Ectopic pregnancy

The blastocyst normally implants in the endometrial lining

of the uterine cavity . Implantation anywhere else is an
ectopic pregnancy. More than 95% of ectopic pregnancies
involve the oviduct, but tubal pregnancy is not synonymous
with ectopic gestation.The risk of death from an extra uterine
pregnancy is 10 times greater than that for a vaginal delivery
and 50 times greater than for an induced abortion. Moreover,
prognosis for a successful subsequent pregnancy is reduced
significantly in these women , especially if they are
primigravid and over the age of 30. A clear understanding of
the contributing factors responsible for ectopic pregnancies
and of effective and modern methods for their earlier diagnosis
is essential .
 General Considerations
Etiology: Etiological factors associated with an increased
incidence of ectopic pregnancy include those outlined in this
section.
• Mechanical Factors - that prevent or retard passage of the
fertilized ovum into the uterine cavity include the following:
• 1. Salpingitis -especially endosalpingitis, which causes
agglutination of the arborescent folds of the tubal mucosa
with narrowing or the lumen or formation of blind pockets.
• 2. Peritubal adhesions subsequent to postabortal or puerperal
infections, appendicitis, or endometriosis. These may cause
kinking of the tube and narrowing of the lumen
• 3. Developmental abnormalities of the tube, especially diverticula ,
accessory ostia, and hypoplasia. Such abnormalities are
extremely rare but may occur following in utero exposure to
diethylstilbestrol.
• 4. Previous ecpotic pregnancy. After one the chance of another is
7 to 15 % .
• 5. Previous operations on the tube, either to restore patency or
occasionally the failure of tubal sterilization.
• 6. Multiple previous induced abortions my increase the risk of
ectopic pregnancy. The risk is unchanged after one induced
abortion; it is doubled after two induced abortions, likely due to
small increases in the incidence of salpingitis
• 7. Tumors that distort the tube, such as uterine myomas and
adnexal masses
• 8. Tubal pregnancies are not increase by abnormal embryos .
 Functional Factors. Functional factors that delay passage of the
fertilized ovum into the uterine cavity include the following:
• 1. External migration of the ovum is probably not an important factor
except in cases of abnormal mulerian development resulting in a
hemiuterus with an attached non-communicating
rudimentary uterine horn.
• 2. Menstrual reflux has been suggested as a cause; however, there is
little supporting evidence for this
• 3. Altered tubal motility may follow changes in serum levels of
estrogens and progesterone. A change in the number and affinity of
adrenergic receptors in uterine and tubal smooth muscle is likely
responsible
• 4. Cigarette smoking at the time of conception has been shown to
increase the incidence of ectopic pregnancy. This probably occurs due
to a change in adrenergic receptor number or affinity in tubal
musculature .
• Assisted Reproduction. Several forms of assisted reproduction
have been reported to increase the incidence of ectopic
pregnancy.
• 1. Tubal pregnancy has been reported to be increased following
ovulation induction, gamete intrafallopian transfer (GIFT), and in
vitro fertilization (IVF) and ovum transfer .
• 2. Heterotypic tubal pregnancy is increased after in vitro
fertilization and embryo transfer and ovulation induction.
Heterotypic cervical pregnancy is also increase following in vitro
fertilization and embryo transfer.
• 3. Abdominal pregnancy has been reported following gamete
intra-fallopian transfer and in vitro fertilization and ovum transfer
• 4. Cervical pregnancy may be increased after in vitro fertilization
and embryo transfer .
• Failed Contraception. - Failed contraception increases the
incidence of ectopic pregnancies . With use of any
contraceptive , the actual number of ectopic pregnancies is
decreased because pregnancy occurs less often. In
contraceptive failures, however , there is an increased
incidence of ectopic pregnancy following some forms of tubal
sterilization and in women using intrauterine devices or
taking progestin-only “minipills”.
• 1. Relative risks for ectopic pregnancy overall are decreased
in users of intrauterine devices oral contraceptives , and
traditional barrier methods compared with non-
contraceptive users
• 2. Contraceptive failure following tubal sterilization has an
ectopic pregnancy rate of 16 to 50 %.
• 3. Tubal pregnancy may occasionally follow hysterectomy.
In most instances , a recently fertilized ovum was trapped in
the oviduct at the time of hysterectomy. More rarely , a
fistula sufficient for passage of sperm developed between
vagina and the severed end of the oviduct.
