Jessica Octaviani

DEFINITION

“Any pregnancy where the fertilised ovum

gets implanted & develops in a site other
than normal uterine cavity”.

It represents a serious hazard to a woman’s

health and reproductive potential, requiring
prompt recognition and early aggressive
intervention.
 IMPLANTATIONS SITES

EXTRAUTERINE UTERINE
1. Cervical <1
OVARIAN ABDOMINAL 2. Angular
3. Caesarean
TUBAL 95-96% 4. Cornual
•Ampulla 70%
•Isthmus 25% SECONDARY
PRIMARY
•Interstistial 18%
•Infundibulum2%
Intraperitoneal Extraperitoneal
Broad Ligament
(rare)
 INCIDENCE
• Risk factor of ectopic pregnancy
• Abnormal fallopian tube anatomy
• Surgeries for a prior tubal pregnancy, for fertility restoration, or for
sterilization confer the highest risk of tubal implantation. After one
previous ectopic pregnancy, the chance of another approximates
10 percent.
• Prior sexually transmitted disease or other tubal infection, which
can distort normal tubal anatomy. One episode of salpingitis can
be followed by a subsequent ectopic pregnancy in up to 9 percent
of women
• Salpingitis isthmica nodosa, which is a condition in which
epithelium- lined diverticula extend into a hypertrophied
muscularis layer.
• Infertility, the use of ART. And “atypical” implantations—cornual,
abdominal, cervical, ovarian, and heterotopic pregnancy—are
more common following ART procedures.
• Smoking is also a known association, although the underlying
mechanism is unclear.
• Rate in Indonesia – 5-6/1000 deliveries
 INCIDENCE
• Last, with any form of contraception, the absolute number of ectopic
pregnancies is decreased because pregnancy occurs less often.
• However, with some contraceptive method failures, the relative
number of ectopic pregnancies is increased. Examples include tubal
sterilization, copper and progestin-releasing intrauterine devices
(IUDs), and progestin- only contraceptives.
ETIOLOGY
:
 Any factor that causes delayed transport of
the fertilised ovum through the tube.

 Fallopiantube favours implantation in the

tubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.

 These factors may be Congenital or

Acquired.
ETIOLOGY

 CONGENITAL

 Tubal Hypoplasia
 Tortuosity
 Congenital diverticuli
 Accessory ostia
 Partial stenosis
 Elongation
 Intamural polyp
 Entrap the ovum on its way.
ETIOLOGY

ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common

Contraceptive Faliure
 CuT - 4%
 Progestasart -17%
 Minipills -4-10%
 Norplant -30%
 ARIAS – STELLA REACTION

Arias – Stella reaction is charecterised by a benign,

focal and unusual decidual changes in the presence
of chorionic tissue,
 Loss of polarity
 Pleomorphism
 Hyperchromatic nuclei
 Vacuolated cytoplasm
 Intraluminal budding
Though seen in Ectopic Pregnancy but is not specific
for it
and can also be seen in uterine pregnancy
 ACUTE ECTOPIC PREGNANCY

 Classical triad is present in 50% of pt with

rupture ectopic.
- PAIN:- most constant feature in 95%
pt
- variable in severity and nature
- AMENORRHOEA:- 60-80% of pt
- there may be delayed period or slight
spotting at the time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
 Feeling of nausea,vomiting,fainting attack, syncope
attack(10%) due to reflex vasomotor disturbance.
 Abdominal pain most comm. Feature. Shoulder tip
 O/E:- patient is restless in agony, looks blanched,
pale, sweating with cold clammy skin. Features of
shock, tachycardia, hypotension.

 P/A:- abdomen tense, tender mostly in lower

abdomen,shifting dullness, rigidity may be
present.

