JESSENIUS FACULTY OF MEDICINE

in MARTIN
––––––––––––––––––––––––––––––––––
COMENIUS UNIVERSITY, BRATISLAVA,
SLOVAK REPUBLIC

Ectopic pregnancy

© Obstetrics & Gynecology Clinic

JLF UK Martin
 Definition

 An ectopic pregnancy is one in which the fertilized egg implants in

tissue outside of the uterus and the placenta and fetus begin to develop
there
 The most common site of occurrence is within a fallopian tube,
however, ectopic pregnancies can occur in the ovary, the abdomen and
in the lower portion of the uterus (the cervix)
 Put very simply, an ectopic pregnancy means "an out-of-place
pregnancy„
 Ectopic Pregnancy is a common, life–threatening condition affecting
one in 100 pregnancies
 As the pregnancy grows it causes pain and bleeding. If it is not treated
quickly enough it can rupture and cause abdominal bleeding, which can
lead to maternal cardiovascular collapse and death
 History

 Ectopic pregnancies were initially described in the 10th century

(Albucasis in 963 A.D.) and for a long time were universally fatal
events for the mother
 Initial treatments (in the old days) were desperate primitive attempts
designed to destroy the growing pregnancy without sacrificing the
mother's life. These included

 starvation (hoping that the fetus would starve before the mother)
 bleeding (intentional exsanguination of the mother in the hope that the fetus
would die and the mother could be spared)
 administration of strychnine (to preferentially destroy the fetus)
 administration of electricity into the growing gestational sac
 History (cont)

 First serious surgery attempts in the 19th century

→ (Lawton Tait in 1884) - resulted in a high maternal
mortality rate (greater than 60%)

 Development in the management of ectopic

pregnancies have led to remarkable success from
firstly aim "saving the mother's life" to recently
"saving the woman's fertility"
 Ectopic Pregnancy

 Ectopics happen in about 0.25-1% of all pregnancies

 The mortality rate is about 1 per 1000 ectopics (10% of all
maternal deaths)
 Ectopic pregnancy rate increased almost 4 fold (from 4.5 per
1000 pregnancies to 16.8 per 1000 pregnancies since 1970)
 Fatality rate from ectopic pregnancies dropped almost 90%
(from 35.5 per 1000 ectopics to 3.8 per 1000 ectopics)
 Most ectopic pregnancies occur in women aged 25-34 years
 Over 75% of ectopics are diagnosed before 12th week of gestation
 Ectopic Pregnancy

 The decrease in maternal morbidity is due to:

 early detection of pregnancy (hCG assays)

 aseptic (sterile) technique
 antibiotics
 anesthetic agents
 availability of blood and transfusions
 surgical techniques (salpingectomy & salpingostomy)
 Classification

 Tubal pregnancy (96-98%)

ampullary (mid) portion of the fallopian tube (80-90%)
isthmic (area closer to uterus) portion of the fallopian tube (5-10%)
fimbrial (distal end away from uterus) portion of the fallopian tube (5%)
cornual (within the uterine muscle) portion of the fallopian tube (1-2%)
 Abdominal (1-2%) primary/secondary
(tubo-abdominal/abdomino-ovarian)
 Ovarian (0.5-1%)
 Cervical (less than 0.5%)
 Heterotopic (combination of ectopic + intrauterine pregnancy)
 Uncommon Ectopics

 Intraligamentous pregnancy (in broad ligament)

 Pregnancy in a uterine diverticulum or sacculation

 Angular pregnancy (inside the uterotubal attachment)

 Pregnancy in a rudimentary horn of uterus

 Intraural pregnancy (in myometrium)

 Vaginal pregnancy

 Multiple tubal pregnancy

 Histology & Anatomy

 The fallopian tubes (oviducts)

are small, hollow muscular
tubes each about ten cm long
 Inside the tube is delicate
mucous membrane that forms
the fimbriae
 In the epithelial lining of the
tubes half the cells are mucus-
secreting and half have cilia-
tiny hair like projections which
beat gently to propel these
secretions towards the uterus
 The muscular wall of each tube
becomes thicker towards the
uterus, and has a natural
peristaltic action which assists
the movement of mucus
Embryology & Physiology
 Risk Factors for Ectopic
Pregnancy

