Ectopic pregnancy slides based on Gynecology by Ten teachers

1. ECTOPIC PREGNANCY (EP)
BY
MUHAMMAD ZEESHAN KHAN
AND
SANA JAWED

2. OBJECTIVE OF PRESENTATION
AT THE END OF PRESENTATION YOU SHOULD KNOW:
 NORMAL SITE OF IMPLANTATION IN PREGNANCY
 DEFINITION OF EP
 ABNORMAL SITES OF IMPLANTATION IN EP
 INCIDENCE
 ETIOLOGY
 CLINICAL MANIFESTATION
 INVESTIGATION
 MANAGEMENT

3. NORMAL SITES OF IMPLANTATION IN
PREGNANCY
 Implantation is the very early stage of pregnancy at
which the conceptus adheres to the wall of the uterus. At
this stage of prenatal development, the conceptus is
a blastocyst.
 Normal site of implantation is posterior-superior wall of
the Body of uterus in most of the cases.
 In addition anterior wall of body of uterus also
constitutes the normal site of implantation.

4. NORMAL SITE OF IMPLANTATION
(shown in green)

5. WHAT IS ECTOPIC PREGNANCY
“IMPLANTATION OF CONCEPTUS OUTSIDE THE
NORMAL UTERINE CAVITY”.
NOTE: 1. ECTOPIC PREGNANCY VIRTUALLY NEVER LEADS TO FETAL
VIABILITY.
2. ALL SITES IN UTERINE CAVITY ARE CONSIDERED NORMAL FOR EP BUT
not IN GENERAL…

6. SITES OF IMPLANTATION OF ECTOPIC
PREGNANCY
 COMMON SITES OF IMPLANTATION ARE
1. Fallopian tubes ( 95 % of total cases of ectopic pregnancy )
a. Ampulla (74 % of 95%)
b. Isthmus ( 12 % of 95%)
c. Fimbrial end of the tube ( 12 % of 95%)
d. Interstitium ( 2% of 95%)
2. Ovaries ( 3-4 % of total)
3. Peritoneal cavity ( 1-2 % of total)

7. COMMON SITES OF EP

8. INCIDENCE
 The frequency of ectopic pregnancy was 1 .3%.
 Majority of patients with ectopic pregnancy were in 2 1-
30 years age group (74%)
 Multiparous women were found to be more prone to have
ectopic pregnancy (6 1%).
 The gestational age ranged between 4-11 weeks and the
most frequent gestational age was around 6 weeks.

9. ETIOLOGY/ RISK FACTORS
AMONG THE KNOWN RISK FACTORS / CAUSES OF ECTOPIC
PREGNANCIES ARE
1. Tubal Disease ; e.g. inflammatory condition due to ascending
infection i.e. PID.  accounts for 40 % cases of ectopic pregnancy.
2. Previous EP
3. Previous tubal surgery.
4. Subfertility
5. Use of IUD.

10. PROBABLE MECHANISM OF TUBAL EP

11. CLINICAL MANIFESTATION OF EP
 SUBACUTE PRESENTATION
1. ABDOMINAL/PELVIC PAIN(79%) , PAIN CAN BE
LOCALIZED TO ILIAC FOSSA
2. VAGINAL BLEEDING(53%) , DARK RED 
INDICATIVE OF OLD BLOOD.
3. PAIN AT SHOULDER TIP  RARE PRESENTATION ,
INDICATIVE OF FREE BLOOD IN ABDOMINAL CAVITY
CAUSING DIPHRAGMATIC IRRITAITON.
CONT.

12. CLINICAL MANIFESTATION OF EP
 ACUTE PRESENTATION
It occurs in cases of ruptured ectopic pregnancy and
patient presents with the symptoms of massive
intraperitoneal bleeding.
1. Hypovolemic Shock
2. Acute abdomen

13. INVESTIGATIONS OF EP
Useful investigations for the diagnosis of ectopic pregnancy.
 OBSERVATIONS- VITALS
 βHCG
 TVS
 LAPROSCOPY
Rarely used
 Progesterone levels

14. βHCG
 This hormone is a glycoprotein produced by placenta
 Half life is 24 hours
 Peaks at around 10weeks
 Levels double every 48 hours in a normally developing pregnancy
 Beta HCG less than 5mIU/ml is considered negative for pregnancy
 Anything more than 25mIU/ml is considered positive for
pregnancy
 In ectopic pregnancy:
Empty uterus on abdominal U/S with BHCG >6000mIU/ml
Empty uterus on vaginal U/S with BHCG >200mIU/ml

