PATHOLOGIC OBSTETRICS

Topic: Ectopic Pregnancy

Lecturer: Dr. Estimo

ECTOPIC PREGNANCY
CLASSIFICATION AND DEFINITION OF ECTOPIC PREGNANCY
 The uterus is the only structures uniquely designed to accommodate
the embryonic and fetal development Type of EP Definition
A pregnancy occurring in the fallopian tube -
 When a pregnancy begins to grow in other surrounding structures, Tubal pregnancy most often these are located in the ampullary
vascular communication is inadequate. (F. Gary Cunningham) portion of the fallopian tube
This is why any pregnancy that would develop outside the uterus A pregnancy that implants within the interstitial
 it will not become successful because the vascular Interstitial pregnancy
portion of the fallopian tube
communication is not adequate Primary – the 1st and only implantation occurs
on a peritoneal surface
Oviducts or Fallopian Tubes
Abdominal pregnancy
Length 8-14 cm Secondary – implantation originally in the tubal
Intramural/Interstitial ostia, subsequently aborted and then
 Surrounded by reimplanted into the peritoneal surface
myometrium Implantation of the developing conceptus in
Cervical pregnancy
the cervical canal
Divisions (Anatomical) Isthmic A secondary form of EP in which a primary
 Most highly developed tubal pregnancy erodes into the mesosalpinx
Ligamentous pregnancy
musculature and is located between the leaves of the broad
ligament
Ampullary A condition in which ectopic and intrauterine
Heterotropic pregnancy
 Widest, Tortuous pregnancies coexist
A condition in which an EP implants within the
Ovarian pregnancy
Infundibulum ovarian cortex
 Trumpet shaped
 Has a finger-like projection
called fimbriae  opens in Sites of Ectopic Pregnancy
the abdominal cavity and it
is the one that gets the
fertilized egg from the
Peristaltic Movement ovum
Greatest during ovum transport
Histology and least during pregnancy
Columnar epithelium (ciliated and
Musculature (Smooth Muscles) secretory)
Inner circular
Outer longitudinal

Lecture Discussion: Oviducts or Fallopian Tubes

When you say proximal part – that is the part of the fallopian tube nearest to the uterus
When you say distal part – that is part of the fallopian tube farthest from the uterus
So from proximal to distal = Intramural/Interstitial  Infundibulum
Classification:
 Fimbrial
Significance of Isthmus  narrowest portion of the fallopian tube Significance of Ampulla  widest portion of the fallopian tube and where fertilization takes place
 Ampullary
 Isthmic
 Interstitial

Lecture Discussion: Sites of Ectopic Pregnancy

Ectopic Pregnancy: 95% of EP are implanted in the various segments of the fallopian tube. The most commo
 Implantation of a fertilized ovum outside the endometrial lining of the
uterine cavity
 0.5 to 1.5% of all first trimester pregnancies
 3% of all pregnancy-related deaths Risk Factors for Ectopic Pregnancy
 Previous tubal pregnancy
Reasons why there is an Increasing Rate of Ectopic Pregnancy: Surgery  Tubal corrective/reanastomisis surgery
 Increase tubal infections due to STD  Tubal sterilization
 Early diagnosis using assays for hCG and transvaginal ultrasound STD/Tubal Infection/Genital  Salpingitis
 Popularity of contraception that predisposes pregnancy failures to be Infection  Chlamydia
ectopic  Salpingitis
 Unsuccessful tubal sterilization Peritubal adhesions  Appendicitis
 Increased Assisted Reproductive Technique (ART)  Endometriosis
 Induced Abortion  Epithelium-lined diverticula extend
Salpingitis Isthmica Nodosa
 Increase tubal surgery hypertrophied muscularis layer
o Salpingotomy for tubal pregnancy Congenital fallopian tube
 In utero diethylstilbestrol (DES) exposure
o Tuboplasty for infertility anomalies
 Assisted Reproductive Technology (ART)
Infertility
 Ovulation Induction

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 PATHOLOGIC OBSTETRICS
Topic: Ectopic Pregnancy
Lecturer: Dr. Estimo

 Copper and Progestin-releasing IUD 2 Types of Outcome of EP:

Contraceptive method
 Progestin-only pills - ↓ fallopian tube  High levels of serum β-hCG
failure
peristalsis Acute EP Rapid growth
 Prior abortion  Abnormal trophoblast dies early Negative or low, static serum β-h
Mechanical  Prior cesarean delivery Chronic EP
 Puerperal infection 
 Smoking – causes vasoconstriction
 Douching - ↑ infection Clinical Manifestations:
Functional
 Multiple sexual partners  Classic Triad:
 Intercourse < 18 y/o 1. Delayed Menstruation / Amenorrhea
2. Abnormal vaginal bleeding or spotting
Evolution 3. Abdominal pain
 Ampullary > Isthmic > Interstitial  stabbing, sharp, tearing pain
 tenderness on palpation
Zygote Implantation:  cervical motion tenderness
 FT lacks a submucosal layer  fertilized ovum promptly burrows
through the epithelium  Bulging posterior vaginal fornix
Posterior vaginal fornix is the dependent portion  more or less if it is bulging =
 Zygote comes to lie near or within the muscularis layer which is
eroded
 Maternal blood vessels are opened  Pelvic mass on one side of the uterus
 Embryo/fetus is usually absent  Slightly enlarged uterus
 Hypotension and tachycardia  due to bleeding
Lecture Discussion: Evolution  Vertigo/syncope
3 Layers of the Uterus:  (+) culdocentesis
Endometrium - Submucosal
 Diaphragmatic irritation
Myometrium - Muscular layer
Perimetrium – Serosa. It is the one covering the uterus Sign that there is diaphragmatic irritation is shoulder or neck pain.
If the EP has a significant bleeding, the patient experiences
shoulder on neck pain when lying down
The fallopian tube is not distensible like the uterus which can accommodate the growing product of conception (fetus, placenta, amniotic). Once an egg fertilizes at the FT  it wou
Signs:
 Nixon Sign – unilateral pulsation
 Dodd’s sign – unilateral tenderness

TUBAL PREGNANCY Differential Diagnosis:

Outcome: Miscarriage (Most common)
Isthmic more prone to early rupture Since it is narrowest  high chanceAdnexal 
of early Pathology
rupture
Ectopic pregnancy
 Ovarian mass
 Sapingitis
Ampullary is more distensible Tubo-ovarian abscess
Interstitial rupture usually occur later Ruptures later (can go big as 16thPain
AOG) Pelvic infection
 because the interstitial part is also Degenerating or enlarging leiomyomas
covered by the myometrium Round-ligament pain
Tubal Rupture Appendicitis
Cystitis
Rupture may be spontaneous Spontaneous means that even if the woman does not do anything, rupture occurs
Renal Stone
Gastroenteritis


Lecture Discussion: Differential Diagnosis

 3 most common cause of 1st trimester bleeding:
Maybe caused by coitus or bimanual examination Ectopic pregnancy
 this is an induced type of rupture Molar (H. mole) pregnancy
Products of conception may be extruded through the fimbriated end into the peritoneal–cavity
Abortion/Miscarriage most common
Distal implantations are favored

Aborted fetus will implant on peritoneal surface → abdominal pregnancy
Tubal Abortion Lithopedion: calcified intraperitoneal pregnancy Small conceptus areAllreabsorbed
these three presents with vaginal bleeding, (+) pregnancy test, abdominal pain (except
Resolved, failed, reabsorbed
Unknown
 number of ectopic pregnancies spontaneously fail and are reabsorbed
Documented
 with sensitive β-hCG assays


Pregnancy Failure

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 PATHOLOGIC OBSTETRICS
Topic: Ectopic Pregnancy
Lecturer: Dr. Estimo