• Epidemiology. There has been a marked increase in both the
absolute number and rate of ectopic pregnancies in the USA
in the past two decades. These rates may be calculated using
three different methods:
• 1. Females 15 to 44 years: The number of ectopic pregnancies
in women 15 to 44 years old per 10.000 females
• 2. Live births: The number of ectopic pregnancies per 1000
live births
• 3. Reported pregnancies: The number of ectopic pregnancies
per 1000 reported pregnancies, which includes live birth,
legally induced abortions and ectopic pregnancies.
• Unfortunately, none of these rates is totally accurate because
the numerator may be falsely low for all calculations. Ectopic
pregnancies certainly occur in women younger than 15 and
older than 44. The denominator is falsely low in rates reported
per live births, because stillbirth rates are not consideres.
• The incidence of ectopic pregnancy is increased in
nonwhite compared with white women. The combined factors
of race and increases age are at least additive.
Causes for increased Rates of Ectopic Pregnancy.
The reasons for increases in ectopic pregnancies in the USA
are not entirely clear; however , similar increases have been
reported from Eastern Europe, Scandinavia and Great
Britain.
The reasons for the disproportionately increased incidence of
ectopic pregnancies in nonwhite women is also not known.
Possible explanations include the following :
(1) health care is less available or acceptable to
nonwhite women compared with white women
(2) sexually transmitted diseases are reported more
frequently in nonwhite compared with white women .
 Mortality

Ectopic pregnancy remains the second leading case of

maternal mortality in many countries.
 Anatomical Considerations.
The fertilized ovum may develop in any portion or the
oviduct, giving rise to ampullary, isthimic and interstitial
tubal pregnancies . In rare instances the fertilized ovum may
be implanted in the fimbriated extremity and occasionally even
on the fimbria ovarica. The ampulla is the most frequent site
of implantation and the isthmus the next most common.
Interstitial pregnancy is very uncommon, occurring in only
about 3% of all tubal gestation . From these primary types,
certain secondary forms of tubo-abdominal , tubo-ovarian and
broad ligament pregnancies occasionally develop.
Zygote implantation. The fertilized ovum does not remain
on the surface but promptly burrows through the epithelium.
As the zygote penetrates the epithelium it comes to lie in the
muscular wall, because the tube lacks a submucosa. At the
periphery of the zygote is a capsule of rapidly proliferating
trophoblast, which invades and erodes the subjacent
muscularis. At the same time , maternal blood vessels are
opened, and blood pours into the spaces, lying within the
trophoblast or between it and the adjacent tissue.
The tube normally does not form an extensive deciduas,
although decidual cells usually can be recognized. Tubal wall
in contact with the zygote offers only slight resistance to
invasion by the trophoblast, which soon burrows through it ,
opening maternal vessels. The embryo or fetus in an ectopic
pregnancy is often absent or stunted.
 Uterine Changes.
In ectopic pregnancy, the uterus undergoes some of the
changes associated with normal early pregnancy, including
softening of the cervix and isthmus and an increase in size.
The degree to which the endometrium is converted to decidua
is variable. The finding of uterine deciduas without
trophoblast suggests ectopic pregnancy but is not absolute
indication.
External bleeding, which is seen commonly in cases of tubal
pregnancy , is uterine in origin and associated with
degeneration and sloughing of the uterine deciduas;
hemorrhage is seldom severe. Soon after death of the fetus, the
deciduas degenerates and is usually shed in small pieces , but
occasionally it is cost off intact as a decidual cast of the
uterine cavity. Absence of decidual tissue, however, does not
exclude an ectopic pregnancy.
 Natural History of Tubal Pregnancy .
Tubal Abortion. A common termination of tubal pregnancy is
separation of the conceptus from the implantation site and
extrusion through the fimbriated end of the oviduct. The
frequency of tubal abortion depends in part upon the site of
implantation. Tubal abortion is common in ampullary tubal
pregnancy, whereas rupture of the tube is the usual outcome
with isthmic pregnancy. The immediate consequence of
hemorrhage with tubal abortion is further disruption of the
connection between the placenta and membranes and the tubal
wall. If placental separation is complete , all of the products
of conception may be extruded through the fimbritaed end into
the peritoneal cavity. At this point , hemorrhage and
symptoms disappear.
• Tubal Rupture . The invading , expanding products of
conception may rupture the oviduct at any of several sites.