 P/S:- minimal bleeding may be present

 P/V:- uterus may be bulky, deviated to opposite

side, fornix is tender, excitation pain on
movement of cervix.
POD may be full, uterus floats as if in
water.
 CHRONIC ECTOPIC PREGNANCY

Symptoms

 It can be diagnosed by high clinical suspicion

 Patient had previous attack of acute pain from which
she has recovered.
 She may have amenorrhoea,
 vaginal bleeding with
 dull pain in abdomen and
 with bladder and bowel complaints like dysuria,
frequency or retention of urine,
 rectal tenesmus.
 O/E:- patient look ill, varying degree of pallor,
slightly raised temperature. Features of shock are
absent.

 P/A:- Tenderness and muscle guard on the lower

abdomen.
A mass may be felt, irregular and tender.

 P/V:- Vaginal mucosa pale, uterus may be normal

in size or bulky, ill defined boggy tender
mass may be felt in one of the fornix.
 UNRUPTURED ECTOPIC
 High degree of suspicion & ectopic conscious clinician
can diagnose.
 Diagnosed accidentally in Laparoscopy or
Laparotomy
C/F – delayed period, spotting with discomfort in
lower abdomen.
P/A – tenderness in lower abdomen
P/V
 should be done gently
 uterus is normal size, firm
 small tender mass may be felt in the fornix
Investigations- TVS, radioimmunoassay of β-HCG
and
Laparoscopy
 DIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb%, CBC, blood grouping and cross
matching,.Serology and Coagulation profile.
 Should be catheterized to know urine output.

Bed side test:-

1. Urine pregnancy test:- positive in 95% cases.

ELISA is sensitive to 10-50 mlU/ml of β hCG and
can be detected on 24th day after LMP.

2. Culdocentesis:- (70-90%)
 Can be done with 16-18 G lumbar puncture needle through
fornix into POD.
posterior
 Positive tap is 0.5ml of non clotting blood.
DIAGNOSIS

Imaging:-
1. Ultra Sonography-

a) Transvaginal Sonography (TVS):

 Is more sensitive
 It detect intrauterine gestational sac at 4-5wks and at
S-β hCG level as low as 1500 IU/L .
b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
- Identify the placental shape
(ring-of-fire pattern) and blood flow
outside the uterine cavity.

c) Transabdominal Sonography:

- can identify gestational sac at

5-6 wks
- S-β hCG level at which
intrauterine gestational
sac is seen by TAS is 1800
2. β-HCG Assay-

a) Single β-HCG: little value

b) Serial β-HCG: is required when result of

initial USG is confusing.

- When hCG level < 2000 IU/L doubling time

help to predict viable Vs nonviable pregnancy.

-Rise of β-HCG <66% in 48 hrs indicate

ectopic pregnancy or nonviable intrauterine
pregnancy .

Biochemical pregnancy is applied to those

women who have two β-HCG values >10 IU/L
3. Serum Progesterone –
 level >25 ngm/ml is suggestive of normal intrauterine pregnancy.
 level <15 ngm/ml is suggestive of ectopic pregnancy.
 level <5 ngm/ml indicates nonviable pregnancy, irrespective of
its
location.

4. Diagnostic Laparoscopy (Gold standard)–

Can be done only when patient is haemodynamically stable.
-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.
 DIAGNOSIS

5. Dilatation & Curettage –

 Is recommended in suspected case of incomplete
abortion vs ectopic pregnancy.
 Identification of decidua without chorionic villi is
suggestive of extra uterine pregnancy.
 “Arias-Stella” endometrial reaction is
suggestive but not
diagnostic of ectopic pregnancy.