 Pelvic inflammatory disease (PID) or Salpingitis → 6 -10 times

higher risk. Mainly invasion of gonorrhea or chlamydia from the
cervix up to the uterus and tubes and infection in these tissues
causes an intense inflammatory response and scar tissue adhesions
in the tube and may damage the cilia of the fallopian tube
 Endometriosis
 History of IUD use
 Progesterone–only contraceptive pill (mini–pill) → alters tubal
motility
 Pregnancy after tubal ligation or coagulation
 Previous tubal surgery
 Ovulation induction or ovarian stimulation
 Risk Factors for Ectopic
Pregnancy
 In vitro fertilization → 2-5% of pregnancies are conected with IVF
 Advancing age
 Previous ectopic → about 10-20% of women attempting pregnancy
after one ectopic will have another
 Salpingitis Isthmica Nodosa → uncommon diverticulae in the proximal
(isthmic) portion of the tube that enhance tubal implantation of the
early developing embryo
 Pelvic adhesions, pelvic tumors
 Atrophic endometrium
 Septate uterus
 Zygote abnormalities (chromosomal abnormatity, neural tube defects,
abnormal spermatozoa)
 Symptoms

 One-sided pain in abdomen (can be persistent and severe, but may not be
on the same side as an ectopic pregnancy)
 Shoulder-tip pain (due to internal bleeding irritating the diaphragm when
woman breathe in and out)
 Bladder or bowel problems (woman feels pain when she has her bowels
open – tenesmus, or when she passes water)
 Collapse (feeling of light-headed or faint, paleness, increasing pulse rate,
sickness, diarrhoea and falling blood pressure)
 Pregnancy test (from urine may be positive but not always → hCG blood
tests to confirm)
 Amenorrhoea (missed or late period)
 Abnormal vaginal bleeding
 Symptoms of pregnancy
 Fever (unusual, occuring in 2% of pacients)
 Ectopics Manifestation

 Emergency presentation - Suddenly, without warning a woman is

very unwell, collapses and is taken to hospital in fase of
haematoperitoneum and hemorrhage shock

 Subacute presentation - The most common presentation is with a

missed period, positive pregnancy test, some abdominal pain, and
irregular vaginal bleeding

 Rrisk pregnancy group - After previous ectopic, tubal surgery or

assisted conception ( IVF) → detection rate is high → women are
primary observed
 Diagnosis

 Early diagnosis of an ectopic pregnancy is critically important

 There is no uniformly accepted diagnostic protocol
 History
 Physical examination (pain, adnexal mass, enlarged uterus)
 Transvaginal or transabdominal ultrasound
 Quantitative hormone tests (HCG, ß-hCG, progesterone)
 Occasionally culdocentesis (thin needle is inserted at the top
of the vagina, between the uterus and the rectum, to check for
blood in CD)
 Sometimes dilatation and curettage (exclude intrauterine
pregnancy or incomplete abortion)
 USG Diagnosis

 Pseudogestational sac in uterus (is seen in 10-20% of ectopics)

 Decidual transformed endometrium (thick & hyperechogenic)
 No presence of developing fetus in uterus
 Adnexal mass or „Tubal ring“ (gestational sac, yolk sac or fetal pole)
 Occasionaly hemosalpinx (tubes fill with blood)
 Enlargement of uterus (not appropriate for date)
 Fluid in Cul –De- Sac
 Hormone Tests Diagnosis

 Obviously first of all is a pregnancy test (urinary RIA, ELISA test)

 HCG more than 200 mIU/mL
 Blod serum quantitative levels of ß-hCG testing
- Common used is ELISA method

- Remember: monitor the progress → In a normal pregnancy level of ß-hCG should

double every 48 hours, in ectopic is ratio lower

- An increase in serum ß -hCG less than 66% over two days is predictive of ectopic
pregnancy

- Results reported in mIU/ml (milliInternational units per milliliter)

- To establish the diagnosis correlate lab results with the clinical picture

- ß-hCG peaks in 10 weeks after last menstrual period

- ß-hCG assay is negative (when less than 5 mIU/mL)

 Other Pregnancy Related
Hormones

 Progesterone
concentration of greater >25 ng/mL is highly correlated
(greater than 95%) with a normal intrauterine pregnancy
concentration of less <15 ng/mL is highly correlated
(almost 100%) with an abnormal and nonviable pregnancy
 Early pregnancy factor (EPF)
 Pregnancy specific beta-1 glycoprotein (SP1)
 Placental protein 5 (PP 5)
 Serum creatine kinase (CK)
 Differential Diagnosis

 Abortion (complete,incomplete, inevitable, missed)

 Threatened appendicitis
 Acute dysmenorrhea
 Placenta previa
 Shock (hemorrhagic, hypovolemic)
 Ruptured corpus luteum cyst
 Adnexal torsion
 Cornual myoma or abscess
 Ovarian tumor
 Endometrioma
 Cervical cancer
 Management