Before sophisticated methods to measure chorionic
gonadotropin were available , many cases of tubal pregnancy
ended during the first trimester by intraperitoenal rupture. As
a rule, whenever there is tubal rupture in the first few weeks,
the pregnancy is situated in the isthmic portion of the tube a
short distance from the cornu of the uterus. When the
fertilized ovum is implanted well within the interstitial
portion of the tube, rupture usually occurs later.
The immediate cause of rupture may be trauma associated
with coitus or a bimanual examination, although in most
cases rupture , the entire conceptus may be extruded from the
tube, or if the rent is small , profuse hemorrhage may occur
without extrusion.
In either event the woman commonly shows signs of collapse
from hemorrhage and hypovolemia.
If an early conceptus is expelled essentially undamaged into
the peritoneal cavity, it may reimplant almost anywhere,
establish adequate circulation, survive and grow. This outcome
is most unlikely, however because of damage during the
transition. The conceptus, if small, may be reorbed or if larger
may remain in the cul-de-sac for years as an encapsulated
mass or even become calcified to form a lithpedion.
 Abdominal Pregnancy.
If only the fetus is extruded at the time of rupture , the effect
upon the pregnancy will vary depending on the extent of
injury sustained by the placenta. If the placenta is damaged
appreciable , fetal death is inevitable; but if the greater
portion of the placenta retains its attachment to the tube,
further development is possible. The fetus may then survive
for some time, giving rise to an abdominal pregnancy.
 Interstitial pregnancy.
Implantation of the fertilized ovum within the segment of
tube that penetrates the uterine wall results in an interstitial
pregnancy . This has also been referred to as a corneal
pregnancy . The account for about 3% of all tubal gestations.
Because of the site of implantation , no adnexal mass is
palpable ; instead there is variable asymmetry of the uterus
that is often difficult to distinguish from an intrauterine
pregnancy. Hence , early diagnosis is more frequently
overlooked than in other types of tubal implantation. Because
of the greater distensibility of the myometrium covering the
interstitial portion of the tube, rupture occurs later between
the end of the 8th and 11th gestational weeks. The hemorrhage
may rapidly prove fatal because the implantation site is
located between the ovarian and uterine arteries .
 Multifetal Ectopic Pregnancy
Heterotypic Ectopic Pregnancy . Tubal pregnancy may be
complicated by a coexisting intrauterine gestation , a
condition designated as heterotypic pregnancy. A heterotypic
pregnancy is quite difficult to diagnose clinically. Typically
laparotomy is performed because of a tubal pregnancy . At the
same time the uterus is congested, softened and somewhat
enlarged. Although these features are suggestive of
intrauterine pregnancy, there are commonly induced by a
tubal pregnancy alone. Gestational products are ultrasonically
demonstrable within the uterine cavity in practically all
instance of heterotypic pregnancy.
Until recently , heterotypic pregnancies have been considered
to be rare, that is 1 per 30.000 intrauterin pregnancies. A
heterotypic pregnancy is more likely and should be considered
(1) after assisted reproduction techniques; (2) with persistent
or rising chorionic gonadotropin levels after dilation and
curettage for an induced or spontaneous abortion ; (3) when
the uterine fundus is larger than menstrual dates; (4) with
more than one corpus luteum; (5) with absence of vaginal
bleeding in the presence of signs and symptoms of an ectopic
pregnancy and (6) when there is ultrasound evidence of
uterine and extrauterine pregnancy .
If such precautions are not observed maternal mortality is
increased appreciably.
Multifetal Ectopic Pregnancy. Twin tubal pregnancy has been
reported with both embryos in the same tube , as well as with
one in each tube. Single-ovum twins result in a far greater
proportion of tubal than uterine pregnancies . Difficulties in
migration and implantation retarded the growth of the zygote ,
which was somehow stimulated to form two identical
embryos. Simultaneous pregnancy in both fallopian tubes is
the rarest from of double-ovum twinning .
Tubo-Uterine, Tubo-Abdomian and Tubo-Ovarian
Pregnancies.
A tubo-uterne pregnancy results from the gradual extension
into the uterine cavity of products of conception that originally
implanted in the interstitial portion of the tube. Tubo-
abdominal pregnancy is derived from a tubal pregnancy in
which the zygote, originally implanted in the neighborhood of
the fimbriated end of the tube , gradually extends into the
peritoneal cavity. In such circumstances the portion of the
fetal sac projecting into the peritoneal cavity may form
troublesome adhesions to surrounding organs. As a result,
removal of the sac is much more difficult. Both of these
conditions are very uncommon.