6. Other Novel Tests –

 Placenta protein (PP14) decrease in EP
 PAPPA (Pregnancy Associated Plasma Protein
A),
PAPPC (schwangerchaft protein 1) has low
value in EP
SUSPECTED ECTOPIC PREGNANCY
SUSPECTED ECTOPIC PREGNANCY
DIFFERENTIAL DIAGNOSIS
D/D of Acute Ectopic

1. Rupture corpus luteum of pregnancy

2. Rupture of chocolate cyst
3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion
6. Acute Appendicitis
7. Perforated peptic ulcer
8. Renal colic
9. Splenic rupture
D/D OF CHRONIC (SUB ACUTE) ECTOPIC

1. Pelvic abscess

2. Pyosalpinx

3. Subserous uterine fibroid

4. Salpingintis

5. Retroverted gravid uterus

6. Appendicular lump
 MANAGEMENT OF ECTOPIC-

PRINCIPLE: Resuscitation and Laparotomy/Laparoscopy

ANTI SHOCK TREATEMENT:

- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching, BT, CT
- Folley’s catheterization done
- Colloids for volume replacement

LAPAROTOMY:
Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given
- Autotransfusion only when donated blood not available.
 MANAGEMENT OF ECTOPIC PREGNANCY-

Laparoscopy
 Preferred method if haemodynamically stable

 Tubal Patency no significant difference

 Followed by similar number of uterine pregnancy

 Shorter operative time

Salpingostomy
 Less than 2cm size

 10-15mm incision
MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
 SURGICAL-
 SURGICALLY ADMINISTERED MEDICAL (SAM)
TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT
 EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA - :
1. Tubal ectopic pregnancies only

2. Haemodynamically stable

3. No rupture or bleeding

4. Adnexal mass of < 3.5 cm without heart beat.

5. Initial β HCG <1000 IU/L and falling in titre (single best)

SUCCESS RATE - Upto 60%

PROTOCOL:
- Hospitalization with strict monitoring of clinical symptom

- Daily Hb estimation

- Serum β HCG monitoring 3-4 days until it is <10 IU/L

- TVS to be done twice a week.

EXPECTANT MANAGEMENT
 Spontaneous resolution occurs in 72%,while 28%
will need laparoscopic salpingostomy

 In spontaneous resolution, it may take 4-67 days

(mean 20 days) for the serum HCG to return to non
pregnant level.

 The percentage fall in serum HCG by day 7 is a

better indicator than the percentage fall by day 2.

 Warning: - Tubal pregnancies have been known

to rupture even when Serum HCG levels are low.
 MEDICAL MANAGEMENT

Surgery is the mainstay of T/t worldwide

Medical M/m may be tried in selected cases
CANDIDATES FOR METHOTREXATE
(MTX)
 Unruptured sac < 3.5cm without cardiac
activity
 S-hCG < 10,000 IU/L
 Persistant Ectopic after conservative
surgery
PHYSICIAN CHECK LIST
 CBC, LFT, RFT, S-hCG
 Transvaginal USG within 48 hrs
 Obtain informed consent
 Anti-D Ig if pt is Rh negative
MEDICAL MANAGEMENT

METHOTREXATE:
 It can be used as oral,intramuscular ,intravenous usually along
with
folinic acid.

 Resolution of tubal pregnancy by systemic administration

of Methotrexate was first described by Tanaka et al (1982)

 Mostly used for early resolution of placental tissue in

abdominal pregnancy.Can also be used for tubal pregnancy.

 Mechanism of action-Methotrexate is a folic acid antagonist that

inactivates the enzyme dihydrofolate reductase.Interferes with the
DNA synthesis by inhibiting the synthesis of pyrimidines leading
to trophoblastic cell death. Auto enzymes and maternal tissues
then absorb the trophoblast.
EXPECTANT MANAGEMENT
 SURGICAL MANAGEMENT OF ECTOPIC
Conservative Surgery

Can be done Laparoscopically or by microsurgical

laparotomy

INDICATION:
- Patient desires future fertility

- Contralateral tube is damaged or surgically removed

previously

CHOICE OF TECHNIQUE: depends on

- Location and size of gestational sac

- Condition of tubes

- Accessibility
 VARIOUS CONSERVATIVE SURGERIES

1. Linear Salpingostomy:
- Indicated in unruptured ectopic <2cm in ampullary
region.
- Linear incision given on antimesentric border over the site
and product removed by fingers, scalpel handle or gentle
suction and irrigation.
- Incision line kept open (heals by secondary intention)

2. Linear Salpingotomy :
- Incision line is closed in two layers with 7-0 interrupted
vicryl sutures.

3. Segmental Resection & Anastomosis:

- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at later
date
4. Milking or fimbrial Expression:
- This is ideal in distal ampullary or infundibular pregnancy.
- It has got increased risk of persistent ectopic pregnancy.

