INVESTIGATIONS &

MANAGEMENT OF ECTOPIC
PREGNANCY
PRESENTED BY:
GAN CHIA YIN
YEAR 3

INVESTIGATIONS
HIGH INDEX OF SUSPICION PROMPT & EARLY
DIAGNOSIS
REDUCE MORBIDITY & MORTALITY ASSOCIATED WITH
ECTOPIC PREGNANCY
SCREEN ANY FEMALE PATIENT IN HER
REPRODUCTIVE YEARS WHO PRESENTS WITH
ABDOMINAL PAIN, CRAMPING, OR VAGINAL
BLEEDING FOR PREGNANCY.

INVESTIGATIONS
1. BED SIDE TEST: UPT
2. ULTRASONOGRAPHY
3. BETAHUMAN CHORIONIC GONADOTROPIN (BHCG) LEVELS
4. PROGESTERONE LEVELS
5. DILATATION AND CURETTAGE
6. CULDOCENTESIS
7. DIAGNOSTIC LAPAROSCOPY (GOLD STANDARD)

BED SIDE TEST

URINE PREGNANCY TEST
POSITIVE IN 95% CASES
ELISA IS SENSITIVE TO 10-50
MIU/ML OF B-HCG & CAN BE
DETECTED ON 24TH DAY AFTER
LMP

ULTRASONOGRAPHY
VISUALIZATION OF AN INTRAUTERINE SAC,
WITH OR WITHOUT FETAL CARDIAC ACTIVITY, IS
OFTEN ADEQUATE TO EXCLUDE ECTOPIC
PREGNANCY.
THE EXCEPTION TO THIS IS IN CASES OF
HETEROTOPIC PREGNANCIES, WHICH OCCUR
IN BETWEEN 1 IN 4000 AND 1 IN 30,000
SPONTANEOUS PREGNANCIES.

ULTRASONOGRAPHY
IN PATIENTS UNDERGOING OVARIAN STIMULATION &
ASSISTED REPRODUCTION, SCREENING THE ADNEXA
BY ULTRASONOGRAPHY IS MANDATORY EVEN WHEN AN
INTRAUTERINE PREGNANCY HAS BEEN VISUALIZED,
BECAUSE THESE PATIENTS HAVE A 10-FOLD INCREASED
RISK OF HETEROTOPIC PREGNANCY.
HETEROTOPIC PREGNANCY IS A COMBINED
INTRAUTERINE AND ECTOPIC PREGNANCY, AND IT MAY
OCCUR IN APPROXIMATELY 1 IN 30,000.

TRANSVAGINAL/ENDOVAGINAL
ULTRASONOGRAPHY
CAN BE USED TO VISUALIZE AN INTRAUTERINE
PREGNANCY BY 24 DAYS POST-OVULATION OR
38 DAYS AFTER THE LAST MENSTRUAL
PERIOD (WHICH IS ABOUT 1 WEEK EARLIER
THAN TRANSABDOMINAL
ULTRASONOGRAPHY)

GESTATIONAL SAC
GESTATIONAL SAC (AN ULTRASONOGRAPHIC TERM & NOT
AN ANATOMIC TERM) IS THE FIRST STRUCTURE
RECOGNIZABLE ON TRANSVAGINAL
ULTRASONOGRAPHIC IMAGES.
IT HAS A THICK, ECHOGENIC RIM SURROUNDING A
SONOLUCENT CENTER CORRESPONDING TO THE
TROPHOBLASTIC DECIDUAL REACTION SURROUNDING
THE CHORIONIC SAC.
STRUCTURES THAT REPRESENT A DEVELOPING EMBRYO

PSEUDOSAC
A PSEUDOSAC IS A COLLECTION OF FLUID WITHIN THE
ENDOMETRIAL CAVITY CREATED BY BLEEDING FROM
THE DECIDUALIZED ENDOMETRIUM AND IS OFTEN
ASSOCIATED WITH AN EXTRAUTERINE PREGNANCY;
THIS SHOULD NOT BE MISTAKEN FOR A NORMAL, EARLY
INTRAUTERINE PREGNANCY.
THE TRUE GESTATIONAL SAC IS LOCATED ECCENTRICALLY
WITHIN THE UTERUS BENEATH THE ENDOMETRIAL
SURFACE, WHEREAS THE PSEUDOSAC FILLS THE
ENDOMETRIAL CAVITY.