Diagnosis:
Expected Minimum & Decline of Initial Serum β-hCG
 Physical findings
Most common key
 Transvaginal ultrasound components
 Serum β-hCG measurements
Key Components
 Diagnostic surgery
o Uterine curettage
o Laparoscopy
o Laparatomy
 EP cannot be diagnosed by a positive PT alone
 hCG assays positive in over 99% of ectopic
pregnancies
 Current PT: ELISA
o Urine: 20 – 25 mIU/ml
o Serum: ≤ 5 mIU/ml Diagnosis…..
 The hCG pattern that is most predictive of EP is one  A value exceeding 25 ng/ml excludes EP
that has reached a plateau (doubling time of more If serum progesterone excess 25 ng/ml = the pregnancy
than 7 days)
β-hCG assays Doubling time  increase in β-hCG
normally occurs after 2 days or 48  Values <5 ng/ml suggest:
hrs o Non-living pregnancy
o Ectopic pregnancy
So you request β-hCG levels every after 2 days.  Limited clinical importance: most ectopic
Example, you requested today and result is 1000. pregnancies the progesterone levels range
Serum Progesterone
After 2 days, if you are expecting it to be an
between 10 and 25 ng/ml
intrauterine pregnancy it would be 2000. Another
 A single progesterone measurement can be
2 days it would be 4000. So if the β-hCG doubles
every after 2 days  pregnancy is probably used to establish that there is normally
intrauterine (a viable pregnancy), not an ectopic developing pregnancy with high reliability
one. If it is ectopic, β-hCG plateaus (no increase)  A value exceeding 25ng/ml excludes EP with
 The level above which an imaging scan should 92% sensitivity
reliably visualize a gestational sac within the uterus  Values <5 ng/ml occur only in 0.3% of normal
in a normal intrauterine pregnancy as follows: pregnancies suggests a dead fetus or EP
o 1500 – 1800 mIU/ml with TVS, but up to 2300  Intrauterine pregnancy
with multiple gestations o GS: 4 ½ and 5 weeks
o 6000 – 6500 mIU/ml with abdominal o YS: 5 and 6 weeks
ultrasonography Transvaginal o FP w/ FHR: 5 ½ to 6 weeks
sonography:
 A value above which failure to visualize pregnancy Endometrial findings  Ectopic pregnancy
Discriminatory indicates that the pregnancy either is not alive or is o Trilaminar endometrial pattern
Zone of hCG ectopic in location o Anechoic fluid collections
 An empty uterus with a serum β-hCG concentration (pseudogestational sac and decidual cyst)
≥ 1500 mIU/ml was 100% accurate for the  Round
diagnosis of ectopic pregnancy (Branhart, 1994)  Eccentric
 Initial β-hCG level exceeds the discriminatory level Transvaginal  Well define margins
and no evidence for a uterine is seen in TVS: sonography: Early  Well defined decidual reaction
o failed uterine pregnancy Intrauterine  Intradecidual sign
o complete abortion Pregnancy  Double decidual sac sign
o ectopic pregnancy  Growth rate: 0.8 mm/day
 Mean doubling time for serum β-hCG levels: 48  Ovoid
hours (2 days)  Central
Lecture Discussion: Discriminatory Zone of hCG TVS:
 Poorly defined margins
Pseudogestational
If the serum β-hCG is 1500-1800 mIU/ml already  if you are going to  Absent decidual reaction
Sac
request for TVS (transvaginal sonography), there should already be an  Single decidual layer
intrauterine pregnancy  No double decidual sac sign
 Visualization of an adnexal mass separate from
Same goes for abdominal pregnancy, if the serum β-hCG is 6000-6500 the ovary
mIU/ml already  if you are going to request for an abdominal UTZ, there  Identification of an extrauterine yolk sac,
should be an intrauterine pregnancy embryo or fetus
 Hyperechoic halo or tubal ring surrounding
Finding Weeks (LMP) β-hCG (mIU/ml) anechoic sac
Gestational sac (25 mm) Discriminatory
5 zone Yolk sac 1000  Inhomogenous complex adnexal mass
TVS: Adnexal findings
Upper DZ Fetal pole 5-6 1000-2000  60% inhomogenous mass – most common finding
Fetal heart motion 6 25,000  20% hyperechoic ring
6-7 3000  13% gestational sac with a fetal pole
7 5000  Ring of fire - not pathognomonic to ectopic
6-7 7000 pregnancy because corpus luteum cysts also presents
this
*This table just shows the possible levels of β-hCG depending on the age of gestation (AOG)  Not all adnexal mass represent EP

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Topic: Ectopic Pregnancy
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TVS: Ring of Fire

But if she is not hemodynamically stable  bring her to the O.R.
 Doppler color imaging for surgical management
 Increased vascularity
 Placental blood flow within the periphery of
the complex adnexal mass So if the TVS reveals:
 (+) ectopic pregnancy and corpus luteum of Uterine pregnancy – do prenatal care
pregnancy Ectopic pregnancy – treat accordingly
Incomplete or missed abortion – do D&C (dilatation and curettage)
 Blood in the peritoneal cavity Nondiagnostic – do serum β hCG
 Anechoic or hypoechoic fluid collections in the Nondiagnostic means that TVS did not detect any intrauterine or extrauterine pregna
TVS: dependent retrouterine cul-de-sac (> 50 ml)
Hemoperitoneum  Blood (400 – 700 ml) will track up the pericolic
gutter to fill Morison pouch near the liver
 Peritoneal fluid + adnexal mass: Ectopic
pregnancy
 A 16 to 18 gauge spinal needle is attached to a
syringe
 Retrouterine cul-de-sac of Douglas is entered
through the posterior fornix
With the spinal needle attached to a
syringe, you perforate the cul-de-sac and
aspirate fluid

