Ectopic Pregnancy

Yohannes T.(GP)
 Ectopic Pregnancy
Definition:
Ectopic pregnancy is one in which the blastocyst implants
anywhere other than the endometrial lining of the uterine
cavity
Ectopic pregnancy accounted for 10 % of all pregnancy-
related deaths
Incidence
Ectopic pregnancies occurred, at a rate of 16 ectopic
pregnancies per 1,000 reported pregnancies (1.6%)
More than 95 % ectopic pregnancy are tubal
Various sites and frequency of ectopic pregnancies.
 Ectopic Contd.
After an ectopic pregnancy, there is a 7- to 13-fold increase in
the risk of a subsequent ectopic pregnancy.
The chance that a subsequent pregnancy will be intrauterine is
50% to 80%, and the chance that the pregnancy will be tubal
is 10% to 25%; the remaining patients will be infertile.
 Risk factor for ectopic pregnancy
Risk factor Odds Ratio
High Risk
Tubal corrective surgery 21.0
Tubal sterilization 9.3
Previous ectopic pregnancy 8.3
In utero DES exposure 5.6
Intrauterine device 4.2–45
Documented tubal pathology 3.8–21
Moderate Risk
Infertility 2.5–21
Previous genital infection 2.5–3.7
Multiple partners 2.1
Slight Risk
Previous pelvic or abdominal surgery 0.93–3.8
Smoking 2.3–2.5
Douching 1.1–3.1
Intercourse before 18 years 1.6
 Risk Factors Contd.
Contraceptives
Most forms of contraception will ironically increase the relative incidence
of ectopic pregnancy by decreasing the number of intrauterine
pregnancies.
The relative number of ectopic pregnancies varies by contraceptive use.
For example, barrier contraception and the TCu380A IUD do not confer
an increased ectopic pregnancy rate .
Hormonal control of the muscular activity in the fallopian tube may
explain the increased incidence of tubal pregnancy associated with
failures of the morning after pill, minipill, progesterone-containing
intrauterine devices (IUDs), and ovulation induction.
Levonorgestrel-containing intrauterine system has a 5-year cumulative
pregnancy rate of 0.5 per 100 users of which half are ectopic.
Tubal sterilization can be followed by an ectopic pregnancy.
Pathophysiology of Ectopic pregnancy

Histopathology
Lack of a submucosal layer within the fallopian tube wall provides easy
access for the fertilized ovum to burrow through the epithelium and
allow implantation within the muscular wall.
As the rapidly proliferating trophoblast erodes the subjacent muscularis
layer, maternal blood pours into the spaces within the trophoblast or the
adjacent tissue.
The lack of resistance allows early penetration by trophoblasts
The anatomic location of a tubal pregnancy may predict the extent of
damage.
 Clinical Manifestations
Symptoms
Triads occur in 50% of patients
o Amenorrhea
o vaginal bleeding
o Abdominal pain on the affected side,
Other pregnancy discomforts such as breast tenderness, nausea, and urinary
frequency may accompany more ominous findings.
Shoulder pain worsened by inspiration, which is caused by phrenic nerve irritation
from sub diaphragmatic blood, or
Vertigo and syncope from hemorrhagic hypovolemia.
Many women with a small unruptured ectopic pregnancy have unremarkable
clinical findings.
 Clinical Manifestations Contd.
Phsical examination
Vital Signs normal or deranged
Abdominal and pelvic findings are notoriously scant in many women
before tubal rupture.
With rupture
o Pale
o Acutely sick
o Signs of fluid collection
o signs of acute abdomen.
o Cervical motion tenderness
o Adnexal mass
o Buldged cul-de-sac
 Clinical Manifestations Contd.
Acute Vs chronic ectopic pregnancy
There may be a difference between an "acute" and a
"chronic" ectopic pregnancy with regard to the risk of tubal
rupture.
Acute ectopic pregnancies are those with a high serumβ -HCG
level at presentation and rapid growth.
These carry the highest risk of tubal rupture compared with
chronic ectopic pregnancies, which demonstrate static serum
β -HCG levels.
 Differential diagnosis
Abortion
GTD
PID
TOA
Corpus luteum cyst
Cystitis
Renal colic
Adnexal cyst torsion
Degenereting Mayoma
Appendicitis
Mesenteric lymph adenitis
 Diagnosis
Clinical: high index of suspicion
Laboratory tests:
Hct
Blood group & Rh
Urine HCG
Serum beta HCG
Serum progesterone
Ultrasound
Culdocentesis
Endometrial Sampling
Diagnostic laparoscopy : Gold standard for diagnosis of ectopic pregnancy
 Diagnosis Contd.
Serum β-HCG Measurements
β-HCG detected as early as 8 days after the LH surge.
With a robust uterine pregnancy, serum β -HCG levels should increase
between 53 and 66 percent every 48 hours.
Inappropriately rising serum β -HCG levels only indicate a dying
pregnancy, not its location
Serum progesterone
With serum progesterone levels of <5 ng/mL, a dying pregnancy was
detected with near perfect specificity and with a sensitivity of 60 percent.
 Diagnosis Contd.
Sonography
• Using TVS, a gestational sac is visible between 4.5 and 5 weeks, the yolk
sac appears between 5 and 6 weeks, and a fetal pole with cardiac activity
is first detected at 5.5 to 6 weeks
• When the last menstrual period is unknown, serumβ–HCG testing is used
to define expected sonographic findings.
• Descriminatory zone, a concentration between 1,500 and 2,000 IU/L(TVS)
&6000 & 6500 IU/L(TAS)
• Free peritoneal fluid suggests intra-abdominal bleeding
 Diagnosis Contd.
The absence of intra uterine pregnancy on TVU with β-HCG
levels above the discriminatory value signifies an abnormal
pregnancy either
Ectopic
Incomplete abortion, or
Resolving completed abortion
Conversely, sonographic findings obtained when β-HCG
values lie below the discriminatory value are not diagnostic in
nearly two-thirds of cases. Repeat in 48 hrs
 Management of ectopic pregnancy

1. Medical: Oral, parenteral or direct Injection into Ectopic Pregnancy

Methotrexate ,Prostaglandins,Mifepristone,Potassium chloride
Hyperosmolar glucose
2. Surgical(Laparotomy or Laparoscopy)
Salpingectomy
Salpingostomy (conservative surgery)
3. Expectant management
4. Anti D for Rh negative women
Thank you