3. Incidence
Increased dramatically in the past few decades
1970: 4.5/1,000 pregnancies
1992: 19.7/ 1,000 pregnancies
From 1947 to1967: only 8.5% of EPs were
diagnosed before rupture (Breen, 1970)
Aboubakr Elnashar
7. Risk factors
(Meta- analyses: Ankum et al 1996; Mol et al 1997& Skjeldestad 1998)
Risk Factor Relative Risk (Fold)
1-Tubal surgery 21.0
2-Tubal Sterilization 9.3
3-Previous Ectopic 8.0
4-Previous Salpingitis 6.0
5-DES Exposure 5.0
6-Contraceptive 4.5
7-Assisted reproduction 4.0
Aboubakr Elnashar
8. Ectopic pregnancy/1000 Woman-
Years (Sivin &Steren,1994)
All U.S. women 1.50
Noncontraceptive users 3.00
Copper T-380 IUD 0.20
Progesterone IUD 6.80
Levonorgestrel IUD 0.20
Norplant 0.28
So Tcu-380A and the Levonorgestrel IUD are acceptable choices
for women with previous ectopic pregnancies.
Aboubakr Elnashar
9. ART
increase the incidence of tubal &
heterotopic pregnancy.
Heterotypic pregnancy:
was 1/ 30,000
now 1/7000.
After superovulation or ART: 1/ 100-
900 (Savare et al ,1993)
Aboubakr Elnashar
10. Clinical presentation
Symptoms
Abdominal pain 95%
Amenorrhoea 80%
Vaginal bleeding 70%
Pregnancy sympt 20%
Dizziness or syncope 50%
Gastrointestinal sym 80%
The most important sign is
abdominal pain
Signs
Adnexal tender 80%
Abd. tender 90%
Adnexal mass 50%
Uterine enlarg 25%
Fever 5%
The most important sign is
adnexal tenderness that is
aggravated by moving the
cervix sideways (cervical
excitation).
Aboubakr Elnashar
11. 1. Acute Cases:
present in the emergency
room with tubal rupture
and cardiovascular
collapse
Unfortunatly it still about 20%
Aboubakr Elnashar
12. 2. Subacute cases:
Frequently give rise to
diagnostic confusion
3. Asymptomatic cases:
suspected early in high-risk
women.
Aboubakr Elnashar
13. Uncommon Sites of Ectopic
Pregnancy
(I) Cornual angular pregnancy:
Implantation in the interstitial portion
of the tube.
Uncommon but dangerous {when
rupture occurs bleeding is severe
and disruption is extensive that it
needs hysterectomy}.
Aboubakr Elnashar
14. (II) Pregnancy in a rudimentary
horn:
In the blind rudimentary horn of a
bicornuate uterus.
{horn is capable of some
hypertrophy and distension},
rupture usually does not occur
before 16-20 ws.
Aboubakr Elnashar
15. (III) Cervical pregnancy:
In the substance of the
cervix below the level of
uterine vessels.
May cause severe vaginal
bleeding.
Aboubakr Elnashar
16. (IV) Ovarian pregnancy:
Etiology:
1. Pelvic adhesions.
2. Ovarian endometriosis.
Pathogenesis:
Fertilization of the ovum inside the ovary or ,
Implantation of the fertilized ovum in the ovary.
Spiegelberg criteria:
1. Gestational sac
located in the region of the ovary,
attached to the uterus by the ovarian ligament,
Its wall contain ovarian tissue
2. The tube on the involved side is intact.Aboubakr Elnashar
17. V) Abdominal pregnancy:
1. Primary:
in the peritoneal cavity from the start.
2. Secondary:
after tubal rupture or abortion.
3. Intraligamentous pregnancy:
abdominal but extraperitoneal, between
the anterior and posterior leaves of the
broad ligament after rupture of tubal
pregnancy in the mesosalpingeal border.
Aboubakr Elnashar
18. Treatment:
1. fetus removed
2. cord severed close to placenta
3. membrane trimmed.
4. Placenta removed only if attached to removable
structures e.g omentum otherwise it is left in place &
methotrexate therapy is given postoperative to hasten
placental involution (controversial)
5. Arterial embolization: embolization for specific
bleeding sites
Aboubakr Elnashar
20. Should be considered:
1. After ART
2. Persistent or rising HCG levels after D & C for
spontaneous or induced abortion
3.uterine fundus > menstrual date
4. more than one corpus luteum
5. Absence of vaginal bleeding in presence of S& S of
ectopic pregnancy
6. Ultrasound evidence of uterine & extrauterine
pregnancy
Treatment:
If retention of the intrauterine gestation is desired, the
ectopic pregnancy must be treated surgically.
Aboubakr Elnashar
21. Multifetal tubal pregnancy
Twin tubal pregnancy has been reported with
both embryos in same tube as well as one
in each tube
Aboubakr Elnashar
23. (1) Serum ß hCG:
Urine pregnancy tests are positive in only 50-60% of
ectopic.