 With a tenculum, outward and upward traction

towards the symphysis pubis is applied to the
Culdocentesis
posterior lip of the cervix Lecture Discussion: Serum β-hCG
 (+) culdecentesis If the level of hCG is >1500 mIU/ml with (-) intrauterine pregnancy:
o Fragments out of old clot Treat it as having ectopic pregnancy
o Non-clotting bloody fluid You can also do curettage
If with no villi – it means that is really (-) intrauterine pregnancy (it is ectopic pregnancy
 (-) culdocentesis If with villi – it means complete abortion (patient had an intrauterine pregnancy)
o unsatisfactory entry to the cul-de-sac
o clotting blood (blood obtained from an If the level of hCG is <1500 mIU/ml with (-) intrauterine pregnancy:
adjacent vessel or from a vigorously Repeat the β-hCG after 2 days (48 hrs.)
bleeding ectopic pregnancy) If after repeat and there is normal increase = probably intrauterine pregnancy then repe
 Lack coexistent trophoblast If after repeat there is abnormal ↑ or ↓ = it is possibly abortion so perform curettage
 Decidual reaction (42%) If after repeat it decreases normally = do observation
Endometrial Sampling
 Secretory endometrium (22%) because it might be ectopic or pregnancy failure
 Proliferative endometrium (12%)
 Direct visualization of the fallopian tubes and
pelvis
 Permits a ready transition to definitive
Laparoscopy
operative therapy
 This is the gold standard that is both diagnostic
and therapeutic

ALGORITHM FOR EVALUATION OF EP

Lecture Discussion: TVS when β-hCG > discriminatory level

So you do transvaginal ultrasound when it reaches > discriminatory level. Just take not
If you found that there is villi – it probably is a complete abortion
If you found no villi – you can just treat it as ectopic pregnancy
Lecture Discussion: Algorithm for Evaluation of EP
This algorithm only applies for hemodynamically stable women. If a patient comes to you with missed period, bleeding, & pain. You have to request for a pregnancy test.
If it is (+)  you know that she is pregnant. Do vital signs and if she is hemodynamically stable do TVS.

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Topic: Ectopic Pregnancy
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Management of Ectopic Pregnancy Predictors of Success:

 Expectant Management  Low initial serum β-hCG
 Medical Management o Single best prognostic indicator of successful treatment w/
 Surgical Management single-dose MTX
o Basically, the lower the initial serum β-hCG = higher rate of
Expectant Management success & vice versa
 Reasonable to observe very early tubal  Small ectopic pregnancy size
pregnancy that are associated with stable or  Absent fetal cardiac activity
falling serum β-hCG levels
 Criteria for Expectant Management: Initial Β-hCG levelFailure Rate
o Asymptomatic, hemodynamically stable <10001.5%
o Tubal ectopic pregnancies only 1000 to 20005.6%
o Decreasing serial β-hCG levels 2000 to 50003.8%
Resolution without treatment was more likely if the initial serum β-hCG ≤ 1500 mlU/ml 5000 to 1000014.3%

Absolute Indications Relative Indications

o Diameter of the ectopic mass < 3.5 cm  Hemodynamically stable patient  Unruptured
o No TVS evidence of:  Non-laparoscopic diagnosis  Mass < 3.5 cm at its greatest
 Intra-abdominal bleeding  Patient desire future fertility dimension
 Rupture  General anesthesia is a risk to  No fetal cardiac Motion
o Less than 100 ml fluid in the pouch of Douglas patient  Patient hCG does not exceed
 Patient can return to follow up 6000- 15000 IU/m
o Objective evidence of resolution
clinic
o Patient must be fully compliant and must be willing to accept
 No contraindication to MTX
the potential risks of tubal rupture

