Ectopic Pregnancy

Definition

Normal pregnancy: Ectopic pregnancy (EP)

fertilized oocyte will go is the implantation of a
through fallopian tube fertilized oocyte outside
to the uterus the uterine cavity.

EP is a complication of
the first trimester of
pregnancy that carries
major morbidity and
mortality

Taran F, Kagan K, Hübner M, Hoopmann M, Wallwiener D, Brucker S. The Diagnosis and Treatment of Ectopic Pregnancy. Deutsches Aerzteblatt Online. 2015.
Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018.
 Ectopic Pregnancy (EP) Location

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Etiology and Risk Factor
• Abnormal fallopian tube underlies many cases of tubal EP
• Women having EP may increase their risk of having another EP
• Previous pelvic operation may increase the risk of EP
• Prior sexually transmitted disease  distort normal tubal anatomy
• Other risk factors:
 Infertility, as well as the use of Assisted Reproductive Technologies (ARTs)
 Advanced maternal age
 Smooking
 Progestin-only contraceptive

Taran F, Kagan K, Hübner M, Hoopmann M, Wallwiener D, Brucker S. The Diagnosis and Treatment of Ectopic Pregnancy. Deutsches Aerzteblatt Online. 2015.
Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018.
Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Epidemiology

EP causes 6% mortality in 1st trimester pregnancy

EP incidence varies through time and population, in 1997 – 2000

the estimated incidence is 20,7 per 1000 pregnancies

The rate of EP among women who go to an emergency department

with 1st trimester bleeding and/or pain ranges from 6 – 16 %

Van Den Eeden SK, Shan J, Bruce C, Glasser M. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol 2005.
Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ 2005.
Stulberg DB, Cain L, Dahlquist IH, Lauderdale DS. Ectopic pregnancy morbidity and mortality in low-income women, 2004-2008. Hum Reprod 2016.
 Pathophysiology
• The underlying cause of EP  fertilized oocyte is blocked  the
embryo has developed before reaching the uterine cavity  fallopian
tube
• The fallopian tube lacks of submucosal layer  the zygote implants
within the muscularis  the trophoblast proliferates rapidly 
rupture and the embryo is often absent or stunted

.Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018.
 Pathophysiology (2)
• Results of EP: tubal rupture, tubal abortion, or failed pregnancy with
instant resolution.
• Tubal EP usually burst spontaneously but may occasionally rupture
following coitus or bimanual examination.
• Tubal rupture  haemorrhage  cease or persist
• Heamorrhage  trickles into peritoneal cavity or forms a
hematosalpinx

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Clinical Manifestation
The classic manifestation of
EP: amenorrhea, vaginal The symptoms of EP could
bleeding and abdominal be acute or chronic
pain

Chronic EP is a more usual

Acute EP is a common
situation and is thought to
clinical problem, diagnosed
result from minor repeated
by a combination of clinical,
ruptures of tubal pregnancy
sonographic and laboratory
that develop into a
findings
hematocele

Abdulkareem T, Eidan S. Ectopic Pregnancy: Diagnosis, Prevention and Management. 2017.

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Diagnosis
• Symptoms of ectopic pregnancy can mimic multiple entities and
difficult to differentiate  β-hCG measurement and transvaginal
ultrasonography
• A definitive EP finding with transvaginal ultrasonography is
extrauterine gestational sac with yolk sac and/or embryo
• Culdocentesis can also be performed in order to prove the
hemoperitoneum  with an 16 to 18 gauge spinal needle

Abdulkareem T, Eidan S. Ectopic Pregnancy: Diagnosis, Prevention and Management. 2017.

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Management: medical
• Medical treatment is useful for patients with an unruptured tubal
ectopic pregnancy
• Medical treatment of EP is quite less expensive than surgery
• Intramuscular methotrexate is the most widely used and successful
medical therapy

Abdulkareem T, Eidan S. Ectopic Pregnancy: Diagnosis, Prevention and Management. 2017.

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Management: medical

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
 Management: surgical

Laparascopic Laparatomy

Salpingectomy Salpingostomy

Abdulkareem T, Eidan S. Ectopic Pregnancy: Diagnosis, Prevention and Management. 2017.

Hoffman B. Williams gynecology, 3rd ed. New York: McGraw-Hill Education; 2016.
Placenta Previa
 Definition

Implantation of placenta in
the lower uterine segment

Over or very near the

internal cervical
Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018
Prawirohardjo S. Ilmu kebidanan. 4th ed. Jakarta: Yayasan Bina Pustaka. 2016
 Etiology & Risk Factors
• The cause of placenta previa is uncertain. However, there is a
relationship between endometrial damage and uterine scarring.
• The implantation of fertilized egg requires an environment rich in
oxygen and collagen.
• Prior uterine scars provide an environment that is rich in oxygen and
collagen. The trophoblast can adhere to the uterine scar leading to
the placenta covering the cervical os.

