Ectopic pregnancy

Ectopic Pregnancy
In ectopic pregnancy, implantation occurs in a
site other than the endometrial lining of the
uterine cavity—in the fallopian tube, uterine
cornua, cervix, ovary, or abdominal or pelvic cavity.
 Ectopic pregnancies cannot be carried to term
and eventually rupture or involute.
Early symptoms and signs include pelvic pain,
vaginal bleeding, and cervical motion tenderness.
Syncope or hemorrhagic shock can occur with
rupture.
 Ectopic Pregnancy(contin--)
Diagnosis is by measurement of the β
subunit of human chorionic gonadotropin and
ultrasonography.
Treatment is with laparoscopic or open
surgical resection or with IM methotrexate.
Incidence of ectopic pregnancy is about 2/100
diagnosed pregnancies.
 Etiology

Tubal lesions increase risk. Factors that particularly increase

risk include
 Prior ectopic pregnancy (10 to 25% risk of recurrence)
 History of pelvic inflammatory disease (particularly due
to Chlamydia trachomatis)
 Prior abdominal or particularly tubal surgery, including
tubal ligation
 Intrauterine device (IUD) use
 Cigarette smoking
 Prior induced abortion
 Heterotopic pregnancy 
 Heterotopic pregnancy is a simultaneous
ectopic and intrauterine pregnancies
 It may be more common among women
who have had ovulation induction or used
assisted reproductive techniques such as in
vitro fertilization (IVF)
 Symptoms and Signs

 Symptoms vary and are often absent until

rupture occurs.
 Most patients have pelvic pain, vaginal bleeding,
or both.
 syncope or sign of hemorrhagic shock.
 Menses may or may not be delayed or missed,
and patients may not be aware that they are
pregnant.
 Cervical motion tenderness, unilateral or
bilateral adnexal tenderness, or an adnexal mass
may be present.
 Diagnosis

 Serum β–human chorionic gonadotropin (β-

hCG) levels (If quantitative serum β-hCG
is < 5000 mIU/mL, ectopic pregnancy is
excluded.
 Pelvic ultrasonography
 Sometimes laparoscopy
 Endocrinology of Pregnancy

2. Quantitative hCG dating of pregnancy. During

weeks 1–6 of a normal pregnancy, hCG levels will
increase by about 70% every 48 hours:
a. 0–2 weeks: 0–250 mIU/mL
b. 2–4 weeks: 100–5000 mIU/mL
c. 1–2 months: 4000–200,000 mIU/mL
d. 2–3 months: 8000–100,000 mIU/mL
e. Second trimester: 4000–75,000 mIU/mL
f. Third trimester: 1000–5000 mIU/mL
 Transvaginal Ultrasonography
 Transvaginal Ultrasonography has a sensitivity of
at least 90% for ectopic pregnancy. 
 The diagnostic ultrasonographic finding in
ectopic pregnancy is an adnexal mass that moves
separately from the ovary.
 In around 60% of cases, it is an inhomogeneous
or a noncystic adnexal mass sometimes known as
the "blob sign".
 The visualization of an empty extrauterine
gestational sac is sometimes known as the "bagel
sign",
 Differential diagnosis

 miscarriage,
 ovarian torsion
acute appendicitis,
 ruptured ovarian cyst, 
 kidney stone,
 pelvic inflammatory disease
 Treatment

 Surgical resection (usually)

 Methotrexate for some small, unruptured
ectopic pregnancies
Salpingectomy is indicated in any of the following
cases:
1- When ectopic pregnancies recur or are > 5 cm
2- When the tubes are severely damaged
3- When no future childbearing is planned
 Treatment (continu--)

 Methotrexate terminates the growth of

the developing embryo; this may cause an
abortion, or the developing embryo may
then be either resorbed by the woman's
body or pass with a menstrual period.
 Contraindications include liver, kidney, or
blood disease, as well as an ectopic
embryonic mass > 3.5 cm.
 Treatment (continu--)
Methotrexate: If unruptured tubal pregnancies
are < 3.0 cm in diameter, no fetal heart activity
is detected, and the β-hCG level is < 5,000
mIU/mL ideally but up to 15,000 mIU/mL,
women can be given a single dose
of methotrexate 50 mg/m2 IM. β-hCG
measurement and ultrasonography are
repeated on about days 4 and 7. If the β-hCG
level does not decrease by 15%, a 2nd dose
of methotrexate or surgery is needed.
Thank You for your
attention