Medical Management Absolute Contraindications Relative Contraindications

 Methotrexate  Breast feeding  Gestational sac > 3.5 cm
o This is commonly used in cancer patients (chemotherapy drugs)  Immune deficiency  Embryonic cardiac motion
o Folic acid antagonist  Alcoholism or patient with
o Block the reduction of dihydrofolate to terahydrofolate chronic liver disease
o Highly effective against rapidly proliferating tissue such as  Blood dyscrasia
trophoblast  Active pulmonary disease
o Ectopic tubal pregnancy resolution rates: 90%  Peptic ulcer, hepatic, renal,
hematologic problem
o Adverse Effects:
 Harmful to bone marrow, GIT and respiratory
epithelium
Inclusions Exclusions
 Directly toxic to hepatocytes and excreted renally
 Hemodynamically stable patient  Clinically unstable patient
 A potent teratogen: craniofacial and skeletal
 Indications:  Severe or persistent abdominal
abnormalities, IUGR
o Unruptured or other ectopic pain
 Excreted in breast milk and may accumulate in pregnancy  Significant hemoperitoneum on
neonatal tissues and interfere with neonatal cellular o Persistent trophoblast after  UTZ scan (>300 ml)
metabolism  so do not give it to breastfeeding mothers salpingotomy  The presence of cardiac activity
 Serum β-hCG <5000 IU/L on ectopic pregnancy
Methotrexate Therapy for Primary Treatment of Ectopic Pregnancy:  Size of ectopic mass < 3.5 cm  Coexistent viable intrauterine
 Normal LFT’s pregnancy
Since MTX is hepatotoxic, you have to do Ectopic
liver function test to
mass >3.5 cmcheck if it is normal

 Px compliance for ff-up: 35 days

Monitoring Therapy Efficacy:

 Linear Salpingotomy
o Serum β-hCG level decline rapidly over days and then more
gradually
o Mean resolution time: 20 days
**If after 3 doses of MTX β-hCG levels does not decrease or fetal cardiac activity persists = do surgical
 Single dose MTX
management**
o Mean serum β-hCG level ↑ for the 1st 4 days then gradually
Patient Selections for Medical Management: decline
o Best candidates are: o Mean resolution time: 27 days
 Asymptomatic  Resolution: serum β-hCG level <15 mIU / ML
So when we say resolution time, the serum β-hCG should be <15 mIU/ml
 Motivated
 Compliant

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Monitoring Therapy Efficacy continued…..

Persistent Trophoblast:
 Single dose therapy:
 Incomplete removal of trophoblast
o β-hCG determination at day 4 &7 ff initial injection on day 1 If after surgery and then you saw that there is a persistent trophoblast  ser
o If the level fails to drop > 15% between day 4 & 7 : 2 dose of
nd

MTX is required
 Multidose MTX  Risk factors:
o Serum β-hCG level are measured at 48 hr. interval until they o Pregnancies <2 cm
fall >15% o Early pregnancy <42 menstrual days
o Then weekly until detectable o Serum β-hCG value >3000 mIU/ML
 Signs of Failure of Medical Management: o Implantation medial to salpingostomy site
o Serum β-hCG plateaus  Treatment: single dose MTX 50 mg/m2 x body surface area (BSA)
o Serum β-hCG rises
o Tubal rupture occurs INTERSTITIAL PREGNANCY
If medical management failed  you schedule the patient to undergo surgical
 management
Diagnosis:
o One that implants within the proximal tubal segment that lies
within muscular uterine wall
Surgical Management
 Risk factors:
 Salpingotomy
o Similar for tubal pregnancy
 Salpingostomy
o Previous ipsilateral salpingiectomy
o Small (<2cm) unruptured ampullary tubal pregnancy
 Rupture 8-16 weeks of AOG
 Salpingiectomy Since it is embedded in the myometrium  has a tendency for late rupture (
 Laparoscopy
o Direct Visualization of the fallopian tubes and pelvis
o Preferred surgical treatment for ectopic pregnancy for  Criteria:
hemodynamically stable patient o An empty uterus
o A gestational sac separate from the endometrium and > 1 cm
Salpingostomy Used to remove a small unruptured from the most lateral edge of the uterine cavity
pregnancy o A thin, < 5 mm myometrial mantle surrounding the sac
A 10-15 mm linear insion on the antimesenteric border over the pregnancy o Echogenic line “interstitial line sign”
Incision is left unsutured to heal by secondary intention o Unclear cases: 3D, MRI, diagnostic laparoscopy
Product will:
Extrude from incision
 Management is Surgical:
Carefully removed
Flushed out using high pressure irrigation o Cornual resection or cornuostomy (laparotomy or
Salpingotomy laparoscopy)
Incision is closed with delayed absorbable suture Cornual Resection Removes the gestational sac and
Prognosis does not differ with or without suturing surrounding corneal myometrium by means
Cornuostomy Incision of the cornua and suction or instrum