 Once an ectopic is diagnosed, there are several different treatments

 It is not possible to take the pregnancy from the tube and put it into
the womb
 In all cases, the pregnancy must be terminated
 Various forms of management
 The appropriate surgery follow up for the patient are serial blood
tests of the pregnancy hormone (ß-HCG)
 Within a few weeks, the pregnancy hormone should not be
measureable
 Management (cont)
The options are as follows:

 Expectant management - proportion of all ectopics will not progress to

tubal rupture, but will regress spontaneously and be slowly absorbed
Level of hCG must falling and a woman becomes clincally well.
Situation needs daily hCG, TVS. If hCG increases or sonographic
findings are suspicious → active management
 Medical treatment – (methotrexate,dyktinomycin, hyperosmolar
glucose, potassium chloride, mifepristone)
given by injection in form of systemic or local administration
Laparoscopic surgery - (salpingotomy or salpingectomy).
 Open surgery (laparotomy) - involves a 5-8 cm incision at the top of the
pubic hairline
The affected tube is brought out and either salpingotomy or ectomy is
performed
 Criteria for Expectant
Management

 Decreasing hCG titers (less than 1500 mIU/mL )

 Tubal location (rather than ovarian, abdominal, cervical)
 No evidence of rupture or significant bleeding
 Ectopic mass with size less than 4 cm
 Highly motivated patient with strong desire to avoid both
 surgery and medical management
 Hemodynamically stable healthy woman
 Absence of fetal heart tones
 Methotrexate Treatment

 Anti-metabolite drug
 Inexpensive, easy to obtain, well tolerated
 Mixture containing at least 85% of folic acid antagonist "4-amino-10-
methylfolic acid„ and 25% of Leucovorum calcium (folic acid agonist)
 The initial dose regimen
MTX (1 mg/kg IM ) or single IM dose of 50 mg/square meter
Leukovorum (0.1 mg/kg IM )
 Don´t exceed 4 doses
 70-95% efficiency of cases treated
 Methotrexate management takes 4-6 weeks for complete resolution of the
ectopic pregnancy
 Complications of
Methotrexate

 Bone marrow suppression

 Acute and chronic hepatotoxicity transient elevations in serum liver
transaminases
 Progressive pulmonary toxicity (pneumonitis and pulmonary fibrosis)
 Dermatologic effects (rashes, itch, folliculitis, photosensitivity, pigment
changes, rarely alopecia)
 Renal impairment
 GI side effects (stomatitis, gastritis, diarrhoea)
 Invasive Treatment

 The standard aim of care is to control the bleeding and remove the
ectopic pregnancy

 Prior to the late 1980's, this was accomplished by first making a large
incision in the woman's abdomen and "looking" to find if there was a
swollen fallopian tube containing the ectopic

 With the advent of advanced laparoscopic technique, the ectopic

pregnancy can be identified with only a small incision below the
umbilicus (navel)

 Microinvasive technique
 Surgical Treatment Forms

 Salpingotomy: Making an incision on the tube and removing the

pregnancy
 Salpingectomy: Cutting the tube out
 Segmental resection: Cutting out the affected portion of the tube
 Fimbrial expression: "Milking" the pregnancy out the end of the tube
 Usually, if the tube is not ruptured → laparoscopy
 Cases of rupture with significant hemorrhage into the abdomen →
laparotomy
 Complications

 Hemorrhage and hypovolemic shock

 Infection
 Loss of reproductive organs following surgery
 Infertility, sterility
 Urinary and/or intestinal fistulas following complicated surgery
 Disseminated intravascular coagulation
 Persistent ectopic (complication of conservative surgical
treatment, incomplete removal of trofoblastic tissue)
 Rh disease
 Emotions Changes

 Ectopic pregnancy can be a devastating experience

(loss of baby, loss of part of fertility, recovery from surgery)

 Postsurgery depression

 Sudden end to pregnancy → hormonal disarray

 Distress and disruption of family life

 Prognosis

 The prognosis with an ectopic pregnancy is good for

patients with an early diagnosis

 Good when fertility is preserved (as much as possible)

 Patients with a previous ectopic pregnancy should be

educated regarding the potential increased risk for
another ectopic pregnancy
 The Future Pregnancy

