PATHOPHYSIOLOGY ECTOPIC PREGNANCY

Defintion of Ectopic pregnancy?

 Aka eccyesis or tubal pregnancy
 Ectopic means abnormal place or position
 An ectopic pregnancy is one in which implantation occurred outside the uterine
cavity. (Pillitteri, 2018).
 Ectopic pregnancy is non- viable pregnancy
Age of viability 20-24th weeks (Pilitteri 2018 pg. 529, vol. 1)
 This is one of the most common complications of pregnancy during the first
trimester (1-12 weeks). There is no exact statistic that would represent ectopic
pregnancy because many cases were masked by misdiagnosis.
 Oftentimes, pregnancy is believed to be normal during its early phase due to the
presentation of some signs indicative of an ideal gestation. This is the reason
why ectopic pregnancy is usually diagnosed late, or when the pain starts to be
manifested as a sign of rupture of the fallopian tube (most common
manifestation) and begins to develop more serious problems such as haemorrhage
 Ectopic embryos can grow and create pressure (blocks the tube) or invade
surrounding tissues, affects surrounding organs and structures that can cause pain,
pressure, and bleeding.

TYPES
 The types of ectopic pregnancy is based on the site of implantation.

With most ectopic pregnancy, fertilization occurs as usual in the fallopian tube.
Unfortunately, because an obstruction is present, the zygote cannot travel the length
of the tube.

1. Tubal ectopic pregnancy—The most common site (in approximately 95% of such
pregnancies) is in the fallopian tube . the fertilized ovum was implanted
anywhere within the fallopian tube. Of these fallopian tube sites, approximately
80% occur in the ampullar portion, 12% occur in the isthmus, and 8% are
interstitial or fimbrial (Jurkovic, 2012).

2. Cervical ectopic pregnancy—less than 1 % on the cervix. this is the abnormal

implantation of a fertilized ovum near or on the cervix. This occurs due to the
inability of the uterus or not ideal set-up of the uterus for implantation. Scar
formation from previous uterine surgery (caesarean delivery-most common)
contributes to the incidence rate.

3. Abdominal ectopic pregnancy—3% to 4% in the abdominal cavity.this is the

abnormal implantation of a fertilized ovum outside the uterus, but, within the
abdominal cavity. A primary abdominal pregnancy refers to a pregnancy that first
implanted directly in the peritoneum. Typically an abdominal pregnancy is a
secondary implantation which means that it originated from a tubal (less common
an ovarian) pregnancy and re-implanted.
4. Ovarian ectopic pregnancy—1% located on an ovary. this is the abnormal
implantation of a fertilized ovum within the ovary. This is due to the non-
progression of a matured ovum through the fallopian tube and got fertilized b a
sperm cell.
5. Heterotopic pregnancy in rare cases of ectopic pregnancy 1/1000, there may be
two fertilized eggs, one outside the uterus and the other inside. This is called a
heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than
the ectopic, mainly because of the painful emergency nature of ectopic
pregnancies.

Normal pregnancy implantation

 Pregnancy is the period during which a woman carries a developing fetus
normally in the uterus, starting from conception (fertilization of ova) until the
baby born.
 After ovulation the ovum is picked up by the fimbria of fallopian tubes and then
swept by ciliary action towards the ampulla where fertilization occurs.
 As soon as the zygote (fertilized egg) travel in the fallopian tube and implant in
the endometrium, it will develops and begins cell divsion called cleaveage they
dividing very rapidly.
 Then hCG is produced by trophoblast, which can be detected in the serum of the
mother in the first week after implantation, its level doubles every 36-48 hours in
normal healthy pregnancy starting from 5 to 50 ,100, till reaching 1000 IU/L
 Delay or obstruction of the passage of fertilized egg down the fallopian tube to
the uterus may result in implantation in the fallopian tube or ovary or peritoneal
cavity, this known as ectopic pregnancy which eventually most fails to develop ,
and the hCG fails to raise dramatically as happens in the normal intra uterine
pregnancy.