DEFINITE INTRAUTERINE
PREGNANCY
IN A DEFINITE INTRAUTERINE
PREGNANCY, A GESTATIONAL SAC WITH
A SONOLUCENT CENTER (>5 MM IN
DIAMETER) IS SURROUNDED BY A
THICK, CONCENTRIC, ECHOGENIC
RING LOCATED WITHIN THE
ENDOMETRIUM & CONTAINS A
FETAL POLE, A YOLK SAC, OR BOTH.

An endovaginal sonogram
reveals an intrauterine
pregnancy at approximately 6
weeks. A yolk sac (ys),
gestational sac (gs), and fetal
pole (fp) are depicted.

DEFINITE ECTOPIC PREGNANCY

IN THE PRESENCE OF A DEFINITE ECTOPIC
PREGNANCY, A THICK, BRIGHTLY ECHOGENIC,
RINGLIKE STRUCTURE IS LOCATED OUTSIDE
THE UTERUS, WITH A GESTATIONAL SAC
CONTAINING AN OBVIOUS FETAL POLE, A YOLK
SAC, OR BOTH.

Bagel
Sign

COLOR-FLOW DOPPLER SONOGRAPHY

TV-CDS
TO IMPROVE THE DIAGNOSTIC
SENSITIVITY AND SPECIFICITY
OF TRANSVAGINAL
ULTRASONOGRAPHY, ESPECIALLY IN
CASES IN WHICH A GESTATIONAL
SAC IS QUESTIONABLE OR ABSENT.
IDENTIFY THE PLACENTAL SHAPE
(RING-OF-FIRE PATTERN) &
BLOOD FLOW OUTSIDE THE

BETAHUMAN CHORIONIC
GONADOTROPIN (B-HCG) LEVELS
SERUM & URINE ASSAYS FOR -HCG DETECTS A
PREGNANCY
BEFORE THE FIRST MISSED PERIOD.
SERUM -HCG LEVELS CORRELATE WITH THE SIZE
AND GESTATIONAL AGE IN NORMAL EMBRYONIC
GROWTH.
IN A NORMAL PREGNANCY, THE -HCG LEVEL
DOUBLES EVERY 48-72 HOURS UNTIL IT REACHES
10,000-20,000MIU/ML.
IN ECTOPIC PREGNANCIES, -HCG LEVELS USUALLY

BETAHUMAN CHORIONIC
GONADOTROPIN (B-HCG) LEVELS
IN EARLY, HEALTHY INTRAUTERINE PREGNANCIES,
SERUM LEVELS OF -HCG DOUBLE APPROXIMATELY
EVERY 2 DAYS (1.4-2.1 D).
KADAR ET AL ESTABLISHED THAT THE LOWER LIMIT
OF THE REFERENCE RANGE TO WHICH SERUM -HCG
SHOULD INCREASE DURING A 2-DAY PERIOD IS
66%.
FOR EXAMPLE, A PREGNANT PATIENT WITH A SERUM HCG LEVEL OF 100 MIU/ML SHOULD HAVE A SERUM HCG LEVEL OF AT LEAST 166 MIU/ML 2 DAYS LATER.

DISCRIMINATORY ZONE
THE DISCRIMINATORY ZONE OF -HCG IS THE
LEVEL ABOVE WHICH A NORMAL
INTRAUTERINE PREGNANCY IS RELIABLY
VISUALIZED.
ONCE -HCG REACHED 1000-1500 MIU/ML, A
GESTATIONAL SAC SHOULD BE SEEN WITHIN THE
UTERUS ON TRANSVAGINAL
ULTRASONOGRAPHIC IMAGES.

