Ectopic Pregnancy

Dr. Samar Thabet

• Definition: implantation of a conceptus
outside the uterine cavity.

• Incidence: 1–2:100 pregnancies and

increasing.

• 98% are tubal; the remainder are abdominal,

ovarian, cervical, or rarely in CS scars
• Risk factors:-
 May be present in 25–50% of patients
(therefore majority will have no obvious risk
factors):
 History of infertility or assisted conception.
 History of PID.
 Endometriosis.
 Pelvic or tubal surgery.
 Previous ectopic (recurrence risk 10–20%).
 I UCD in situ.
 Assisted conception, especially IVF.
 Smoking.
• Symptoms :-
• amenorrhoea (usually 6–8wks)
• pain (lower abdominal, often mild and vague,
classically unilateral)
• vaginal bleeding (usually small amount, often
brown)
• diarrhoea and vomiting should never be ignored
• dizziness and light-headedness
• shoulder tip pain (diaphragmatic irritation -
haemoperitoneum)
• collapse (if ruptured).
• Signs:

 Often Have No Specific Signs

 Uterus Usually Normal Size
 Cervical Excitation And Adnexal Tenderness
Occasionally
 Adnexal Mass Very Rarely
 Peritonism (Due To Intra-abdominal blood if
ectopic ruptured).
 Differential diagnosis:-

• Threatened Or Complete Miscarriage

• Bleeding Corpus Luteal Cyst
• Ovarian Cyst Accident
• Pelvic Inflammation.
• Investigations:-
 TVS/USS: to establish the location of the
pregnancy, the presence of adnexal
masses or free fluid: a good EPAU will
positively identify EP on TVS in 90% of
cases, rather than the absence of an
intrauterine gestation.
 Investigations

Serum hCG: repeated 48h later:

the rate of rise is important a rise of ≥ 66%
suggests an IUP a suboptimal rise is
suspicious, but not diagnostic of an EP.
 Investigations
Laparoscopy:
gold standard, but should only be necessary
for clinical reasons or in a minority where a
diagnosis cannot be made (remember TVS/
USS should pick up 90%!)
 Management
 Conservative:-

 Clinically stable.
 US confirmed ectopic.
 BHCG < 1500.
 Management
Conservative:-
Requires serum hCG initially every 48h until
repeated fall in level; then weekly until <15IU.

with a plateauing hCG, as long as they remain

clinically well it is perfectly acceptable to wait as
the hCG will usually decline if given time as the
pregnancy fails—hCG measurement is as above.

With slow rising hCG in asymptomatic patient, a

decision for expectant management should only
be made by a senior early pregnancy unit (EPU)
clinician.
 Management
 Medical:-
 Methotrexate is given intramuscularly as a
single dose of 50mg/m2.

 HCG levels should be measured at 4 and 7

days, and another dose of methotrexate
given (up to 25% of cases) if the decrease
in hCG is <15% on days 4–7.
 Criteria for methotrexate:-

1) Hemodynamically stable.
2) No IUP
3) No fetal cardiac activity.
4) Serum BHCG < 5000
5) Mass < 35mm.
6) No sensitivity for methotrexate.
7) Can attend for follow up
 Side effects of methotrexate:-

• Conjunctivitis.
• Stomatitis.
• Gastrointestinal upset (bloating, pain,
ulcer)
• Bone marrow suppression
• Liver involvement
• Ectopic rupture
 Pre-requisite:
 Repeat BHCG in 48hrs.

 Confirm ectopic W/O IUP

 LFT.

 Advice women to avoid pregnancy at least

3months after management.
 Surgical:-
 Laparoscopy is preferable to laparotomy as
it has shorter operating times and hospital
stays, decrease analgesia requirements, and
decrease blood loss.

 In haemodynamically unstable patients,

laparotomy is more appropriate, as it is
quicker.
 Surgical:-
 Salpingectomy is preferable to salpingotomy
when the contralateral tube and ovary appear
normal.
 There is no difference in subsequent intrauterine
pregnancy rates, but salpingectomy is
associated with lower rates of persistent
trophoblast and recurrent ectopic pregnancy.

 In the presence of visible contralateral tubal

disease, laparoscopic salpingotomy is
appropriate if safe or possible.
• Remember Anti-D in Rh –ve patients.
 ha nk
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