A tubo-ovarian pregnancy occurs when the fetal sac is
adherent partly to tubal and partly to ovarian tissue. Such
cases arise from the development of the zygote in a tubo-
ovarian cyst or in a tube, the fimbriated extremity of which
was adherent to the ovary at the time of fertilization or
became so soon thereafter .
 Clinical and Laboratory Features of Tubal
Pregnancy
General Considerations -clinical manifestations of a tubal
pregnancy are diverse and depend on whether rupture has
occurred. Commonly the woman believes she is normally
pregnant or believes she is aborting an intrauterine pregnancy
. Less often she does not suspect she is pregnant. In
“classical” cases, normal menstruation is replaced by variably
delayed slight vaginal bleeding , which usually is referred to
as “spotting”. Suddenly, the woman is stricken with severe
lower abdominal pain, frequently described as sharp , stabbing
or tearing in character . Vasomotor disturbances develop,
ranging from vertigo to syncope.
Abdominal palpation - tenderness
Virginal examination - especially motion of the cervix causes
exquisite pain.
The posterior fornix of the vagina -may bulge because of
blood in the cul-de-sac, or a tender , boggy mass may be felt
to one side of the uterus.
Symptoms of diaphragmatic irritation, characterized by pain
in the neck or shoulder especially on inspiration , develop in
perhaps 50 % of women in whom there is sizable
intraperitoneal hemorrhage. This is cause by intraperitoneal
blood irritating cervical sensory nerves that supply the
inferior surface of the diaphragm.
The woman may or may not be hypotensive while lying
supine. If she is not hypotensive when supine , she may
become so when place in a sitting position . The diagnosis
in such cases is not difficult to make. The physician must
make every reasonable effort to diagnose the condition before
catastrophic events occur, but the task may not be simple.
 Symptoms and Signs .
Pain . The most frequently experienced symptoms of ectopic
pregnancy are pelvic and abdominal pain and amenorrhea
with some degree of vaginal spotting or bleeding. Pain may
be anywhere in the abdomen. With a large hemoperitoneum ,
pleuritic chest pain may occur from diaphragmatic irritation.
 Amenorrhea.
The absence of a missed menstrual period does not exclude
tubal pregnancy. A history of amenorrhea is not obtained in a
quarter or more of cases. Thus , the woman may mistake the
uterine bleeding that frequently occurs with tubal pregnancy
for a true menstrual period. This important source of
diagnostic error can be eliminated in many cases by carefully
obtained menstrual history.
Vaginal Spotting or Bleeding . As long as placental endocrine
function persists, uterine bleeding is usually absent; but when
endocrine support for the endometrium declines , uterine
mucosa bleeds. Bleeding is usually scanty , dark brown, and
may be intermittent or continuous.
Abdominal and Pelvic Pain . Exquisite tenderness of abdominal
palpation and vaginal examination , especially on motion of
the cervix, is demonstrable in over three fourths of women
with ruptured or rupturing tubal pregnancies.
Uterine Changes. Because of placental hormones, in about one
fourth of cases , the uterus grows during the first 3 months of a
tubal gestation to nearly the same size as it would with an
intrauterine pregnancy. The uterus may be pushed to one side
by an ectopic mass, or if the broad ligament is filled with
blood , the uterus may be greatly displaced.
Blood Pressure and Pulse. Early responses to moderate
hemorrhage may range from no change in pulse and blood
pressure to a slight rise in blood pressure ,or a vasovagal
response with bradycardia and hypotension. In a healthy
pressure will fall and pulse rise only if bleeding continues and
hypovolemia becomes intense.
• Hypovolemia . Important to detect significant hypovolemia
before development of hypovelemic shock.
• Temperature. After acute hemorrhage , the temperature may
be normal or even low. Temperature up to 38 c. may develop
but higher temperatures are rare in the absence of infection.
• Pelvic Hematocele. Often there is gradual disintegration of
the tubal wall followed by slow leakage of blood into the
tubal lumen, the peritoneal cavity, or both. Signs of active
hemorrhage are absent and even mild symptoms may
subside , but gradually the trickling blood collects in the
pelvis, more or less walled off by adhesions and a pelvic
hematocele results.
 Laboratory Tests.