DISCRIMINATORY ZONE
ONCE IT HAS REACHED 4500-6000 MIU/ML, A
GESTATIONAL SAC SHOULD BE VISUALIZED WITHIN
THE UTERUS ON ABDOMINAL SCAN IMAGES.
THE LACK OF AN INTRAUTERINE PREGNANCY
WHEN THE -HCG LEVEL IS ABOVE THE
DISCRIMINATORY ZONE REPRESENTS AN
ECTOPIC PREGNANCY OR A RECENT
ABORTION.

PROGESTERONE LEVELS
SERUM PROGESTERONE LEVELS HAVE THE FOLLOWING
CHARACTERISTICS:
THEY ARE NOT GESTATIONAL AGEDEPENDENT
THEY REMAIN RELATIVELY CONSTANT DURING THE FIRST
TRIMESTER OF NORMAL AND ABNORMAL PREGNANCIES
THEY DO NOT RETURN TO THE REFERENCE RANGE IF
INITIALLY ABNORMAL
THEY DO NOT CORRELATE WITH BETAHUMAN
CHORIONIC GONADOTROPIN (-HCG) LEVELS

PROGESTERONE LEVELS
>25 NG/ML IS SUGGESTIVE OF NORMAL
INTRAUTERINE PREGNANCY
<15 NG/ML IS SUGGESTIVE OF ECTOPIC
PREGNANCY
<5 NG/ML INDICATES NON-VIABLE
PREGNANCY IRRESPECTIVE OF ITS LOCATION

DILATATION AND CURETTAGE

RAPID, COST-EFFECTIVE METHOD
DIFFERENTIATE BETWEEN AN
INTRAUTERINE AND AN ECTOPIC
PREGNANCY.
IF THE TISSUE OBTAINED IS POSITIVE FOR
VILLI
= NONVIABLE INTRAUTERINE PREGNANCY
IN THE ABSENCE OF VILLI = ECTOPIC
PREGNANCY
LAPAROSCOPY CAN BE PERFORMED AT
THAT ONLY
TIME,IN
ORCASES
THE CASE
MAY BE
USED
IN WHICH
CONTINUATION OF A PREGNANCY
FOLLOWED
USING
SERIAL
-HCG
IS
NOT DESIRED
EVEN
IF ITSERUM
WERE AN
INTRAUTERINE GESTATION.

CULDOCENTESIS
RAPID & INEXPENSIVE
EVALUATE RUPTURED ECTOPIC
PREGNANCY.
INSERT A NEEDLE THROUGH THE
POSTERIOR FORNIX OF THE VAGINA
INTO THE CUL-DE-SAC & ATTEMPTING
TO ASPIRATE BLOOD.
WHEN NON-CLOTTING BLOOD IS
FOUND WITH SUSPECTED ECTOPIC
PREGNANCY, OPERATIVE
INTERVENTION IS INDICATED,

DIAGNOSTIC LAPAROSCOPY
(GOLD STANDARD)
PATIENTS IN PAIN AND/OR THOSE WHO ARE
HEMODYNAMICALLY UNSTABLE SHOULD PROCEED TO
LAPAROTOMY
LAPAROSCOPY ALLOWS ASSESSMENT OF THE PELVIC
STRUCTURES, THE SIZE & EXACT LOCATION OF THE
ECTOPIC PREGNANCY, THE PRESENCE OF
HEMOPERITONEUM & OTHER CONDITIONS, SUCH AS
OVARIAN CYSTS & ENDOMETRIOSIS, WHICH, WHEN
PRESENT WITH AN INTRAUTERINE PREGNANCY, CAN MIMIC
AN ECTOPIC PREGNANCY.