Serum ß hCG:
more sensitive
can detect very early pregnancy about 10 days after
fertilization i.e. before the missed period.
Detection level: 25 mu/Ml
Negative test: exclude EP in > 98% of cases.
Useful in:-
1. Acute cases
2. Sub acute (D.D. of extra-uterine causes)
(Barnes etal, 1985; Cartwrighte et al, 1986; Kim and Fox; 1999)Aboubakr Elnashar
25. Doubling time:
Normal pregnancy:
ß hCG level is doubling/48 h during the first 42 days of
gestation.
Ectopic pregnancy:
ß hCG level usually shows <66% increase within 48 h.
This is not specific to ectopic pregnancy
15% of normal pregnancies as well as in abortions:
Unfortunately, there is also slow doubling time.
Aboubakr Elnashar
27. 2. Ultrasonography
A.Uterine
1. No IU gestational sac
2. Pseudogestational sac (a fluid collection or debris in
the cavity)
10-20% of Ectopic P.
No double decidual sac sign
No yolk sac or embryo
Not eccentric (within the cavity)
3. No yolk sac in a G. sac > 20 mm
Aboubakr Elnashar
28. B. Adnexal
1. Non cystic mass: (Blob sign)
inhomogeneous small mass
next to the ovary with no sac or embryo.
By pressing the vaginal probe gently against the ectopic
it moves separately to the ovary.
The most appropriate sign.
Sensitivity 84% & specificity 99%
Aboubakr Elnashar
29. 2. Cystic mass:
3. Ring: (Bagel sign)
hyperechoic ring around the gestational sac
4.Sac & embryo.
Ipsilateral side: Corpus luteum: 85% of cases
Aboubakr Elnashar
31. Discriminatory zones:
Diagnosis of ectopic pregnancy is made if there is:
1. An empty uterine cavity by TAS with ß hCG > 6000
mIU/ml.
2. An empty uterine cavity by TVS with ß hCG >1500-
2000 mIU/ml.
Aboubakr Elnashar
32. TVS Versus TAS
1-IUG sac can be excluded 1-2 w earlier than TAS.
2. Discrimination Zone is (1500 Vs 6000 mu/ml)
3-More ability to detect the adnexal mass
4- Early detection of cardiac activity .
5- More ability to dd true from pseudo-sac
Aboubakr Elnashar
33. True sac
False sac
Uterine:
Double Decidual Sac Sign: Two
concentric reflective rings
The outer is the reflective ring of
decidua vera
The inner is the reflective ring of
combination of chorion & decidua
capsularis
Aboubakr Elnashar
45. (5) Curettage:
Helpful when:
HCG < 2000 mU/mL & non-rising
(Stovell et al ,1992)
1. IU abortion:
decidua & chorionic villi.
2. Ectopic:
Decidua only or
Arias Stella reaction in the endometrium as well cellular
atypism, mitotic activity and glandular proliferation
3. IU complete abortion:
Decidua only
Aboubakr Elnashar
46. 6. Laparoscopy
The need decreased after the use of B-HCG &
TVS (Speroff et al, 1999)
Indications:
1-Definite diagnosis if there is doubt
2-Concurrent operative Laparoscopy
3-Local injection of chemotherapeutics
Aboubakr Elnashar
56. (7) CBC:
Hgb & hct:
assess anemia.
Leucocytic count:
exclude infections as appendicitis & salpingitis.
(8) Special investigation: (abdominal pregnancy)
MRI:
preoperative detection of placental anatomic
relationships
Plain X-ray:
shows abnormal lie.
In lateral view the fetus overshadows the maternal
spines Aboubakr Elnashar
57. •Ruptured ovarian cyst.
•Bleeding corpus L.
•Adnexal torsion.
• Endometriosis.
•Salpingitis .
Differential Diagnosis
A. Extra uterine causes of Acute Abdominal Pain
All can be exclude by:
1-Clinical Characteristics
2-B sub unite Qualitative HCG 25 mu / ml .
•Diverticulitis
•Appendicitis.
•Mesenteric lymphadenitis
•Acute gastroenteritis
•Acute cholecystitis
•Perforated ulcer
•Acute pancreatitis
•Intestinal obstruction
•Ureteral calculus
•Pyelonephritis
Aboubakr Elnashar
58. B. Intrauterine Pregnancy
Exclude by:
1-Clinical Characteristics.
2- Quantitative B sub unit HCG.
3- TVS .
4-Laparoscopy.
5-Curettage
Aboubakr Elnashar
60. S. BHCG levcl Mu/mL
<2000 >2000
Ectopic PRepeat in 2-3 D
Abnormal rise Normal rise IUP
Active
management
Suspected Ectopic Pregnancy
Positive B Qualitative B-HCG 25mu/Ml
No Sac
TVS
IUP
Extr UP
Active
manageme
nt
B HCG level mu/ml
Aboubakr Elnashar
61. Failed IUP
Decreasing
Villi identified No Villi
Rising or
plateauing
FollowHCG until negative
Repeat HCG in 2-3 D
Expectant
Active
management
Suspected Ectopic Pregnancy Cont.