ADVANTAGES OF LAPAROSCOPY

- It helps in diagnosis, evaluation, and treatment .

- Diagnose other causes of infertility.
- Decreased hospitalization, operative time, recovery period,
analgesic requirement.

Follow up after conservative surgery

- With weekly Serum β HCG titre till it is negative.

- If titre increases methotrexate can be given.
 OVARIAN ECTOPIC PREGNANCY
Incidence: 1:40,000
Risk factor: - IUCD
- Endometriosis on surface of ovary
Course:
C/F are same as tubal
pregnancy ruptures within 2-
3 wks
Diagnosis: On Laparotomy
Spiegelberg’s Criteria
1. Ipsilateral tube is intact and
separate from sac
2. Sac occupies the position of
the ovary Unruptured
Ruptured
3. Connected to uterus by
ovarian ligament
Laparotomy Ovarian wedge resection
4. Ovarian tissue found on its Ovarian Cystectomy
Oophorectomy
wall on HP study
 ABDOMINAL PREGNANCY
Incidence: Rarest
MMR : 7-8 times > tubal ectopic
90 times > Intrauterine pregnancy
H/O : - Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation,
diarrhoea, abdominal pain.
- Fetal movement may be painful and high
in
the abdomen
O/E : - Abnormal fetal position, easy in palpating
fetal parts.
- uterus palpated separate from sac
- no uterine contraction after oxytocin
infusion
Diagnosis: Confirmed by
USG, CT scan, MRI, Radiography

TYPE

Primary Secondary
Studiford’s criteria
Conceptus escapes out
1. Both tubes and ovaries normal through a rent from
primary site
2. Absence of Uteroperitonal fistula

3. Pregnancy related to Peritoneal

Intraperitoneal Extraperitoneal
surface & young enough to
Broad ligament
rule out possibility of
secondary implantation
FATE OF SECONDARY ABDOMINAL PREGNANCY :

1. Death of ovum – complete absorption

2. Placental separation – massive intraperitoneal
haemorrhage
3. Infection – fistulous communication with
intestine, bladder, vagina, or umbilicus
4. Fetus dies (majority) – mummification, adipocere
formation, or calcified to lithopaedion
5. Rarely – continue to term (malformation)
M/M:
- Urgent Laparatomy irrespective of period of
gestation

- Ideal to remove entire sac fetus, placenta,

membrane

- Placenta may be left if attached to vital organs, get

CORNUAL
PREGNANCY
SITE: Implantation occurs in rudimentary
horn of Bicornuate uterus

COURSE :Rupture of horn occurs by

12-20 wks

D/D :
1. Interstitial tubal pregnancy
2. Painful leiomyoma along with
pregnancy
3. Ovarian tumor with
pregnancy
4. Asymmetrical enlargement of
uterus.
Implantation into cornu of normal uterus is sometime
called Angular pregnancy .

TREATEMENT:
- Affected cornu with pregnancy is removed
- Hysterectomy
- Hysteroscopically guided suction curettage if
communication with Cx is patent
 HETEROTYPIC PREGNANCY

Co-existing intrauterine and extra uterine pregnancies

Incidence: 1 : 30,000
- With ART – 1:7000
- With ovulation induction – 1:900
More likely:
a) Ass. reproductive technique
b) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomy
M/M :
Depends on the site. Ectopic site may be removed
with continuation of IU pregnancy
(Rh Immunoglobulin: dose of 50 μ gm is sufficient to
prevent sensitization.)
Thank You