Ectopic

Pregnancy
Jessa Mae Nona V. Dionisio
Cllinical Clerk

Dr. Nyssa Callosa

Resident-in-Charge

Dr. De Juan
Consultant-in-Charge
 OBJECTIVES
To understand the pathogenesis of ectopic pregnancy

To differentiate tubal from non tubal pregnancy

To know the risks factors leading to ectopic pregnancy

To be able to diagnose ectopic pregnancy

To know how to manage each classification of ectopic pregnancy

• Implantation elsewhere other than in the endometrial lining of uterine cavity is
considered as an Ectopic pregnancy\
 Fallopian Tube
Intramural or
surrounded by myometrium
Interstitial

most highly developed musculature; narrow section

Isthmus connecting ampulla to uterine cavity

Ampulla widest, tortous; where fertilization usually occurs

trumpet-shaped near the ovary to which fimbriae are

Infundibulum attached

several finger like projections that surround the

Fimbrae abdominal ostia of the tube which capture ovum

• columnar ciliated epithelium

• secretory columnar cells
HETEROTROPHIC PREGNANCY
 Occasionally, a multifetal pregnancy is composed of one conceptus
with normal uterine implantation coexisting with one implanted
ectopically.

 1 per 30,000 pregnancies

ETIOLOGY
● Tubal Factors
● Genetic Factors
● Overdevelopment of Ovum
● Menstrual Reflux
● Endometriosis
01
TUBAL
PREGNANCY
Tubal Pregnancy
 95% of all ectopic pregnancies
 Ampulla is the most frequent site followed by isthmus
 5% of nontubal pregnancies implant in
• ovary
• peritoneal cavity
• cervix
• prior cesarean section scar
RISK FACTORS
Salpingitis Isthmica
Nodusa
● specific type of chronic salpingitis;
characterized by nodular thickenings in
the isthmus
 PATHOPHYSIOLOGY

Arrest of fertilized ovum to

01 the uterine cavity

Implantation in tubal mucosa

02 and muscularis

Proliferative trophoblast
03 invade the muscularis layer
and maternal blood vessels
OUTCOMES
Tubal Rupture
if it ruptures in first few weeks - ISTHMUS
if it ruptures later - INTERSTITIAL

Tubal Abortion
common in FIMBRIAL and AMPULLARY Pregnancy

Pregnancy Failure with

Resolution
 Hemoperitonuem
• built-up blood in peritoneal cavity
• blood initially collects in the
rectouterine cul-de-sac and surrounds
the uterus as it fills the pelvis
TYPES OF ECTOPIC
PREGNANCY
 Acute Chronic
Ectopic Pregnancy Ectopic Pregnancy

 high serum Beta-hCG  negative or low Beta-hCG levels

 rapid growth --- immediate  rupture occurs later

diagnosis

 higher risk of rupture  form complex pelvic mass which

often prompt diagnostic surgery
SIGNS AND SYMPTOMS
TRIAD; ”Classical
Presentation”

Delayed Menstruation
TRIAD; ”Classical
Presentation”

Pelvic Pain
• sharp, stabbing and tearing
• Tenderness upon palpation
• (+) Cervical Motion
Tenderness
-tender, boggy mass may be
felt at the sides of the uterus
TRIAD; ”Classical
Presentation”
 Vaginal Bleeding or Spotting
• present in 60%-80% of patient
with tubal pregnancy
• passage of Decidual cast

 if no clear gestational sac

 if no villi are identified
histiologically within the cast
possibility of ECTOPIC
PREGNANCY is TO BE
 DIFFERENTIAL DIAGNOSIS
ABDOMINAL PAIN WITH PREGNANCY • Miscarriage
• Infection
• degenerating or enlarging leiomyoma
• molar pregnancy
• round-ligament pain

ADNEXAL DISEASE • ectopic pregnancy

• hemorrhagic, rupture torsed ovarian
masses
• salpingitis
• tubo-ovarian abscesses

NON-GYNECOLOGIC • appendicitis
• renal stone
• gastroenteritis
DIAGNOSIS
● History and Physical
Examination
● Beta-hCG
● Serum Progesterone
● Transvaginal Sonography
DIAGNOSIS
● History and Physical Examination
 (+) Pregnancy Test
 (+) Triad
• Vaginal Bleeding
• Ammenorrhoea
• Pelvic Pain

