First, dose anybody know the meaning of this word, ectopic. Well, most of you look a little bit confused. Actually, this term is derived from Greek word ”ektopos”. It means out of place or misplaced. Knowing this, I think you can figure out the definition.板书 ：定义 which means a pregnancy out of place, in other words, a pregnancy in which the embryo is implanted and develops outside the endometrial lining of the uterus .
In the previous slide, the pregancy is implanted in the fallopian tube. As a matter of fact, ectopic pregnancy can also occur at other locations.板书 According to the site of implantation , the ectopic prenancy can be classified as tubal pregnancy, ovarian pregnancy, abdominal pregnancy and cervical pregnancy. 97% of ectopic pregnancies occur in the Fallopian tube. What I would like to point out although interstitial tubal pregnancies , together with ovary, cervix, or abdomen are very rare, they represent nearly 20% of deaths due to ectopic pregnancies. The high morbidity at these locations are due to massive bleeding when they rupture.
The primary risk factor for ectopic pregnancy is a prior history of pelvic inflammatory disease, eg. previous chlamydia or gonorrhoea. It is one of the main causes of the increase seen in ectopic pregnancies in recent years. Risk of an ectopic increases about 7-fold after a woman suffers acute pelvic infection. Infection may lead to : -destruction of the tubal epithelium with reduction or loss of ciliary current -intratubal adhesions resulting in partial tubal obstruction -peritubal adhesions resulting in restricted tubal motility: these figures show the peritubal adhesions that distort the tubal. All these situations, acting alone or in combination, can slow the passage of the egg which gives it time to implant itself in the tube.
In this short animation, we can see that the sperm enters the follopian tube and meet with the ovum. However, due to some reasons, the fertilized egg is trapped here before it reached the uterus and develops into a misplaced embryo. This misplaced embryo is somewhat like a time bomb because tissues at these abnormal locations for implantation are vulnerable and thin, they cannot support and accommodate the growing embryo. After several weeks , it may rupture and cause massive intraperitoneal bleeding, resulting in a potentially serious situation.
The tubal pregnancy dose not usually proceed beyond 8-10 weeks due to : Lack of decidual reaction in the tube, the thin wall of the tube , the inadequacy of tubal lumen, bleeding in the site of implantation as trophoblast invades Eventually, tubal pregancy will end up in either one of the following four outcomes. 1. Tubal abortion -This occurs more if ovum had been implanted in the ampullary portion of the tube -as shown in this figure, gestational sac is seperated is expelled into the peritoneal cavity through the tubal ostium --if explulsion was complete the bleeding usually ceases but it may continue due to incomplete separation or bleeding from the implantation site.
Tubal rupture Rupture of tubal pregancy can cause profuse internal bleeding and even death. More common if implantation occurs in the narrower portion of the tube which is the isthmus. Rupture may occur in the anti-mesenteric border of the tube and cause intraperitoneal hemorrhage. Or rupture into the mesenteric border of the tube and develops broad ligament hemotoma .
Secondary abdominal pregnancy Most abdomianl pregancies occur after the embryo first implants in the follopian tube, after it is aborted from the fimbrial opening of the tube and it is implanted in the abdomen structure and form a secondary abdominal pregnancy. In most cases , the baby will die to but occasionally they may survive.
1. ECTOPIC PREGNANCY
Dr Manal Behery
Zagazig university 2014
(Ektopos) out of place
Ectopic pregnancy: fertilized embryo
implanted outside the uterine cavity
3. Classification of ectopic pregnancy
4. Mechanical factors
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.
5. RISK FACTORS
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
6. Prior history of PID (pelvic
7. TUBAL SURGERY
8. Animation of intrauterine implantation
athology of E
11. 2. Rupture of tubal pregnancy
12. Ruptured ectopic pregnancy
13. •Extraperitoneal rupture (rupture through floor of the tube)
•may lead to broad ligament hematoma with death of the
ovum, or intraligamentary pregnancy.
14. 3. Secondary abdominal pregnancy
16. 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.
19. Subacute type:Symptoms:
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
20. With ruptured ectopic pregnancy
abdominal guarding and rigidity,
21. When a woman presents with an
Ask yourself two questions…
Where is this pregnancy?
Is it viable?
22. 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!
23. 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
24. 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.
25. 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.
26. Doubling sign:
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.
27. Tran abdominal US
28. Transvaginal ultrasound ( TVS):
29. 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
31. 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
33. 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
35. 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
36. •Segmental resection: removal of
a portion of the affected tube.
37. 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
39. Algorithm for the diagnosis of unruptured ectopic pregnancy
40. Management of ectopic pregnancy
11- Positive pregnancy test
Lowe abdominal pain +
Minimal Vaginal bleeding
Asymptomatic with factors
for ectopic pregnancy
2. History + clinical examination
41. 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