 If one of the tubes was removed, woman ovulate as before, but

chances of conceiving will be reduced to about 50%

 Woman can still become pregnant and have a successful

pregnancy with one intact tube

 Overall chances of a repeat ectopic are between 7–10% and

depends on the type of surgery

 If infertility occurs, fertility treatment techniques can still

help a woman achieve pregnancy (IVF)
 Tubal Pregnancy

 Is a pregnancy that grows in

the fallopian tube, not the
uterus
 If the pregnancy continues
and the tube ruptures, there
may be life-threatening
intraabdominal bleeding
 Even with the modern
practice of medicine, the
rupture of the tubal ectopic
pregnancy is still one of the
leading causes of
gynecological deaths
 Tubal Pregnancy
Findings

 Acute tubal rupture (40% of tubal pregnancies)

 Chronic tubal rupture (60% of tubal pregnancies)
 Early unruptured tubal pregnancy
 Tubal abortion
 Tubal Pregnancy at USG

 Ultrasound showing uterus

and tubal pregnancy
 2D scan
 Uterus outlined in red
 Uterine lining in green
 Ectopic pregnancy yellow
 Fluid in uterus at blue circle
is called a
"pseudogestational sac"
 Tubal Pregnancy at USG
 Detailed view of ectopic (thick, brightly echogenic, ringlike structure
outside the uterus)
 Tubal pregnancy circled in red
 4.5 mm fetal pole (between cursors) in green
 Pregnancy yolk sac in blue
 Tubal Pregnancy
 A right tubal ectopic pregnancy seen at laparoscopy
 The swollen right tube containing the ectopic pregnancy is on the
right at E
 The stump of the left tube is seen at L - this woman had a previous
tubal ligation
 Tubal Pregnancy

After laparoscopic resection

of the tube, the tubal stump
is seen at S

Close view of the

same ectopic
 Tubal Pregnancy

Same situation after rupture

Right tubal ectopic

pregnancy in 11 th
week of gestation
 Tubal Pregnancy
DIAGNOSIS & TREATMENT OPERATIVE
LAPAROSCOPIC SURGERY

 Laparoscopist must try to remove the ectopic pregnancy, preserve the

fallopian tube, and early send the patient home
 Diagnostic LSK picture below
 Tubal Pregnancy

 The first step of this technique involves making a linear slit into the
fallopian tube over the ectopic with a monopolar needle tip.
 Tubal Pregnancy

 The second step involves teasing out the ectopic pregnancy intact, and
then irrigating the incision to make sure it is free of any ectopic tissue
 LAPAROSCOPIC SALPINGECTOMY
FOR ECTOPIC PREGNANCY
CASE REPORT
 Laparoscopic left salpingectomy
after attempted salpingostomy
for a left tubal ectopic pregnancy
in a 32-year-old gravida 3 para 2
 Because patient wished to retain
her fertility, salpingostomy was
initially attempted to save the tube,
but hemorrhage and retained
trophoblastic tissue dictated a
partial salpingectomy (removal of
part of the tube)
 The ectopic pregnacy is visualized in
the ampullary region of the left
fallopian tube
 LSC salpingectomy (cont)

Salpingostomy on the anti-mesenteric

border. Is perfomed to allow withdraw
of the products of conception and
preservation of the tube

After the tube is opened, a

grasper is used to remove
the products of conception
LSC salpingectomy (cont)
Bleeding occuring after removal
of the products of conception →
Electrocoagulation is used to
achieve hemostasis

Electrocoagulation has achieved

hemostasis
The tube was partially removed due
to the retained trophoblastic tissue
 LSC salpingectomy (cont)

The distal tube has been

removed through the port

Successive electocoagulation of
the mesosalpinx and subsequent
sharp dissection allows partial
salpingectomy
 LSC salpingectomy (cont)

 Once hemostasis is
assured, the hemo-
peritoneum is evacuated

 A single follow up ß-HCG

should be examine for 2-3
weeks post operation
 Ovarian Pregnancy

 Ovary is the white structure in

the middle
 Pregnancy is implanted on the
far right side of the ovary at the
"X„
 Around the ovary are seen
bleeding and clotted blood
 Abdominal Pregnancy

 Incidence of 1 in 8000 births

 Mostly secondary form of abdominal pregnancy
 Predominant symptom si pain with hemorrhage
 Genitourinary symptoms discomfort
 Immediate surgical removal of the fetus
 Retain attached placenta in site and start with MTX treatment
 High maternal & fetal mortality rate
 Keep in Mind

Why is ectopic pregnancy

so dangerous?

 If the ectopic does´nt die, the thin wall of the tube will
stretch and cause pain, discomfort in the lower abdomen
 There may be some vaginal bleeding at this time
 As the pregnancy grows, the tube may rupture, causing
severe abdominal bleeding, pain, collapse and if not
recognized ► death
 Even if woman has ectopic, first urine pregnancy test-may
be negative !
End with Funny

Thanks for your attention !