 (+) Cervical Motion Tenderness

 Hypovolemic signs:
• Hypotension
• Tachycardia
 (+)Nausea
 (+) Fainting
DIAGNOSIS
● Beta-hCG
 hormone produced by developing placenta
 levels rise rapidly in early weeks and detected
in blood and urine

DISCRIMINATORY ZONE
 specific range of B-hCG levels
 1500-2000 mIU/mL

NO EVIDENCE OF UTERINE
PREGNANCY WITH TVS
 Filed uterine pregnancy
 completed abortion
 ectopic pregnancy
DIAGNOSIS
● Serum Progesterone
 most ectopic pregnancy progesterone levels
range between 10-25ng/mL

 >25ng/mL EXCLUDES ectopic pregnancy

with 92.5% sensitivity

 <5ng/mL --> nonliving uterine or ectopic

pregnancy
DIAGNOSIS
● Transvaginal Sonography
 4 1/2 to 5 weeks - Intrauterine
 5 to 6 weeks- Yolk Sac
 5 1/2 weeks- Fetal pole with cardiac activity

In Ectopic Pregnancy

 TRILAMINAR ENDOMETRIAL
PATTERN - Diagnostic
 gestational sac
 yolk sac/pseudosac
 decidual cyst
RING OF FIRE
 inhomogeneous adnexal mass
 reflects vascularity brought
abourt by the blood supply to
the trophoblastic tissue of
ectopic pregnancy
Areas we cover
 Management

Medical Surgical

 ANTIMETABOLITE  LAPAROSCOPY
METHOTREXATE (MTX)
 SALPINGOSTOMY

 SALPINGECTOMY
 Methotrexate
 Folic Acid antagonist

 Overall ectopic tubal pregnancy resolution rate of 90%

 Adverse Effects: bone marrow, gastrointestinal mucosa and

respiratory epithelium can also be harmed.

 directly toxic to hepatocyte; is a potent teratogen

• Methotrexate Embryopathy notable for craniofacial
and skeletal abnormalties and fetal-growth restriction

 Renally excreted; may also be excreted in breast milk and

accumulate in neonatal tissues and interfere with
metabolism
 MECHANISM OF ACTION
competitively binds to
enzyme DHFR

Prevent conversion of dihydrofolate tetrahydrofolate

without tetrahydrofolate, DNA synthesis and

reair and replication will be impaired

Actively proliferating cells like malignant cells, bone marrow

cells, fetal cells and mucosal cells of the mouth, intestines,
and urinary bladder are generally most sensitive to these
effects
Can lead to BONE MARROW DEPRESSION

 This can be blunted by early

administration of
LEUCOVORIN
 increased risk for anemia,
fatigue, infection and
bleeding
METHOTREXATE
 Methotrexate
SINGLE MULTIPLE
 simple  higher success rate
 less expensive post therapy
monitoring
 does not require Leucovorin

 Day 1 -
administration

 Day 4 - repeat
B-hCG

 Day 7 - Repeat
B-hCG

*weekly repeat hCG

levels until
resolution is
complete
Methotrexate may be given in one dose at 50 mg/m2 for the treatment of an ectopic.

Methotrexate may also be given using a “multidose” regimen of 1 mg/kg intramuscularly,

alternating with 0.1 mg/kg of leucovorin intramuscularly for up to four daily doses of each
drug
Sample
● 26 year old G1P0, Height of 160 cm, weight of 55 kg. Compute for the
Methotrexate dose.
➢ BSA (m²) = √ (height)(weight)/3,600
Methotrexate may be given in one dose at 50 mg/m2 for the treatment
➢ BSA (m²) = √(160cm)(55kg)/3,600 of an ectopic.
➢ BSA (m²) = √8,800/3,600
Methotrexate may also be given using a “multidose” regimen of 1
➢ BSA (m²) = √2.4 mg/kg intramuscularly, alternating with 0.1 mg/kg of leucovorin
➢ BSA (m²) = 1.55 m² intramuscularly for up to four daily doses of each drug