Measurement of hemoglobin, hematocrit and leukocyte count ,
as well as pregnancy tests and progesterone are useful in
certain cases if their limitations are understood.
Hemoglobin and Hematocrit . After hemorrhage, depleted
blood volume is restored toward normal by hemodilution over
the course of a few day . Even after a substantive hemorrhage ,
therefore , hemoglobin or hematocirt readings may at first
show only a slight reduction.
Leukocyte Count - varies considerably in ruptured ectopic
pregnancy . In about half the patients , it is normal but in the
remainder, varying degrees of leukocytosis up to 30.000 /ml
may occur.
Pregnancy Tests. Ectopic pregnancy cannot be diagnosed by
a positive pregnancy test alone. The key issue, however, is
whether the woman is pregnant. In virtually all cases of
ectopic gestation , chorionic gonadotropin will be detected is
serum but usually at markedly reduced concentrations
compared with normal pregnancy .
 Urinary pregnancy tests . These most often are latex
agglutination inhibition slide tests with sensitivities for
chorionic gonadotropin in the range of 500 to 800 mlU /ml.
Their ease of use and rapidity is offset by their small chance of
being positive in a woman with an ectopic pregnancy.
• Serum Chorionic Gonadotropin Assays (β-hCG). Serum
radioimmunoassay for β-hCG is the most precise method, and
virtually any pregnancy event can be detected. In fact,
because of the sensitivity of this assay , a pregnancy may be
confirmed before there are pathological changes in the
fallopian tube.
The essential diagnostic step in the identification of a
suspected ectopic pregnancy is to establish or exclude the
diagnosis of pregnancy.
• Sonography.
• Abdominal sonography. Identification of products of conception in the
fallopian tube is difficult using abdominal sonographpy. If a gestational
sac is clearly identified within the uterine cavity , it is unlikely an
ectopic pregnancy coexists. Moreover with sonographic absence of an
intrauterine sac, and an abnormal pelvic mass , ectoipic pregnancy is
almost certain.
• Vaginal Sonography. According to most invistigators vaginal
compared with abdominal sonography is a more sensitive and specific
technique to diagnose ectopic pregnancy . With vaginal sonography,
identification of both ovaries allows the operator to exclude conditions
such as ovarian cysts or endometiromas and to detect directly tubal
pathology. Nevertheless, even vaginal sonographpy can be misleading
and ectopic pregnancies can be missed when a tubal mass still is small
or obscured by bowel. Vaginal sonography results in earlier and more
specific diagnoses of intrauterine pregnancy.
Culdocentensis .
The simplest technique for indentifying hemoperitoneum is
culdocentesis, because it can be performed without
hospitalization . The cervix is pulled toward the symphysis
with a tenaculum and a long 16 or 18-gauge needle is inserted
through the posterior vaginal fornix into the cul-de-sac.
Fluid, if present can be aspirated . Failure to aspirate fluid can
be interpreted only as unsatisfactory entry into the cul-de-
sac. Fluid containing fragments of old clots, or bloody fluid
that does not clot, are compatible with the diagnosis of
hemoperitoneum resulting from an ectopic pregnancy.
Curettage.
Differentiation between threatened or incomplete abortion
of an intrauterine pregnancy and a tubal pregnancy may be
accomplished in many instances by curettage. Curettage in
suspected cases of incomplete abortion versus ectopic
pregnancy when serum progesterone is less than 5 gn/ml., β-
hCG titers are rising abnormally (less than 2000 mU/mL),
and an intrauterine pregnancy is not seen using trans-vaginal
sonography. If embryo, fetus or placenta are identified , a
simultaneous tubal pregnancy is unlikely. When none of these
structures is identified , tubal pregnancy is a probability and
further follow-up with serial quantitative β-hCG titer and
sonography is required.
Laparoscopy.
Fiber-optic laparoscopy provides a means of visual diagnosis
of pelvic disease , including ectopic pregnancy. Complete
visualization of the pelvis, however may be impossible if
there is pelvic inflammation or active bleeding. At times ,
identification of an early un-ruptured tubal pregnancy may be
difficult, even though the tube is fully visualized.
 Differential Diagnosis.
Prompt diagnosis of a ruptured tubal pregnancy may be
lifesaving and the earlier an un-ruptured tubal pregnancy is
diagnosed the greater will be the likelihood of a future
successful pregnancy . Unfortunately, there are few other
disorders in obstetrics and gynecology that present so many
diagnostic pitfalls. Women with ectopic pregnancy ,
approximately one third had been seen once and 11 % twice
before the correct diagnosis was made .
