Ectopic pregnancy for undergraduatePresentation Transcript
Dr Manal Behery
Zagazig university 2014
(Ektopos) out of place
Ectopic pregnancy: fertilized embryo
implanted outside the uterine cavity
Classification of ectopic pregnancy
Congenital: long narrow tube, diverticulae and
Traumatic: operation on the tube as salpingoplasty
and tubal reversal following ligation.
Inflammatory: Chronic salpingitis
Neoplastic: Narrowing of the tube by a fibroid or a
broad ligament tumor.
Functional: As tubal spasm or antiperistaltic
endometriosis in the tube. encourages embedding
of the fertilized ovum.
Hz of tubal surgery
Hx of STD’s (such as chlamydia)
Hx of ART
Hx of ectopic (esp if conservatively
managed without surgery)
IUD in place at time of conception
Prior history of PID (pelvic
Animation of intrauterine implantation
athology of E
2. Rupture of tubal pregnancy
Ruptured ectopic pregnancy
•Extraperitoneal rupture (rupture through floor of the tube)
•may lead to broad ligament hematoma with death of the
ovum, or intraligamentary pregnancy.
3. Secondary abdominal pregnancy
Symptoms & Signs:
In a woman of child bearing age with
pelvi-abdominal pain and/ or vaginal
bleeding …… ALWAYS….think
Clinical Finding: Undistrubed ectopic
A dull aching pain is usually present in
one iliac fossa. It is due to distension of the
tube and stretching of its peritoneal coat.
Classic signs –
adnexal or cervical motion
Abdominal examination: Tenderness in one
(cervical motion tenderness or jumping sign)
The cervix is soft and severe pain occurs
when it is moved from side to side
A mass may be felt to one side of the uterus.
It is very tender, soft and may be pulsating.
Short period of amenorrhea in (25%) no history
of amenorrhea due to occurrence of post
conceptional bleeding that mistaken as a true
Pain: It is felt in one iliac fossa. It may be dull
aching or sharp stabbing or colicky
Fainting attacks or even shock
Vaginal bleeding occurs after pain
With ruptured ectopic pregnancy
abdominal guarding and rigidity,
When a woman presents with an
Ask yourself two questions…
Where is this pregnancy?
Is it viable?
Where is this pregnancy?
In a woman with an early pregnancy you
must determine if the pregnancy is
intrauterine or an ectopic, because her
life could depend on it!
How to you determine location of
First determine dating by LMP
Then perform ultrasound
If you can see location of the pregnancy, you
If you cannot…it becomes more
β-hCG discriminatory value (or zone)
It is the lower limit of hCG at which an
examiner can reliably visualize pregnancy
on ultrasound. It is 1000-2000 IU/L with
vaginal ultrasound and 5000-6000 IU/L
with abdominal ultrasound.
If β-hCG levels above the
The absence of uterine pregnancy
signifies an abnormal pregnancy; ectopic,
If β-hCG levels are still below the
discriminatory value, serial β-hCG and
ultrasound should be done.
In normal pregnancy a 66% or greater increase
in serum β-hCG levels should be observed
every 48 hours (nearly doubles).
Inappropriately rising serum β-hCG levels
suggest (but do not diagnose) an abnormal
pregnancy including ectopic, however, they do
not identify its location.
Tran abdominal US
Transvaginal ultrasound ( TVS):
Early pregnancy with unknown
Check a serum BHCG
If it is above the discriminatory zone (DZ)an
intrauterine pregnancy should be seen
Then do an ultrasound to see if you see the
Treatment of tubal pregnancy
If the patient is shocked: antishock measures.
If the patient is Rh negative and not sensitized
anti-D serum is given.
methotrexate (a folic acid antagonist).
IM methotrexate given as a single dose.
The best candidate is the woman who is
asymptomatic, compliant with follow-up, with
an initial serum value <5000 IU/L.
Immunodeficiency / active infection
Chronic liver disease
Active pulmonary disease
Active peptic ulcer or colitis
Hepatic, Renal or Haematological
Signs and Treatment failure and tubal
Significantly worsening abdominal pain,
Level of HCG do not decline by at least 15%
between Day 4 & 7 post treatment
or plateauing HCG level after first week of
If the β-hCG level does not decline (plateau or
increase), the patient may require either a
second dose of methotrexate or surgery.
Laparoscopy approach – salpingostomy
Laprotomy – salpingostomy
Salpingostomy / Salpingotomy is only indicated
1. The patient desires to conserve her fertility
2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 4Cm. In size
5. Contralateral tube is absent
•Segmental resection: removal of
a portion of the affected tube.
laparatomy (if the mass is greater than 3.5 cm in
diametar, internal bleeding, cardiovascular colapse)
-metotrexate (if the mass is less then 3.5 cm in diametar)
intrapertoneal blood then peritoneal toilet.
Removal of any pelvic hematomas or
Algorithm for the diagnosis of unruptured ectopic pregnancy
Management of ectopic pregnancy
11- Positive pregnancy test
Lowe abdominal pain +
Minimal Vaginal bleeding
Asymptomatic with factors
for ectopic pregnancy
2. History + clinical examination
If sure of date of LMP and /or
Regular cycle, i.e.
>6 wks. gestation,
Arrange TV ultrasound
If unsure of date of LMP
and /or irregular cycle,
Measure serum hCG
If hCG <1000
? Ectopic pregnancy
If Hcg >1000, use
3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000
Meet criteria for
Does not meet criteria
for methotrexate treatment
Salpingectomy ?Proceed to
laparotomy OR Laparotomy if