**In both procedures you close the incision**

*SalpingoStomy (with S) and Salpingotomy are somewhat similar. They are

o Intraoperative intramyometrial vasopressin injection may
used to remove a small unruptured ectopic pregnancy (<3.5 cm). BUT:
limit surgical blood loss
 SalpingoStomy  incision is left unsutured (no need for suture)
Vasopressin  a vasoconstrictor = decrease bleeding
 Salpingotomy  you have to suture the incision
o Postoperatively: β-hCG level monitoring
Salpingiectomy
ANGULAR PREGNANCY
Diagnosis:
Used for both ruptured and unruptured ectopic pregnancies
Complete excision of fallopian tube  Implantation within the endometrial cavity but at one cornu and
o Prevent recurrence of pregnancy in tubal stump medial to the uterotubal junction and round ligament
So angular pregnancy is NOT an ectopic pregnancy. Why? Because
the implantation is in the endometrium

 It displaces the round ligament upward and outward

Angular pregnancy is a differential diagnosis for Interstitial pregnancy.
If the round ligament is displaced = it is an angular pregnancy
If round ligament is not displaced = it can be an interstitial pregnancy

 Pregnancy can be carried to term but with increased risk of abnormal

placentation and its consequences. (unlike interstitial pregnancy you have
to do surgery since the pregnancy cannot be carried to term due to rupture)

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Topic: Ectopic Pregnancy
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CESAREAN SCAR PREGNANCY

Identification:
Diagnosis:
 Speculum Examination
 Implantation within the myometrium of a prior CS scar
 Palpation
 1 in 2000 pregnancies and ↑ with cesarean delivery rate
 Transvaginal ultrasound
 Pathogenesis: placenta accrete (↑ risk for hemorrhage)
 Usually present early with pain and bleeding
To confirm diagnosis:
 40% are asymptomatic
 MRI
 TVS is the first line imaging tool  3-D sonography
 MRI if TVS is inconclusive
Doppler Studies:
What will you see in the Ultrasound?
 Locate the uterine arteries and presence of blood flow around the sac
 An empty uterine cavity
 An empty cervical canal Sonographic Findings:
 An intrauterine mass in the anterior part of the uterine isthmus  Hourglass uterine shape and ballooned cervical canal
Isthmus  area between the uterus and the internal cervical os.
 Gestational tissue at the level of the cervix
Significance of this is that when one becomes pregnant, it becomes
 Absent intrauterine gestational tissue
the lower uterine segment
 Portion of the endocervical canal seen interposed between the
gestational and the endometrial canal
 Myometrium between the bladder and gestational sac is absent or
thinned (1-3 mm)
Management:
 Surgical Methods
Management:
o Total Abdominal Hysterectomy – if patient wants sterilization
 Risks: hemorrhage, placenta, accrete, uterine rupture
o Dilatation and Curettage – if patient wants preserve fertility
 Hysterectomy in those desiring sterilization
o Tamponade by inflating Foley’s catheter balloon
 Fertility preserving option: MTX with or w/o conservative surgery
o Uterine artery embolization
 Surgical option: suction curettage, hysteroscopic removal, isthmic
 Medical Methods
incision
o Methotrexate
o Chemoembolization
CERVICAL PREGNANCY
o Intracervical catheter or balloon tamponade
Diagnosis:
o Goals of Medical Management:
 Rubin’s Criteria
 Minimize hemorrhage
o Uterus is smaller than the surrounding distended cervix
 Resolve the pregnancy
o Internal cervical os is not dilated
 Preserve fertility
o Curettage of the endometrial cavity is non productive of
placental tissue
ABDOMINAL PREGNANCY
o External os opens earlier than in spontaneous abortion
Diagnosis:
o Cervical glands must be opposite the attachment of placenta
 Implantation in the peritoneal cavity exclusive of tubal, ovarian, or
or trophoblast
intraligamentous implantations
o Attachment of trophoblast must be below the level of
 Follow early tubal rupture or abortion with reimplantation
entrance of uterine vessels in the uterus or anterior
peritoneal reflection Primary – implantation was abdominal at the start
Secondary – implantation started from tubal  abort and it got
o Fetal elements must be absent from the corpus uteri
implanted abdominally and developed
o The endocervic is eroded by trophoblast and pregnancy
develops in the fibrous cervical wall.
 With advanced extrauterine pregnancy, the placenta is still partially
attached to the uterus or adnexa
 Clinical Criteria (Paalman & Elin)
o Uterine bleeding w/o cramping pain following amenorrhea
Clinical:
o Hourglass shape uterus
 History of spotting/irregular bleeding with abdominal pain
o Partly open external os
 Multiparas may state it does not “feel right”
o Closed internal os
 Abnormal fetal presentation
o Product of Conception entirely confined w/in the cervix
 Fetal parts may feel exceedingly close to the examining fingers
o Firmly attached to the endocervix
 Abdominal massage does not stimulate the mass to contract
Risk Factors:
Laboratory:
 Previous therapeutic abortion
 Not really diagnostic
 Asherman’s Syndrome
 Unexplained transient anemia
 Previous CS
 Fetal well being is normal until fetal demise
 DES exposure
 Increase alpha-fetoprotein
 Leiomyomas
 Normal amnionic alpha-fetoprotein
 In Vitro Fertilization