• Gastrointestinal Disturbance. In some women with a ruptured
ectopic pregnancy, the prominent symptoms are diarrhea,
nausea and vomiting along with abdominal pain.
• Abortion of intrauterine Pregnancy. In threatened or
uncompleted abortion , uterine bleeding is usually more
profuse and shock from hypovolemia, when present, is
usually in proportion to the extent of vaginal hemorrhage. In
tubal pregnancy, however, hypoveolmic shock almost always
is far in excess of observed vaginal blood loss.
• Rupture of a Corpus Luteum or follicular Cyst.
Intraperitoneal bleeding from an ovarian cyst may be difficult
to distinguish from a ruptured tubal pregnancy. Even though
identification of chorionic gonadotropin will sometimes help
to make the diagnosis preoperatively , most often , the
diagnosis is made only at the time of exploratory laparotomy.
• Twisted Cyst or Appendicitis. In both ovarian cyst torsion
and appendicitis, signs and symptoms of pregnancy, including
amenorrhea , are usually lacking, and there is rarely a history
of abnormal vaginal bleeding. The mass formed by twisted
ovarian cyst is more nearly discrete, whereas that of a tubal
pregnancy is usually less well defined. With appendicitis,
only rarely is there a amass found by vaginal examination,
and pain on motion of the cervix is much less severe than
with a ruptured tubal pregnancy.
• Intrauterine Devices. Diagnosis of ectopic pregnancy is often
more difficult in women with intrauterine devices. Cramping
pelvic pain and uterine bleeding both common features of
ectopic pregnancy, may be caused by an intrauterine device.
 Tubal Pregnancy: Treatment and prognosis
Treatment has most often been salpingectomy to remove a
chattered, bleeding oviduct with or without ipsilateral
oophorectomy. The goal of such treatment was an should
remain the preservation of the woman’s life. Recently ,
treatment has changed from salpingectomy to surgical and
medical procedures that favor tubal conservation. Such
conservative management is made possible by the earlier
diagnosis of ectopic pregnancy using vaginal ultrasound and
serum quantitative β-hCG determinations.
Surgical Management: Laparascopy and Laparotomy
Salpingectomy. When removing the oviduct , it is advisable
to excise a wedge no more than the outer third of the
interstitial portion of the tube ( so-called corneal resection) in
an effort to minimize the rare recurrence of pregnancy in the
tubal stump. Resection so extensive as to reach the cavity of
the uterus must be avoided, lest the defect created lead to
uterine rupture in a subsequent intrauterine pregnancy. Even
with cornual resection, a subsequent interstitial pregnancy
may not be prevented. Salpinegtomy can be performed
through an operative laparoscope and may be used for both
ruptured and unruptured ectopic pregnancies.
• Sterilization. If childearing has been completed or if the
ectopic pregnancy is the consequence of failed contraception,
concomitant sterilization should be considered. Tubal
sterilization can usually be performed via laparoscopy or
laparotomy without increased risk. Conversely, all organs
possible should be conserved in a woman of low parity with a
strong desire for future pregnancies . She must know,
however , that she has an increase risk of a subsequent ectopic
pregnancy.
• Salpingostomy. this technique is used to remove a small
pregnancy that is usually less than 2 cm in length and located
in the distal one third of the fallopian tube. A linear incision ,
2 cm in length or less, is made on the antimesenteric border
immediately over the ectopic pregnancy. The ectopic usually
will extrude from the incision and can be carefully removed.
Small bleeding sites are controlled with needlepoint
electrocautery or laser, and the incision is left unsutured to
heal by secondary intention.
Medical Management
Methotrexate. It is recommended the use of methotrezate to
treat interstitial pregnancy. In general the following
principles apply: Success is greatest if the gestation is less
than 6 weeks, the tubal mass is not more than 3.5cm in
diameter and the fetus is not alive . With more advanced
gestations , success has been less frequent except after
multicourse therapy, single high-dose therapy with folinic acid
rescue , or fetal death induced by direct injection of potassium
chloride and methotrexate into the amniotic sac using either
trans-virginal sonopraphy or laparoscopy.