 Single dose = 50mg/m2 = (50)(1.55) = 77 mg IM

 Multiple Dose = 1mg/kg = 55 mg IM Methotrexate (Day 1)
0.1mg/kg= 5.5 mg IM Leocovorin (Day 2)
Adverse Effects Treatment Failure
 Liver involvement - 12%  Worsening abdominal pain
 Stomtitis 6%  Signs of hemodynamic instability
 Gastroenteritis 1%  <15% decline between Day 4 and Day 7
 Bone Marrow Depression hCG levels
 Increasing or plateauing hCG levels after
lthe 1st week of treatment

Predictors for Success

 Low initial serum B-hCG levels (best prognostic indicator od success)
 small ectopic pregnancy size
 absent fetal cardiac activity

♥ 93% success rate if ectopic mass <3.5 cm

♥ 87% if ectopic mass is >3.5 cm

♥ INCREASED FAILURE rate if there is cardiac activity

Surgical Management
 Salpingostomy
 small unruptured <2cm length and located
in distal 3rd of fallopian tube

 desire fertility preservation

 incision left unsutured and heal by

secondary intention
 Salpingotomy
 rarely used nowadays

 same with salpingostomy but incision site is

closed with delayed absorbable suture

 no difference in prognosis with or without

suturing
 Salpingectomy
 for both ruptured and unruptured
ectopic pregnancies

INDICATIONS:
 recurrent ectopic pregnancy
in same tube
 several damaged tube
 uncontrolled bleeding
 heterotrophic pregnancy
 lack of desire to bear more
children
Salpingostomy Salpingectomy

Salpingotomy
MEDICAL
VS
SURGICAL
● Compared a multidose MTX protocol with laparoscopic
salpingostomy and found no differences for tubal
preservation and primary treatment success.

● Health-related quality-of-life factors were significantly

impaired after systemic MTX compared with laparoscopic
salpingostomy.

● Provided similar 2-year rates of attaining a uterine

pregnancy

● Single-dose MTX was overall less successful

● Ectopic-resolution success rates were not significantly

diferent
 Persistent Trophoblast
 incomplete removal of trophoblast
 complicates 5-20% of salpingostomies
 identified by stable rising B-hCG

Factors that Increase Risk of Persisting trophoblast

 pregnancies <2cm
 early pregnancy <42 menstrual days
 serum B-hCG >300 mIU/mL
 implantation medial to Salpingostomy site
EXPECTANT MANAGEMENT
● Criteria for Expectant Management:
○ Hemodynamically stable and no or minimal
abdominal pain
○ Initial B-hCG levels or <1000 mIU/mL
○ No Gesttaional Sac or extrauterine mass sicious
for ectopic pregnancy

● Almost 1/3 of 333 tubal ectopic pregnancies measuring

<3 cm and with β-hCG levels <1500 mIU/mL resolved
without intervention (Mavrelos and coworkers, 2013);
 Other Types of
Ectopic Pregnancy
02
INTERSTITIAL
PREGNANCY
 INTERSTITIAL
PREGNANCY
● Implant within the proximal tubal segment that lies within the
muscular uterine wall

● Conception that develops in the rudimentary horn of a uterus with

a mullerian anomaly

● Previous IPSILATERAL SALPINGECTOMY is a specific risk

factor for interstitial pregnancies

● Greater distensibility of the myometrium covering the interstitial

fallopian tube segment

● due to proximity of these pregnancies to the uterine and ovarian

arteries, there is a risk of severe hemorrhage
03
ABDOMINAL
PREGNANCY
 ABDOMINAL
PREGNANCY
● Implantation in the PERITONEAL CAVITY exclusive of tubal,
ovarian, or intraligamentous implantations

● RARE; incidence of 1 in 10,000 to 25,000 live births

● most abdominal pregnancies are thought to follow early tubal

rupture or abortion with reimplantation

● Diagnosis is difficult

● Clues include:
 fetus seen separate from the uterus or eccentrically
positioned within the pelvis
 lack of myometrium between fetus and maternal anterior
abdominal wall or bladder
 extrauterine placental tissue
ABDOMINAL PREGNANCY

● Studdiford Criteria
Visualization of fetus separate from the uterus

Failure to visualize uterine wall between fetus and urinary bladder

Close approximatin of fetal parts to the maternal abdominal wall

Abnormal fetal attitude and visualization of extrauterine placental

tissue
 MANAGEMENT
 Life-threatening

 Stevens (1993) reported fetal malformations and deformations in 20%

 limb deficiency (facial and cranial asymmetry; joint abnormalities)
 central nervous system anomalies

