ECTOPIC

PREGNANCY
Definition
ectopic pregnancy
(extra uterine pregnancy ) refers to:
implantation of the fertilized ovum
outside the uterine cavity
Incidence: 1 ： 100

year other country our country

1970 1:222 1:167~322

1989 1:51 1:56~93

Categories

tubal pregnancy 95%

ovarian pregnancy

abdominal pregnancy
broad ligment pregnancy
cervical pregnancy
Positions of ectopic pregnancy
TUBAL PREGNANCY
the site of tubal pregnancy:
ampulla (55-60%) isthmus (20-25%)
infundibulum(17%) interstitial portion(2-4%)
一、 Etiology

for any reason there is

delay in the passage of the
fertilized ovum along the tube
A. Chronic salpingitis

It is common cause of tubal pregnancy.

inflammation destroy the ciliated

epithelium
forming adhesions of epithelial folds
or obstruction of tubal lumen
 B. Previous tubal surgery.
plastic tubal repair (reconstructive
surgery)
tubal ligation （结扎 术）
C. abnormalities or dysfunction of the tube
excessive length of the tube
congenital diverticula ( 憩室 )
D. Transmigration of the fertilized ovum

E. Intrauterine devices (IUD)

F. Others: pelvic endometriosis,

myoma, ovarian tumors
 二、 Pathology
1. The outcome of tubal pregnancy
The fertilized ovum burrows into the
thin tubal muscle and ultimately
penetrates a tubal wall or artery, local
bleeding occurs .
The tubal pregnancy may
terminate by tubal abortion or
tubal rupture
A. Tubal abortion
tubal abortion occurs most in
ampulla about 8th-12th week
Two categories:
complete tubal abortion
incomplete tubal abortion
The blood issuing from tube may
collect in the Pouch of Douglas
forming a pelvic hematocele.
B. Rupture of tubal pregnancy
 tubal rupture occurs at about
6th week in isthmus pregnancy
(the lumen is narrower)

tubal rupture may occur at about

4th month in interstitial portion

bleeding is heavier than tubal

abortion
If implantation is in the interstitial portion
rupture is often delayed at the 4th month of
pregnancy or more later .
If invasive trophoblast erodes a large vessel
severe intraperitoneal hemorrhage occurs
C. Secondary abdominal pregnancy

Occasionally, the villi maintain their

tubal attachment or the entire
conceptus implants again at other site,
and the growth of embryo continues ,
results secondary abdominal
pregnancy.
D. Persistent ectopic pregnancy

HCG increase after operation

2. Uterine changes

A. uterus increases in size ,

usually is not larger than the

size of 8 weeks gestation.

B. the endometrium of uterus still
undergoes decidual change( 蜕膜样
变)
The decidua will shed after the death
of the embryo, and may be passed in
fragments or intact as a decidua cast
（蜕膜管型） .
“Arias -Stella” (A-S) reaction

An atypical change
in endometrial epithelium
due to the over stimulation of
estrogen and progesterone.
三、 Clinical Findings
1 . Symptoms
three essential symptoms:
A. amenorrhea
B. abdominal pain
C. vaginal bleeding
A . Amenorrhea

A history of amenorrhea
about 6-8 weeks before
vaginal bleeding occurs in
about 80% of patients
B . Abdominal pain
the most common

When tubal rupture, clinical

features may present as acute or
chronic form
C . Vaginal bleeding

When embryo is dead ，

endocrine support becomes
inadequate, uterine bleeding with
shed of the decidua occurs.
The bleeding is usually less than
menstrual bleeding.
D . Syncope and shock

E. Other symptoms
2 . Signs
A . General examination
when the intraabdominal bleeding
is rapid and severe:
♦ acute anemia, pallor
♦ rapid and feeble pulse
♦ falling blood pressure

B . Abdominal examination
C. Pelvic examination
• Vaginal: vaginal bleeding
• Cervix: tenderness especially on moving the
cervix
• Uterus: soft and slightly enlarged
corresponding with or not the duration
of pregnancy
4. Adnexa: fullness or an indefinite tender
mass, size varies, in cul-de-sac or lateral.
四、 Diagnosis
 Clinical Findings
 Signs
 Need special examinations
1. Pregnancy test hCG
2. Ultrasonography
3. Culdocentesis ( 后穹隆 穿刺 术 )
4. Laparoscopy
5. D&C
A. Pregnancy test
a positive pregnancy test
associated with pain and bleeding is
an abnormal pregnancy, highly
suspected of ectopic pregnancy.

♦ But if HCG negative can not exclude

ectopic pregnancy
B. Ultrasonography
C. Culdocentesis

inserting a needle through the posterior

fornix into the cul-de-sac
It is the simplest technic for identifying
hemo-peritoneum.

blood does not coagulate

Culdocentesis
 D. Laparoscopy
for early unruptured or suspected
cases

Nowadays laparoscopy is used to

treatment
 E. D&C
may exclude intrauterine pregnancy
 五、 Differential
Diagnosis
uterine abortion
acute appendicitis
salpingitis
ruptured corpus luteum cyst
torsion of ovarian tumor
 Table Differential Diagnosis
Ectopic acute ruptured torsion of
pregna- appendic- corpus ovarian
abortion luteum tumor
ncy itis
Amenorr
-hea
＋ ＋ － － －
Abdominal
pain ＋ center transfer one side one side

Vaginal
bleeding
＋ ＋ － ± －
－ /
Shock ＋ ＋ － ＋
－
Temperat-
ure － /± － ↑ － /↑ －
Pelvic
examination
 Ectopic acute ruptured torsion of
pregn- appendic corpus ovarian
abortion luteum tumor
ancy -itis

WBC － /↑ － ↑ － /↑ Slight ↑

Hb ↓ － － ↓ －

Culdocen
＋ － － ＋ －
-tesis

hCG ＋ ＋ － － －

B-scan
六、 Treatment
1 . Surgical treatment
Immediate surgery is indicated when
the diagnosis of tubal pregnancy is made,
and the patients’ situation is unstable.
Treatment of shock and surgery should
be performed simultaneously.
A. The surgery usually performed is
salpingectomy
• conservative surgery to preserve
the affected tube must be
considered
salpingectomy
2. Medical treatment

♦ If the situation is not acute, the conserve

therapy with medicine can be used
♦ MTX has been successfully used. It is a
drug of chemotherapy to kill the embryo
♦ It is important to follow up
diameter of mass ＜ 3cm
no rupture or abortion
no abdominal hemorrhage
β-HCG ＜ 2000U/L