Patient selection. Candidates for methotrexate therapy must be
hemodynamically stable with a normal hemogram and normal
liver and renal function. Women given methotrexate are instructed
that (1) medical therapy fails in 5 to 10 % of patients and this rate
is higher in pregnancies past 6 weeks gestation or with a tubal
mass greater than 3.5cm in diameter; (2) failure of medical
therapy means elective surgery, or if tubal rupture occurs
(approximately a 5% chance), emergency surgery; (3) if treated
as an outpatient rapid transportation must be available for transfer
to the hospital; (4) signs and symptoms of tubal rupture such as
vaginal bleeding, abdomen and pleuritic pain , weakness,
dizziness or syncope must be reported promptly and should
constitute a cause for immediate medical attention; (5) sexual
intercourse is prohibited until after serum β-hCG is
undetectable; (6) no alcohol can be consumed and (7)
multivitamins with folic acid should not be taken.
• Monitoring methotrexate toxicity. Although some
investigators report minimal or no side effects, toxicity may
develop suddenly and be severe.
• Monitoring efficacy of therapy.
• Various placental protein and steroid hormones have been
used to monitor placental viability following medical and
surgical therapy for ectopic pregnancies. The most widely
used are serial quantitative β-hCG titers. The rationale for
measuring serial β-hCG values is that after therapy the
hormone usually disappears from plasma between 14 and 21
days. Occasionally, however hormone levels remain elevated
for 28 days.
Systemic therapy . Systemic therapy with methotrexate , 34
of 36 patients (94%) had complete remission of tubal
pregnancy. The other 2 ruptured, one 23 days after
commencing methotrexate therapy and the other one day 14.
The latter woman had fetal heart activity noted throughout
most of therapy.
Anti-D Immune Globulin. If the woman is D-
negative but not yet sensitized to D-antigen and
the potential for reproduction persists, anti-D
immune globulin should be administered to protect
against isoimmunization. Moreover, if platelets are
transfused, in all likelihood some contaminating
D-positive red cells were also included. Therefore
, D-negative patients also should receive anti-D
immune globulin soon after platelet transfusion.
• Abdominal Pregnancy
• Frequency . In incidence of abdominal pregnancy
is influenced by the (1) frequency of ectopic
gestation in the population, (2) availability of care
early in pregnancy, (3) use of assisted reproductive
techniques and (4) degree of suspicion exercised by
those providing care. Almost all cases of abdominal
pregnancy follow early rupture or abortion of tubal
pregnancy into the peritoneal cavity.
• Etiology. Typically, the growing placenta, after penetrating the
oviduct wall, maintains its tubal attachment but gradually
encroaches upon and implants in the neighboring serosa.
Meanwhile, the fetus continues to grow within the peritoneal
cavity . In such circumstances , the placenta is found in the
general region of the oviduct and over the posterior aspect of
the broad ligament and uterus. Even more rarely, the conceptus
appears to have escaped after tubal rupture to reimplant
elsewhere in the peritoneal cavity. Primary peritoneal
implantation of the fertilized ovum is very rare. There are
required some criteria : (1) normal tubes and ovaries with no
evidence of recent or remote injury, (2) absence of any
evidence of uteroplacental fistula and (3) presence of a
pregnancy related exclusively to the peritoneal surface and
young enough to eliminate the possibility of secondary
implantation following primary nidation in the tube .
Status of Fetus. Fetal viability in an abdominal pregnancy
is exceedingly precarious and the great majority succumb. If
the pregnancy is diagnosed after 24 weeks’ gestation
scientists await fetal viability with in-hospital expectant
management . Such management carries a risk for sudden life-
threatening intra-abdominal bleeding .
• Diagnosis. Because early rupture or abortion of a tubal
pregnancy is the usual antecedent of an abdominal pregnancy,
in retrospect, a suggestive history can usually be obtained .
Abnormalities likely to be recalled include spotting or
irregular bleeding along with abdominal pain that usually was
most prominent in one or both lower quadrants .
• Symptoms. Women with an abdominal pregnancy are likely
to be uncomfortable but not sufficiently so to warrant
thorough evaluation. Nausea, vomiting , flatulence ,
constipation, diarrhea and abdominal pain may each be
present in varying degrees. Multiparas may state that
pregnancy does not “feel right”. Late in pregnancy, fetal
movements may cause pain. Near term, the empty uterus has
been alleged to go into spurious labor.