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Abdominal pregnancy continued…..

Akhan Sonographic Criteria:
 Visualization of the fetus separate from the uterus
 Lack of myometrium between the fetus and the maternal anterior
abdominal wall or bladder
 Close approximation of the fetal parts to the maternal abdominal wall
 Eccentric position, abdominal fetal attitude and extrauterine placental
tissue
 Bowel loops surrounding the gestational sac
Studdiford’s Criteria:
 Presence of normal tubes and ovaries with no evidence of recent or
past pregnancy
 No evidence of uteroplacental fistula
 The presence of pregnancy related exclusively to the peritoneal
surface and early enough to eliminate the possibility of secondary
implantation after primary tubal abortion
Lecture Discussion: Ovarian Pregnancy Management
If you see that it is really an ovarian pregnancy  do oophorectomy (removing the ov
HETEROTYPIC ECTOPIC PREGNANCY
Diagnosis:
 Tubal pregnancy with co-existing intrauterine gestation
 Ultrasound can demonstrate products of conception within the
uterine cavity
 After ART – common to patients who underwent ART
 Persistent or rising hCG after curettage
 Uterine fundus larger than menstrual dates
 More than one corpus
 (-) vaginal bleeding with s/sx of ectopic pregnancy
 Ultrasound evidence

 May occur in both tubes or in only

Fetal Outcome: Multifetal Tubal Pregnancy one tube
 Perinatal loss is 75%  Both tubal involvement is the rarest
 Surviving fetuses may be abnormal form
 Fetal Deformation  Due to gradual extension into the
Tubo-uterine
o Cranial asymmetry uterine cavity
o Various joint abnormalities  Due to gradual extension into the
Tubo-abdominal
 Fetal Malformation peritoneal cavity
o Limb deficiency  When the fetal sac is adherent partly
o CNS anomalies Tubo-ovarian Pregnancy to the tubal and partly to ovarian
tissue
Management of Abdominal Pregnancy:
 Conservative management carries a maternal risk for sudden and  Period of Viability: (from old trans)
dangerous hemorrhage o 24 viable
 Termination is indicated upon diagnosis o < 24 not viable
 Objective: delivery of the fetus and careful assessment of placental
implantation w/o provoking hemorrhage
 If the placenta can be safely removed or there is already hemorrhage:
remove immediately
If on your assessment you see that there will be profuse hemorrhage if you remove the placenta and your only choice is to leave the placenta in place  just remove th

 Blood vessels supplying the placenta should be ligated first

 Leaving the placenta in place causes:
o Infection
o Abscess
o Adhesions
o Intestinal or ureteral obstruction
o Wound dehiscence

OVARIAN PREGNANCY
Spiegelberg Criteria:
 Ipsilateral tube is intact and distinct from the ovary
 Ectopic pregnancy occupies the ovary
 The ectopic pregnancy is connected by the uteroovarian ligament to
the uterus
 Ovarian tissue can be demonstrated histologically amid placental tissue

Transvaginal Ultrasound:
 An internal anechoic area is surrounded by a wide echogenic ring,
which in turn is surrounded by ovarian cortex
 Diagnosis may not be made until surgery

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