ECTOPIC

PREGNANCY
 “
Fertilized ovum implanted
outside the uterus

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 epidemiology
✘ 4.5 cases per 1000 pregnancies in 1970
✘ 19.7 cases per 1000 pregnancies in 1992
✘ Most common cause of maternal
mortality in 1st trimester

✘ 13% in 2005 to 17% in 2009

✘ Mortality rate at 0.01-0.03%

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 Risk factors

✘ Abnormal anatomy
✘ Prior tubal pregnancy
✘ Prior STI
✘ Infertility and ART

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 Pathogenesis

1. Immunologically-mediated
○ Altered expression of prokinectin factors 1 and 2
○ TLR 2 and 4 expressed in the fallopian tube were expressed’
○ TLR ligation  downstream signaling  activation of
transcription factors  alter tubal function

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 Pathogenesis

2. infection-induced inflammatory response

Infection  inflammation  epithelial destruction  functional

impairment of oviducts  inhibition/disruption of gamete
transport

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 Pathogenesis

3. Progesterone
o Reduces tubal contractility
o Slow ovum or blastocyst transport

4. Smoking
o Affect ciliary function
o Affect smooth muscle contraction

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 Pathogenesis

5. E-cadherin
o Associated with tubal pregnancies following IVF

6. Age
o Physiological changes in tubal function

7. Multiparity

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 tubal
interstitial Abdominal

infundibular

ovarian

Types of Ectopic Pregnancy

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 “
In patients presenting with pain
and/or vaginal bleeding
associated with a positive
pregnancy test  DETERMINE
LOCATION OF PREGNANCY

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TUBAL PREGNANCY

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 Tubal Pregnancy

✘ Ampullary
✘ Isthmic
✘ Fimbrial
✘ Interstitial

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 Diagnosis

Physical findings
Transvaginal sonography
Serum beta-hCG levels

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Clinical Manifestations

Delayed menses
Vaginal bleeding or spotting
Pain

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Clinical Manifestations

Abdominal/pelvic pain
Cervical motion tenderness
Boggy mass palpable on uterus
Slightly enlarged uterus
Neck or shoulder pain
Decidual cast

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 Transvaginal Sonography

Most helpful tool in the diagnosis and

prevention of sequelae

 No ionizing radiation
 Readily available
 98.5% sensitivity
 99% specificity

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 Transvaginal Sonography

Yolk sac/embryo CONFIRMATORY!

Extrauterine sac
cardiac activity

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 “
Sonographic determination of
intrauterine pregnancy cannot
rule Out ectopic pregnancy

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 Transvaginal Sonography

 Trilaminar endometrial pattern

 Endometrial stripe <8mm
 Presence of a pseudosac
 Decidual cyst
 Adnexal mass separate from the ovary
 Ring of fire
 hemoperitoneum

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 Beta-hCG

DISCRIMINATORY ZONE
serum beta-hCG levels above which gestational sac
should be present by TVS

 3510IU/L
 Minimizes risk of interfering with normal intrauterine pregnancy
 Averts unnecessary methotrexate administration
 Avoids harming an early normal multifetal pregnancy
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 “
Beta-hCG conc >2000IU/L +
Absent intrauterine pregnancy
on Transvaginal sonography is
STRONGLY SUGGESTIVE of ectopic
pregnancy but is NOT an
ABSOLUTE parameter
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 Others

 Progesterone
 Endometrial sampling
 Laparoscopy

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 Medical Management
Methotrexate
 Folic acid antagonist
 Arrested DNA, RNA,
protein synthesis
 Effective against rapidly
proliferating trophoblast
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✘ bone marrow, GI mucosa,
respiratory epithelium may
be damaged
✘ Hepatotoxic
✘ Potent teratogen
✘ Excreted onto breast milk
✘ Interfere with neonatal
cellular metabolism
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 Medical Management

Candidates for Medical Treatment

 Asymptomatic
 Motivated
 Compliant
 Low initial beta-hCG
 Ectopic mass <3.5cm

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 Medical Management

Single dose therapy

○ Serum beta-hCG at day 4 and 7
○ Injection on day1
*if level fails to drop more than 15% bet day 4 and 7, 2nd dose of
Methotrexate is required

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 Medical Management
Multi-dose therapy
○ Serum beta-hCG at 48-hour intervals until levels fall below 15%
○ Up to 4 doses may be given

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Medical Management

15% weekly
drop determinations
until nondetectable

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 Surgical Management
Salpingostomy
1.
 small unruptured
pregnancy
 10-15mm linear incision 2.
 High pressure irrigation
 Needlepoint
electrocoagulation
 Incision to heal by 3.
secondary intention

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 Surgical Management
Salpingectomy
 Both ruptured and unruptured
 Minimize recurrence of tubal pregnancy
1. 2. 3. 4.