Physical Examination. Abnormal fetal positions can frequently
be palpated but the ease of palpating fetal parts is not a
reliable sign. Fetal parts sometimes feel exceedingly close to
the examining fingers even in normal pregnancies, especially
in thin, multiparous women. Abdominal massage over the
pregnancy does not stimulate the mass to contract as it almost
always does with advanced intrauterine pregnancy. The cervix
is usually displaced, depending in part on the fetal position,
and it may dilate, but appreciable effacement is usually
absent .
• Laboratory Tests. An unexplained transient anemia early in
pregnancy may accompany the initial tubal rupture or
abortion. Almost all other laboratory values, including those
reflecting fetal well-being , are normal until fetal demise
occurs.
• Radiological Examination. A strong suspicion of abdominal
pregnancy may be confirmed by x-ray with a probe or
radiopaque material in the uterus. The fetus then is shown
clearly to lie outside the uterine cavity. Unfortunately , such
techniques are not safe diagnostic procedures if the fetus is
intrauterine.
• Sonography. Ultrasonic findings with an abdominal
pregnancy most often do not allow an unequivocal diagnosis
to be made; however , in some suspected cases, these findings
may be diagnostic . For example , if the fetal head is seen
to lie immediately adjacent to the maternal bladder with no
interposed uterine tissue , a specific diagnosis can be made.
• Magnetic Resonance Imaging . Magnetic resonance imaging
has been used to confirm abdominal pregnancy following a
suspicious sonographic examination , and the technique
appears to be the most accurate and specific technique.
• Computed Tomography. Scientists maintain that computed
tomography is superior to magnetic resonance imaging , but
its use is limited because of fetal radiation effects.
• Treatment. Surgery for abdominal pregnancy may
precipitate massive hemorrhage . Without massive blood
transfusion, the outlook for many such women is hopeless.
Hence , it is mandatory that at least 2000mL of compatible
blood be on hand in the operating room, with more readily
available . Preoperatively , two intravenous infusion systems,
each capable of delivering large volumes of fluid at a rapid
rate , should be functioning. At the same time , techniques for
monitoring the adequacy of the circulation should be
employed. The massive hemorrhage that often ensues in the
course of operations for abdominal pregnancy is related to
the lack of constriction of hypertrophied opened blood
vessels after placental separation. It has been recommended
by some that the operation be deferred until fetal viability is
achieved .
• Prognosis. Two of the 10 cases described by scientists resulted
in maternal deaths. Morbidity in surviving patients is excessive
in many cases .
• Ovarian Pregnancy
• In 1878, Spiegelberg formulate his criteria for diagnosis of
ovarian pregnancy : (1) the tube on the affected side be intact,
(2) the fetal sac must occupy the position of the ovary, (3) the
ovary must be connected to the uterus by the ovarian ligament
and (4) definite ovarian tissue must be found in the sac wall.
Although the ovary can accommodate itself more readily than
the tube to the expanding pregnancy, rupture at an early period
is the usual consequence. Nonetheless, there are recorded cases
in which the ovarian pregnancy went to term, and a few infants
survived.
Symptoms and Signs . Symptoms and physical findings are
likely to mimic those of a tubal pregnancy or a bleeding
corpus luteum. At the time of operation, early ovarian
pregnancies are likely to be considered corpus luteum cysts
or a bleeding corpus luteum.
Management. Early ovarian pregnancies should be treated
when possible, by wedge resection or cystectomy ; otherwise;
oophorectomy is performed
 Cervical pregnancy
Cervical pregnancy in the past has been rare form of ectopic
gestation . It is less common but the incidence appears to be
increasing in part due to newer forms of assisted reproduction,
but especially after in-vitro fertilization and embryo
transfer . In a typical case, the endocervix is eroded by
trophoblast, and the pregnancy proceeds to develop in the
fibrous cervical wall. The duration of the pregnancy and
ultimately its capacity for growth is dependent upon the site of
embryo implantation. The higher it is implanted in the cervical
canal, the greater is its capacity to grow and bleed.
Other Sites of Ectopic Pregnancy
A primary splenic pregnancy has been reported by scientists.
The symptoms and signs that led to laparotomy included pain
in the epigastrium and left shoulder, hypotension ,
tachycardia, syncope and tenderness in the vaginal fornices.
At laparotomy considerable hemoperitoneum but normal
pelvic organs were found. A rent in the hilar surface of the
spleen prompted splenecotmy. Microscopically , chorionic
villi were identified in the splenic rent. A few cases of
primary hepatic pregnancy have been described , including
one with lithopedion formation .
The end.