Laparoscopic picture of an unruptured right ampullary tubal

pregnancy; bleeding out of the fimbriated end has resulted in
hemoperitoneum.

MANAGEMENT

EXPECTANT MANAGEMENT
BASED ON THE ASSUMPTION THAT A SIGNIFICANT
PROPORTION OF ALL TUBAL PREGNANCIES WILL RESOLVE
THROUGH REGRESSION OR A TUBAL ABORTION WITHOUT
ANY TREATMENT.
THIS OPTION IS SUITABLE FOR PATIENTS WHO ARE
HAEMODYNAMICALLY STABLE & ASYMPTOMATIC.
THIS REQUIRES SERIAL B-HCG MEASUREMENTS &
ULTRASONOGRAPHY.

MEDICAL TREATMENT
SYSTEMIC METHOTREXATE FOLIC ACID ANTAGONIST
INHIBITS DNA SYNTHESIS IN TROPHOBLASTIC CELLS
SINGLE INTRAMUSCULAR INJECTION OR MULTIPLE FIXED
DOSE REGIMEN
DOSE IS CALCULATED BY PATIENTS BODY SURFACE AREA
50MG/M2
AVOID FOLIC ACID, ALCOHOL, EXPOSURE TO
SUNLIGHT & SEXUAL INTERCOURSE DURING
TREATMENT

INDICATIONS FOR USAGE OF

METHOTREXATE:
1. CORNUAL PREGNANCY
2. PERSISTENT TROPHOBLASTIC DISEASE
3. PATIENT WITH 1 FALLOPIAN TUBE & FERTILITY
DESIRED
4. PATIENT WHO REFUSES SURGERY OR IN WHOM
RISKS OF SURGERY IS TOO HIGH
5. TREATMENT OF ECTOPIC PREGNANCY WHERE
TROPHOBLAST IS ADHERENT TO BOWEL OR

CONTRAINDICATIONS
1. CHRONIC LIVER, RENAL OR
HAEMATOLOGICAL
DISORDER
2. ACTIVE INFECTION
3. IMMUNODEFICIENCY
4. BREASTFEEDING

SIDE EFFECTS
NAUSEA
VOMITING
STOMATITIS
CONJUNCTIVITIS
GASTROINTESTINAL UPSET
PHOTOSENSITIVE SKIN
REACTION
NON-SPECIFIC ABDOMINAL
PAIN

SURGICAL TREATMENT
LAPAROSCOPY OR LAPAROTOMY
LAPAROSCOPIC BETTER THAN LAPAROTOMY:
1. LESS BLOOD LOSS
2. SHORTER OPERATING TIME
3. LESS ANALGESIA REQUIREMENT
4. SHORTER HOSPITAL STAY
5. SHORTER CONVALESCENCE

SURGICAL TREATMENT
LAPAROTOMY RESERVED FOR SEVERELY
COMPROMISED PATIENTS OR DUE TO LACK OF
ENDOSCOPIC FACILITIES
DURING SURGERY, FALLOPIAN TUBE CAN EITHER BE:
1. REMOVED (SALPINGECTOMY)
2. SMALL OPENING MADE AT THE SITE OF ECTOPIC
PREGNANCY & TROPHOBLASTIC TISSUE EXTRACTED
VIA OPENING (SALPINGOTOMY)
IF PATIENT HAS NORMAL REMAINING TUBE,
SALPINGECTOMY IS THE TREATMENT OF CHOICE
SALPINGOTOMY MAY BE ASSOCIATED WITH HIGHER

Linear
Salpingostomy

Linear incision being made at the antimesenteric

side of the ampullary portion of the fallopian tube.

Schematic of a tubal gestation being tease

out after linear salpingostomy.

Laparoscopic picture of an ampullary ectopic pregnancy protruding

out after a linear salpingostomy was performed.

THANK YOU FOR YOUR ATTENTION