ECTOPIC

PREGNANCY
Dr.Ksrishna Karthik S
 DEFINITION
• An ectopic pregnancy is defined as the implantation
and
• development of the blastocyst at a site other than
the
• endometrial lining of the uterine cavity.

Ectopic pregnancy is a significant cause of

maternal
mortality and morbidity throughout the world
ETIOLOGY

• Various factors which delay transport of fertilized ovum

• through fallopian tube can cause tubal pregnancy.

• 1. Infections
• (a) Sexually transmitted infections (STIs) and
• pelvic inflammatory diseases (PID)
• (b) Postabortal sepsis, puerperal sepsis and
• appendicitis
• (c) Genital TB
• 2. Congenital factors
• 3. Salpingitis isthmica nodosa
• Failed contraception.
• IUCD.
• Sterilization procedure
• Previous tubal surgery
• Assisted reproductive technology
• Previous ectopic
• Other miscellaneous causes
• Abdominal adhesions
• Endometriosis
• IV Drug abusers,drug addicts
 EVOLUTION
• Tubal pregnancies rapidly invade the
mucous ,feeding from the tubal vessels which
become enlarged and engorged .The segment of
the affected tube is distended as the pregnancy
grows
MORBID ANATOMY
• Changes
• Implantation - intercolumnar or between mucosal foods
• Decidual changes
• Muscle hyperplasia and hypertrophy
• Intramuscular implantation
• pseudocapsule formation
• Trophoblast invasion - erosion of blood vessel

• Pregnancy is unable to survive owing to its poor blood supply thus resulting in a
• Tubal abortion
• Resorption (rare)
• Tubal rupture
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
CLINICAL APPROACH

• Dignosis can be done by history, detail examination and

• judicious use of investigation
• H/o past PID, tubal surgery,current contraceptive measures
• should be asked
• Wide spectrum of clinical presentation from asymtomatic pt
• to others with acute abdomen and in shock.
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 pain.
• 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.
• High degree of suspicion & ectopic conscious clinician
• can diagnose.
• UNRUPTURED ECTOPIC
• Diagnosed accidentally in Laparoscopy or Laparotomy
• C/F - delayed period, spotting with discomfort in
• lower abdomen.
• tenderness in lower abdomen
• P/A
• P/V
• • should be done gently
• • uterus is normal size, firm
• • small tender mass may be felt in the fornix
• Investigations- TVS, radioimmunoassay of B-HCG and
DIAGNOSIS

• In recent years, inspite of an increase in the incidence of

• ectopic pregnancy there has been a fall in the case
• fatality rate.
• This is due to the widespread introduction of diagnostic
• tests and an increased awareness of the serious nature
• of this disease.
• This has resulted in early diagnosis and effective
• treatment.
• Now the rate of tubal rupture is as low as 20%.
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 mIU/ml of ß 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 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-B hCG level as low as 1500 IU/L.
USG PICTURE
• 1.'Bagel' sign - Hyperechoic ring around gestational sac in
• adnexal region
• 2. 'Blob' sign-Seen as small inconglomerate mass next
• to ovary with no evidence of sac or embryo.
• 3. Adnexal sac with fetal pole and cardiac activity is most
• specific.
• 4. Corpus luteum is useful guide when looking for EP as
• present in 85% cases in Ipsilateral ovary.
• 2. B-HCG Assay-
• a) Single B-HCG: little value
• b) Serial B-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 B-HCG <66% in 48 hrs indicate
• ectopic pregnancy or nonviable intrauterine
• pregnancy.
• 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.
• Biochemical pregnancy is applied to those
• women who have two B-HCG values >10 IU/L
• 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
• CA-125, Maternal serum creatine kinase, Maternal
serum
• AFP elevated in ectopic pregnancy.
• VEGF, Fetal Fibronectin, Mass spectrometry
• 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
• . Pelvic abscess
• 2. Pyosalpinx
• 3. Subserous uterine fibroid
• 4. Salpingintis
• 5. Retroverted gravid uterus
• 6. Appendicular lump
• Expectant
• management
• MANAGEMENT
• Local
• (USG or Laparoscopic)
• salpingocentesis
• 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- C
• 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)
• MEDICAL TREATMENT
• EXPECTANT MANAGEMENT
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.
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
• Single dose
• Mtx 50mg/m² IM
• Two dose on Day
• 0,4
• Variable doses
• 1. Mtx 1gm/kg IM
• D1357
• 2. Leucovorin
• 0.1mg/kg IM
• D2468
• MEDICAL MANAGEMENT
• BHCG levels at days 4 & 7
• If difference 215% repeat weekly till s5IU/ml
• If difference <15% between day 4 & 7 repeat dose & begin D₁
• If fetal Cardiac +ve at D, repeat D, Mtx
• Surgical management if BHCG not or fetal cardiac +ve after 3doses
• Follow-up same as One dose regimen
• Measure BHCG levels at D1357. Continue alternate day regimen
• until BHCG levels decrease ≥15% in 48hrs, or 4 doses of Mtx given.
• Then, weekly BHCG levels until <5iu/ml
• SURGICALLY ADMINISTERED MEDICAL TT

• (SAM)

• o Aim-trophoblastic destruction without systemic

• side effects

• o Technique- Injection of trophotoxic substance into

• the ectopic pregnancy sac or into the affected tube

• by-

• Laparoscopy or

• Ultrasonographically guided

• o Transabdominal

• o Transvaginal

• With Falloposcopic control

SURGICALLY
ADMINISTERED MEDICAL
• Trophotoxic substances used-
• ►Methtrexate
• Potassium Chloride
• ➤Mifiprostone
• ➤PGF2α
• >Hyper osmolar glucose solution
• ►Actinomycin D
• Advantage of local MTX :
• - Increase tissue concentration at local site
• - Decrease systemic side effects
• - Decrease hospitalization
• - Greater preservation of fertility
• Follow up: - Serum ß HCG twice weekly till < 5 IU/L
• - TVS weekly for 4-6 weeks
• - HCG after 6 months for tubal patency
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 ß HCG titre till it is negative.
• - If titre increases methotrexate can be given.
• Thank you