 Termination generally is indicated when the diagnosis is made

 Preoperative angiographic embolizationhas been used successfully in some

women with advanced abdominal pregnancy.
 MANAGEMENT
 Catheters placed in the uterine arteries may be inflated to decrease intraoperative
blood loss.
 insertion of ureteral catheters
 bowel preparation
 assurance of sufficient blood products
 availability of a multidisciplinary surgical team or elective transfer to a tertiary
care facility

 The principal surgical objectives involve delivery of the fetus and careful
assessment of placen- tal implantation without provoking hemorrhage.

 leaving the placenta in place as the lesser of two evils. It decreases the chance of
immediate life-threatening hemorrhage
 04
INTRALIGAMENTOUS
PREGNANCY
 INTRALIGAMENTOUS
PREGNANCY
● zygotes implanted toward the mesosalpinx, rupture may occur at the portion of
the tube not immediately covered by peritoneum, gestational contents may then
be extruded into a space formed between the broad ligament leaves and become
an intraligamentous or broad ligament pregnancy.

● Rare

● Clinical findings and management mirror those for abdominal pregnancy

● Laparotomy required in most instances

05
OVARIAN
PREGNANCY
OVARIAN PREGNANCY
● Implantation of the fertilized egg in the ovary
is rare

● Spiegelberg’s Criteria:
 ipsilateral tube is intact and distinct
from ovary
 the ectopic pregnancy occupies the
ovary
 the ectopic pregnancy is connected by
the uteroovarian ligament to the uterus
 ovarian tissue can be demonstrated
histologically amid the placental tissue

● CLassically, management has been surgical

06
CERVICAL
PREGNANCY
 CERVICAL PREGNANCY
● endocervix is eroded by trophoblast, and the
pregnancy develops in the fibrous cervical wall.

● The more cephalad that the trophoblast is

implanted along the cervical canal, the greater is
its capacity to grow and hemorrhage.

● Another risk is previous D&C

● Painless vaginal bleeding is reported by 90

percent of women with a cervical pregnancy

● distended, thin-walled cervix with a partially

dilated external os may be evident
 CERVICAL PREGNANCY
● Transvaginal Ultrasound FIndings:
○ An hourĀlass uterine shape and ballooned
cervix.

○ Gestational tissue at the level of cervix

○ Absent intrauterine Āestational tissue

○ Portion oÿ the endocervical canal seen

interposed between the gestation and
endometrial canal
 CERVICAL PREGNANCY
● Rubin’s Criteria:
○ Cervical glands are present opposite the placental attachement

○ Intimate attachement of placenta to cervix

○ Placenta is below the entrance of the uterine vessels or below peritoneal reflection on
the anteroposterior uterine surfaces

○ Fetal elements absent in the uterine corpus

● a
 MANAGEMENT
 Conservative management – minimize hemorrhage, resolve the pregnancy, and
preserve fertility
o Methotrexate – first-line therapy in stable women
o MTX infusion combined with uterine artery embolization "chemoembolization“

 Hysterectomy – may be required with bleeding uncontrolled by conservative methods

 If cervical curettage is planned, intraoperative bleeding may be lessened by

preoperative UAE, by intracervical vasopressin injection, or by a cerclage placed at
the internal cervical os to compress feeding vessels.
07
CESAREAN SCAR
PREGNANCY
 CESAREAN SCAR PREGNANCY
● Incidence approximates 1 in 2000 normal pregnancies
and has increased alongside the cesarean delivery rate

● Women with CSP usually present early, and pain and

bleed_x0002_ing are common

● 40 percent of women are asymptomatic; and diagnosis

is made during routine sono- graphic examination
 MANAGEMENT
 Hysterectomy is an acceptable initial choice in those desiring sterilization.

 Fertility preserving options:

• systemic or locally injected methotrexate

 Surgeries:
 visually guided suction curettage or transvaginal aspiration
 hysteroscopic removal
 isthmic excision

 Often uterine artery embolization is used preop- eratively to minimize hemorrhage

risk
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