15. TRANSVAGINAL U/S SCAN(TVS)
 An intrauterine GS should be visualized at 4.5weeks and corresponding
BHCG is 1500mIU/ml.
 At 5th week GS with fetal heartbeat is detected with BHCG level around
3000mIU/ml
 High BHCG level and no IU pregnancy seen on TVS is suggestive of
ectopic pregnancy
 Presence of free fluid during TVS is suggestive of ruptured ectopic
pregnancy
 FALSE NEGATIVE occurs in case of heterotopic pregnancy. i.e.
simultaneous pregnancy within and outside the uterus.

16. DIAGRAM SHOWING TVS

17. LAPROSCOPY
 This is the gold standard test
 Endoscope is inserted into the abdomen to allow a
surgeon to see fallopian tubes and other organs and
do surgery at the same time

18. DIAGRAM SHOWING LAPROSCOPY

19. PROGESTERONE LEVELS
 Progesterone is a hormone formed by corpus luteum
 >25ng/ml is related with normal intrauterine
pregnancy
 <5ng/ml is related with ectopic or non viable
pregnancy

20. MANAGEMENT OF EP
Depending on clinical presentation and patients
choice:
EXPECTANT (Do nothing)
MEDICAL (Do something)
SURGICAL (Do everything)

21. EXPECTANT
 Based on assumption that all tubal pregnancies
will resolve through regression or miscarriage
without any treatment.
 Suitable for patients who are hemodynamically
stable and asymptomatic
 Requires serial βHCG measurements and
ultrasonography

22. MEDICAL MANAGEMENT BY
METHOTREXATE
METHOTREXATE
 Folic acid antagonist that inhibits DNA synthesis in the
trophoblastic cells
 Standard dose is 50mg/m2
 Can be administered as a single I/M injection or multiple
fixed dose regimen.

23. INDICAITONS
 Cornual pregnancy
 Persistent trophoblastic disease
 Patient with one fallopian tube and fertility desired
 Patient who refuses surgery
 Ectopic pregnancy where trophoblast is adherent to
bowel or blood vessel
 GS is <4cm

24. CONTRAINDICATIONS
 Chronic liver, renal or hematological disorder
 Active infection
Immunodeficiency
 Breastfeeding

25. SIDE EFFECTS
 Nausea, vomiting
 Stomatitis, conjunctivitis
 GI upset
 Photosensitive skin reactions
 Non specific abdominal pain

26. SPECIAL ADVICE PRIOR TO USE
 Avoid sexual intercourse during treatment
 Take contraception for 3months after treatment
 Avoid alcohol and sunlight exposure during
treatment

27. SURGICAL MANAGEMENT
INDICATIONS FOR SURGEICAL MANAGEMENT
 Patient is not suitable for medical therapy
 Medical therapy has failed
 Patient has heterotropic pregnancy with viable
uterine pregnancy
 Heamodynamically unstable and needs immediate
treatment
 GS is >4cm

28. METHODS OF SURGERY
1. LAPROSCOPY- surgery through small incision,
having many advantages, like. less blood loss, shorter
hospital stay, less analgesia requirement, shorter
convalescence than laprotomy.
2. LAPROTOMY- surgery through large incision
especially reserved for severely compromised patient or
due lack of endoscopic facilities.

29. PROCEDURE OF SURGERY
1. SALPINGECTOMY
 During surgery the fallopian tubes are removed
 Done in patients:
• Who have tubal rupture
• Who no longer desire fertility
• Who have history of ectopic pregnancy in the same tube before
• Who have severely damaged tubes

30. PROCEDURE OF SURGERY
2. SALPINGOTOMY
 During surgery, a small opening can be made at the site of ectopic
pregnancy and the trophoblastic tissue is extracted out via that
opening
 Done when the tube has not ruptured or patient desires to
conserve her fertility
 Monitoring needed for BHCG levels to identify persistent
trophoblast
 High risk of subsequent ectopic pregnancy

31. PROGNOSIS AFTER MANAGEMENT
Rate of IU pregnancy may be higher following
treatment with methoteraxate as compared to
surgery
Rate of fertility may be better following
salpingotomy as compared to salpingectomy