Ectopic Pregnancy

• Definition:
Presence of conceptus outside of the uterus. It’s an emergency because it could cause
massive Obstetric bleeding. (most commonly > intraperitoneal bleeding that you wouldn’t
know about)
Incidence: 1-2%

• Site:
1- Most common site: Tubal pregnancy 98% (ampullary is the most common part of the
tube).
2- Most dangerous site: cervical or interstitial part of the tube because it’s very vascular
and very difficult to deal with. (sometimes you’d have to do hysterectomy)
3- Others: isthmic, fimbrial, ovarian, broad ligament, abdominal (rare).

• Risk factors/etiology:
1- 50% idiopathic
2- Hx of ectopic pregnancy (20% risk)
3- Hx of PID. (specially chlamydia or gonorrhea)
4- ART: assistive reproductive technology like IVF, ICSI (intracytoplasmic sperm injection),
GIFT, ZIFT.
5- Anything that would decrease tubal motility like: smoking, progesterone P4 like the one
in Plan B.
6- IUD in situ specially cupper
7- Any kind of tubal or pelvic surgery
8- Endometriosis

• Presentation:
1- Classical triad: 1- Amenorrhea 6-8wks
2- Unilateral pelvic pain
3- Spotting (decidual bleeding of thick endometrium)

2- Could present with rt shoulder pain: if there was bleeding inside, the endometrium
will irritate the peritoneum and diaphragm > radiating pain
3- N/V, Diarrhea
4- Collapse > in case of rupture ectopic > emergency

• Examination:
1- Vital signs: BP, temp, HR > make sure it’s afebrile, vital signs stable (AFSS)
2- Abdominal examination: lower abdomen tenderness, or guarding rigidity, cullen’s
sign, grey-turner sign in case of ruptured ectopic due to peritonitis.
3- Sterile speculum examination: like any case of Obgyn with bleeding to exclude local
causes (Contraindicated in placenta previa)
4- Bimanual examination: cervical motion tenderness, or adnexal tenderness
• Investigation:
1- Serial serum HCG: → To confirm pregnancy
→ Check pattern of raise: -> Doubling every 2-3 days? -> normal
→ Not doubling /slowly increasing (suboptimal)? -> Abnormal
2- Transvaginal sonogram TVS: Location of gestational sac? intrauterine or extrauterine
So if you have HCG >1500 mIU and you did TVS
→ you would find an intrauterine gestational sac in a normal pregnancy
→ if you find an empty uterus -> 95% ectopic pregnancy
→ if you don’t have TVS and only transabdominal sonogram the level of HCG has to be 6000

3- MRI (safe in pregnancy) but not usually needed

4- Cludocentesis > of you get blood or pus in the needle from the pouch of Douglas >
intraabdominal bleeding
5- Gold standard: laparoscopy invasive so we depend on HCG and US but can be diagnostic
and therapeutic

• Management:

Hemodynamically unstable Hemodynamically stable

• Loss of consciousness, increased HR, • Expectant: if HCG <3000-6000 mIU

hypotension, pale, cold clammy
peripheries. → emergency
(Hypovolemic hemorrhagic shock)
• Resuscitation /ABCs
• Call for help! Airway, breathing, insert
two IV lines:
→ one for cross match and 6 blood
units
→ one for IV fluids
• Take pt for laparotomy (She doesn’t
need to be fasting > emergency)
• Do a salpingectomy
1- Measure HCG every 2-3days
→ if it’s decreasing pregnancy is failing
it will go away by its own just put her
under monitoring
• Medical: if HCG is low3000 -6000
and gestational size <3.5 cm
and stable pt
→ you can use IM methotrexate MTX
(it’s anti-folic acid)
→ After MTX check HCG every 1wk until
it reaches < 10 mIU
→Side effects of MTX: conjunctivitis,
stomatitis, GI upset

• Laparoscopy:
→ salpingectomy
→ Salpingostomy: has risk of another
ectopic

• Give Rhogam (anti-D) IM like any case of RH-ve mother with pregnancy

Rand Alazzaz
Source: Wessam Khalfallah Youtube channel