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 Persistent trophoblast

✘ Rare following salpingectomy

✘ Complicates 5-15% of salpingotomies
✘ Risks: increased B-hCG, small ectopic size
✘ Complication: bleeding
✘ Incomplete removal: signified by stable or rising B-hCG levels (<50%
on day 1 post op)
✘ MTX 50mg/m2 x BSA, SD or surgery

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 Medical vs Surgical Therapy

MEDICAL
✘ Pain
✘ Posttherapy depression

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 Expectant Management
Very early tubal pregnancy
1/3 of tubal pregnancies <3cm and with B-hCG
<1500mIU/mL resolve without intervention
Declining B-hCG
Subsequent pregnancy rates comparable with medical
and surgical treatment

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INTERSTITIAL PREGNANCY

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 Interstitial Pregnancy
eccentrically implanted uterine pregnancy

Angular Pregnancy
Implantation within endometrial cavity but at one cornu and
medial to the uterotubal junction and round ligament

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 Diagnosis
Transvaginal sonography
eccentrically implanted uterine pregnancy

 Empty uterus
 Gestational sac separate from endometrium and 1 cm away
from lateral edge of uterine cavity
 <5mm myometrial mantle surrounding the sac
 Interstitial line sign from gestational sac to endometrial cavity
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 Diagnosis
laparoscopy
Enlarged protuberance found outside the round ligament
Normal distal fallopian tube and ovary

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 Management

Laparoscopy or laparotomy
Intraoperative intramyometrial vasopressin
Beta-hCG levels monitored postoperatively

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 Management
Cornual resection

Remove gestational sac and surrounding corneal

myometrium
Via wedge excision
Myometrial closure

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 Management
Cornuostomy

Incision of cornua
Suction or instrument extraction
Myometrial closure

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 Medical management
Methotrexate

✘MTX 50mg/m2 x BSA

✘Direct injection into gestational sac

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CESAREAN SCAR
PREGNANCY

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 Diagnosis
implantation within myometrium of prior cesarean scar

Pain
Bleeding

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 Diagnosis
Transvaginal sonography

 Bright hyperechoic endometrial

stripe on sagittal view
 Empty cervical canal identified
 Intrauterine mass in anterior part
of uterine isthmus
 Myometrium between bladder
and gestational sac is absent or
thinned

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 management
Expectant Management

✘Hemorrhage
✘Placenta accrete
✘Uterine rupture

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 management
hysterectomy

✘Initial choice for those desiring sterilization

✘Necessary if with uncontrolled bleeding

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 management
Methotrexate

✘Fertility-preserving option
✘Given systemic or locally injected

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 management
Surgical options

Visually-guided suction curettage

Hysteroscopic removal
Isthmic excision

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CERVICAL PREGNANCY

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 “
Cervical glands noted histologically opposite the
placental attachment site and by all or part of the
placenta in part of the placenta found below the
entrance of the uterine vessels or below peritoneal
reflection on the anterior uterus

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 Diagnosis

 Endocervix is eroded by trophoblast

 Pregnancy develops in fibrous cervical wall
 Painless vaginal bleeding
 Thin-walled cervix with partially dilated external os
 Slightly enlarged uterine fundus above cervical mass

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 Diagnosis
Transvaginal sonography
 Hourglass uterine shape
 Ballooned cervical canal
 Gestational tissue at level of cervix
 Absent intrauterine gestational
tissue
 Endocervical canal interposed
between gestational and
endometrial canal

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 Management
methotrexate
 Minimize hemorrhage, Resolve pregnancy, Preserve fertility
 1st line therapy in stable women
 Some used with uterine artery embolization
 Resolution achieved for gestation <12weeks
 Failure higher if
 Gest age >9weeks
 Beta-hCG >10,000mIU/mL
 CRL>10mm
 Fetal cardiac activity
 50-75mg/m2 x BSA 54
 Management
Surgical
 Hysterectomy
 Suction curettage
 Cervical curettage
 intracervical vasopressin or cerclage prior

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ABDOMINAL PREGNANCY

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 Diagnosis
PHYSICAL FINDINGS
 Abnormal fetal positions
 Cervix is displaced
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SONOGRAPHIC FINDINGS
✘ Often missed sonographically
✘ Oligohydramnios common
but nonspecific
✘ lack of myometrium between
fetu and maternal ant abd
wall
✘ Extrauterine placental tissue
✘ Bowel loops
 Management

DEPENDENT on gestational age

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