Peng Z, Xiong Z, Zhao B, Zhang G, Song W, Tao L et al. Prophylactic abdominal aortic balloon occlusion: An effective method of controlling hemorrhage in patients with placenta previa or
accreta. Experimental and Therapeutic Medicine. 2018.
 Etiology & Risk Factors (2)

Advanced Smoking &

Multiparity
maternal age cocaine use

Assisted
Prior suction Prior placenta
reproductive
and curettage previa
technology

History of
cesarean
section

Martinelli K, Garcia É, Santos Neto E, Gama S. Advanced maternal age and its association with placenta praevia and placental abruption: a meta-analysis. Cadernos de Saúde Pública. 2018.
Baldwin H, Patterson J, Nippita T, Torvaldsen S, Ibiebele I, Simpson J et al. Antecedents of Abnormally Invasive Placenta in Primiparous Women. Obstetrics & Gynecology. 2018.
 Epidemiology
• Prevalence of placenta previa is approximately 4 per 1000 births.
• The frequency of previa was 0.5% for women <35 years compared
with 1.1% in those ≥35 years.
• 2.2% incidence in women with parity of five or greater was
significantly higher than that of women with lower parity.
• Cigarette smoking increases the relative risk of placenta previa at
least twofold.

Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018
Cresswell JA, Ronsmans C, Calvert C, Filippi V. Prevalence of placenta praevia by world region: a systematic review and meta-analysis. Trop Med Int Health 2013.
 Classification
• Placenta previa: the internal os • Low-lying placenta: implantation
is covered partially or in the lower uterine segment
completely by placenta. such that the placental edge
does not cover the internal os
but lies within a 2 cm wide
perimeter a round the os.

 The classification of some cases of previa will depend on cervical dilatation at

the time of assessment.
 Nearly 90% of placentas identified as "low lying" will ultimately resolve by the
third trimester due to placental migration

Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018
Feng Y, Li XY, Xiao J, Li W, Liu J, Zeng X, Chen X, Chen KY, Fan L, Chen SH. Relationship between placenta location and resolution of second trimester placenta previa. J. Huazhong Univ. Sci. Technol.
Med. Sci. 2017.
 Pathophysiology
• 3rd trimester or earlier  formation lower uterine segment 
lacerations of the placenta.
• Formation of uterine lower segment is progressive  laceration and
bleeding will happen rapidly  detachment of decidua  bleeding
from maternal circulation.
• Because of lower uterine segment is lack of muscle, the contractions
in that area are poor and bleeding easily happens.

Prawirohardjo S. Ilmu kebidanan. 4th ed. Jakarta: Yayasan Bina Pustaka. 2016
Feng Y, Li XY, Xiao J, Li W, Liu J, Zeng X, Chen X, Chen KY, Fan L, Chen SH. Relationship between placenta location and resolution of second trimester placenta previa. J. Huazhong Univ. Sci. Technol.
Med. Sci. 2017.
 Clinical Manifestation

Painless bleeding
Usually begins without any Varies from
warning and pain or slight to
contractions profuse

Happen repeatedly Abdomen Happen during the

without any certain palpation doesn’t end of the 2nd
underlying reason cause any pain trimester or later

Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018
Prawirohardjo S. Ilmu kebidanan. 4th ed. Jakarta: Yayasan Bina Pustaka. 2016
 Diagnosis
• Uterine bleeding after midpregnancy  consider placenta previa or
abruption
• Placenta previa should not be excluded until sonographic evaluation
has clearly proved its absence, transabdominal sonographic is usually
performed.
• If placental location remains in question  transvaginal sonography
• Sonography is not available  double set-up technique

Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018
Prawirohardjo S. Ilmu kebidanan. 4th ed. Jakarta: Yayasan Bina Pustaka. 2016
 Management
• Three prominent factors  fetal age and maturity, labor, and bleeding
severity
• Bleeding ceased for 2 days  discharge
• Patient diagnosed with placenta previa  elective caesarean section
at 36 to 37 weeks
• Placenta previa + complication  urgent caesarean section

Williams J, Cunningham F, Leveno K, Bloom S, Spong C, Dashe J. Williams obstetrics. 25th ed. Mac Graw Hill Education. 2018
ACOG Committee Opinion No. 764: Medically Indicated Late-Preterm and Early-Term Deliveries. Obstet Gynecol. 2019..