ETIOLOGY
 Any factors that causes delayed transport of the fertilized ovum through the tube.
 Fallopian tube favors implantation in the tubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.
 Can be congenital or acquired

 CONGENITAL:
1. Tubal hypoplasia
- fallopian tube is underdeveloped or incomplete.
2. Tortuosity
- result of endometriosis and cysts in the ovaries

3. Congenital diveriticuli
-nodular scarring of the fallopian tube
 - may develop into salpingitis isthmica nodosa

4. Partial stenosis
- aka fallopian tube obstruction
- partial narrowing of the lumen of the fallopian tube.

5. Intamural polyp of the fallopian tube

-small focal lesion of ectopic endometrial tissue located at the intramural
portion of the FT
 6. Accessory ostia
- aka FT accessory tube ostium
- rare fallopian tube anomaly
- are rare müllerian duct anomalies and are thought to result from the
bifurcation of the distal ends of the müllerian duct

 ACQUIRED:
7. Pelvic Inflammatory Disease (PID)
-chlamydia trachomitis (most common STD that causes PID)

- PID causes scar tissue that prevents the fertilized egg from making its way
through the FT to implant in the uterus.

8. Contraceptive Failure
- IUD (intrauterine device)
 (1) it causes irritation to the FT because of the presence of IUD in the uterine
cavity may prevent the egg from going in the uterus.
(2) bacteria brought to IUD insertion may cause FT infection.
- Oral Contraceptives (progesterone only pill)
(1) due to the MOA of POP which reduces the activity of the cilia of the FT
alter tubal motility
(2) modified tubal function reduces contractility and thus slows the rate of
ovum or blastocyst transport.

9. Tubal Sterilization Failure

- technical failure may be caused by fistula formation that allows the sperm to
pass through
- 1 out of every 200 ligated women

 Bipolar Cauterization (65%)

- the FT is in grasped between two poles of electrical conducting
forceps and electrical current passes through the tube between the two
ends of the forceps.

 Partial Salpingectomy (43%)

  Silicone Rubberband tubal ligation (17%)

10. Reversal of Sterilization

- depends on the method of sterilization and site of tubal occlusion and
residual tubal length.
  Reanastomosis of cauterized (15%)
 Reversal of Pomeroy (3%)

11. Tubal Reconstructive Surgery

- depends to a large extent on the amount of previous damage to the tube and
its potential reversibility.
12. Assisted Reproductive Techniques
-Ovulation induction, IVF-ET, and GIFT (4-7%)
- risk of heterotrophic pregnancy (1%)
- IVF embryos are injected into the uterine cavity and one or more embryos
can be sucked back in the fallopian tube.
 13. Previous Ectopic Pregnancy
- 7-15% chances of repeat EP
- after an EP, if not treated with medication or surgery, 10% chance of it to re-
occur again.

Other Risk Factors

1. Age 35-45 years old
2. Previous induced abortion
3. Smoking
- chemical in cigarette smoke (cotinine) triggers reaction which increases
protein PROKR1 in the fallopian tube.
4. DES exposure in the utero
- diethylstilbestrol is the first synthetic form of estrogen prescribed by
physicians in 1938-1971.
5. Infertility
- due to damage or constriction to the fallopian tube when the muscle that
contracts doesn’t work perfectly.
6. Genital Tuberculosis
- mycobacterium tuberculosis bacilli reaches the genital tract; spreading is via
haematogenous or lymphatic routes.
7. Fundal fibroid and adenomyosis of the tube
- causes intramural EP
- fibroid (tumors) abnormal growths that develops in the fundal area of the
uterus.
 - adenomyosis of the tube is present in a firm and thickened segment of medial
tubal isthmus; rare entity benign tumors.

Sign & Symptoms

 Classic Symptoms:
1. Abdominal/Pelvic Pain (pain can be sharp, dull, and/or crampy, often mimics
appendicitis especially if the pain is at the lower right side)
2. Vaginal Bleeding (bleeding usually occurs 6 weeks after LMP)
3. Tender cervix, adnexal mass or tenderness
4. Amenorrhea
 Pregnancy Symptoms:
1. Nausea
2. Vomiting
3. Urination
4. Fatigue
5. Breast tenderness
 Destruction/rupture of the fallopian tube symptoms:
1. Abdominal distention
2. Generalized tenderness
3. Peritonitis
4. Hypovolemic shock due to excess bleeding (low BP, high HR, feeling cold)