, these
conditions may exist concurrently with pregnancy—either intrauterine
or ectopic. Transvaginal sonography and serial serum β-hCG measure-
ments are the most valuable diagnostic aids to confirm clinical
suspicions of an ectopic pregnancy
Serum β-hCG Measurements
Human chorionic gonadotropin is a glycoprotein produced by
syncytiotrophoblast and can be detected in serum as early as 8 days
after the luteinizing hormone (LH) surge.
In normal pregnancies, serum β-hCG levels rise until 60 or 80 days after
the last menses, at which time values plateau at approximately 100,000
IU/L. interpretation of serial values is more reliable when performed by
the same laboratory.
With intrauterine pregnancy (IUP), serum β-hCG levels should increase
at least 53 to 66 percent every 48 hours
Serum β-hCG
UPT not always positive
Serum β-hCG detects very early pregnancy about 10 days after
fertilization i.e. before the missed period.
Discriminatory zone:
1000-2000 IU/L TVS; 5000-6000 IU/L TAS
Absence of uterine pregnancy. abnormal pregnancy( ectopic,
incomplete abortion)
β-hCG levels still below the discriminatory value, serial β-Hcg, USG
should be done.
Doubling sign:
Normal : >66% increase levels every 48 hours (nearly 2X).
Inappropriately rising serum β-hCG levels suggest (but do not
diagnose) abnormal pregnancy including ectopic, Do not identify its
location.
Serum Progesterone Levels

Serum progesterone concentration is used by some to aid ectopic

pregnancy diagnosis when serum β -hCG levels and sonographic
findings are inconclusive . Serum progesterone concentration varies
minimally between 5 and 10 weeks’ gestation, thus a single value is
sufficient.
a single serum progesterone level can be used to differentiate ectopic
from uterine pregnancy. The results were most accurate when
approached from the viewpoint of healthy versus dying pregnancy.
With serum progesterone levels < 5 ng/mL, a
dying pregnancy was detected with near perfect
specificity and with a sensitivity of 60 percent.
Conversely, values of > 20 ng/mL had a sensitivity
of 95 percent with specificity approximating 40
percent to identify a healthy pregnancy.
Ultimately, serum progesterone levels can be
used to buttress a clinical impression, but again
they cannot reliably differentiate between an
ectopic and intrauterine pregnancy.
Sonography

High-resolution sonography has revolutionized the clinical

management of women with a suspected ectopic pregnancy. With
transvaginal sonography ( TVS), a gestational sac is usually visible
between 41⁄2 and 5 weeks, the yolk sac appears between 5 and 6
weeks, and a Fetal pole with cardiac activity is first detected at 51⁄2 to
6 weeks. With transabdominal sonography, these structures are
visualized slightly later. The sonographic diagnosis of ectopic pregnancy
rests on visualization of an adnexal mass separate from the ovary
When β -hCG levels are above the set discriminatory value, the absence
of an IUP may suggest an abnormal pregnancy. The abnormality may
be an ectopic pregnancy, an incomplete abortion, or a resolving
completed abortion. Conversely, when β-hCG values lie below the
discriminatory value, sonographic findings are not diagnostic in nearly
two thirds of cases.
In an attempt to unify the language used with sonographic evaluation of
early pregnancies, a consensus statement was drafted with five categories:
(1) defnitive ectopic pregnancy (extrauterine gestational sac with yolk sac
and/or embryo),
(2) probable ectopic pregnancy (inhomogeneous adnexal mass or
extrauterine sac-like structure),
(3) probable IUP (intrauterine echogenic sac),
(4) definite IUP (intrauterine gestational sac with yolk sac and/or embryo),
(5) pregnancy of unknown location (PUL) (lacking signs of either ectopic
pregnancy or IUP)
Systematic sonographic evaluation is critical to establish the correct
diagnosis. Most begin with the endometrial cavity. In pregnancies
conceived spontaneously, identifcation of an IUP effectively excludes
the possibility of ectopic implantation , however, careful examination of
the tube and ovary is performed even with an intrauterine pregnancy.
An intracavitary fluid collection caused by bleeding from the decidua
can create a pseudogestational sac, or pseudosac. this one-layer
collection lies typically in the midline of the uterine cavity. In contrast, a
normal gestational sac is eccentrically located . Another intracavitary
finding is a trilaminar endometrial pattern, which represents two
adjacent proliferative-phase endometrial layers double decidual sac
sign
The fallopian tubes and ovaries are also inspected. Visualization of an
extrauterine yolk sac or embryo clearly confirms an ectopic pregnancy,
although such findings are less commonly seen. In some cases, a halo or
tubal ring that surrounds an anechoic sac can be seen.
With transvaginal color Doppler imaging, placental blood flow within the
periphery of the ectopic pregnancy (ring of fire) can be seen.
During sonographic evaluation of the pelvis, TVS can detect as little as 50 mL
of free peritoneal fluid in the cul-de-sac of Douglas. This may be
intraabdominal bleeding or physiologic peritoneal fluid. A large volume of
fluid or fluid that is echogenic is more worrisome for hemoperitoneum.
Detection of peritoneal fluid in conjunction with an adnexal mass is highly
predictive of ectopic pregnancy.
Culdocentesis

With a16 to 18 gauge spinal needle, the cul-de-sac of Douglas may be

entered through the posterior vaginal fornix . The aspirate
characteristics, in conjunction with clinical findings, may help clarify
the diagnosis. Normal appearing peritoneal fluid is designated as a
negative test. If fragments of an old clot or nonclotting blood are
found in the aspirate when placed into a dry, clean test tube, then
hemoperitoneum is diagnosed.
Doppler
sonography
Free fluid at
POD