Uterine Curettage
Abnormal S. B HCG rise
Laparoscopy
>2000Mu/mL<2000Mu/mL
Aboubakr Elnashar
63. A. Active B. Expectant
I. Surgical T. II. Medical T.
1. Laparoscopy 2.Laparotomy
Salpingectomy Salpingotomy
Systemic Local
Kim and Fox, 1999Aboubakr Elnashar
66. laparoscopic surgery appears to be the tt of
choice (Cochrane library,2002).
• Compared to open surgery, laparoscopic
conservative surgery was:
*less successful in the elimination of tubal
pregnancy {higher persistence of trophoblast}
*Safe
*comparable intrauterine pregnancy
*less costly
*lower repeat ectopic pregnancy rate.Aboubakr Elnashar
67. A. Salpingectomy:
Indications :
1. Childbearing completed.
2. Second ectopic pregnancy in the same tube.
3. Uncontrolled bleeding.
4. Severely damaged tube (Kim and Fox,1999)
. In the presence of a healthy contralateral tube there
is no clear evidence that salpingotomy should be
used in preference to salpingectomy
(RCOG Recommendations May 2004 “Grade B”)
Aboubakr Elnashar
68. Indications
(RCOG Recommendations,2004 Grade B)
Contralateral tubal disease and desire for
future fertility.
Women must be made aware of the risk of
a further ectopic pregnancy.
Aboubakr Elnashar
69. B. Salpingotomy
Not preferable:
*IU pregnancy rates were similar (salpingotomy 60% vs
54%)
*1. Trend toward lower repeat ectopic pregnancy rates
(salpingeotomy 18% vs 8%).
2. Trend towards higher rates of persistent trophoblast
(RCOG May 2004, Evidence level IIa)
Aboubakr Elnashar
70. Operative Complications: Bleeding from Fallopian
Tube
Occurs during:
salpingotomy or
extraction of ectopic pregnancy.
Prevention:
Careful manipulations.
Injection of petrissin in the mesosalpinx.
Treatment:
Grasping the bleeding point for 5 m with raising of the
tube to kink blood flow
Bipolar coagulation or endocoagulation of bleeding point
Laparoscopic salpingectomy.
Aboubakr Elnashar
71. Indications (Kim and Fox, 1999)
* Hemodynamical unstability.
* Laparoscopic contraindication: obesity or
severe adhesions
* Surgeon is not trained in laparoscopic
surgery
* Necessary laparoscopic equipment is not
available
2. Laparotomy
Aboubakr Elnashar
72. Persistent Trophoblast
Incidence (Graczykowski and Mishell 1997):
5% after laparotomy
10% after laparoscopy
15% after Salpingostomy
Factors that increasing the risk:
1. Higher preoperative serum hCG levels (>3000 iu/l
2. Rapid preoperative rise in serum hCG
3. The presence of active tubal bleeding
(RCOG May 2004 Evidence level IV)
Prophylaxis:
Single dose Methot 1mg/kg
Aboubakr Elnashar
73. Prophylactic Methotrexate:
(Gracia et al,2002)
single dose 1 mg/kg after laparoscopic
salpingostomy:
Reduce
risk of tubal rupture by 90%,
need for additional surgery by 60%,
costs by 46%.
Aboubakr Elnashar
75. Indications of medical treatment:
(Stovall et al 1991,, Gross et al 1995& Alito et al 1999)
1. The Patient:
hemodynamically stable.
Healthy
(SGOPT<50U, creatinine <1.3 mg/ml& WBC >3000mm3)
2. U/S:
Gestational sac <4 cm
No intrauterine pregnancy.
No evidence of rupture (haemoperitoneum)
No fetal cardiac activity
3. HCG:
< 10,000 IU/mL.
Best results when <3,000 (RCOG,2004)Aboubakr Elnashar
76. Women should be given clear information
(preferably written) about the possible need for
further treatment & adverse effects following
treatment.
Women should be able to return easily for
assessment at any time during follow-up
(RCOG, Grade B)
Aboubakr Elnashar
77. 1. Systemic:
A. Single-dose
(50 mg/m2) I.M.
In UK
• The most widely used medical tt
• Serum hCG: checked on days 4 & 7
• Further dose: if hCG failed to fall by > 15%
• Surface area: 4wt+7/wt+90 or from table
• Results:
Success rate: 80-90% (Lipscomb et al, 1998; Morlock, 2000).
15%: require more than one dose .
10%: require surgical intervention.
• cost-effective (Lecuru et al, 2000; Morlock, 2000)
• Side effect: <1 % (Speroff, 1999)
Aboubakr Elnashar
79. Methotrexate in a single dose IM is not effective
enough to advocate its routine use
(Cochrane library,2002).
•Additional injections for inadequately declining serum
hCG concentrations are frequently necessary.
Aboubakr Elnashar
80. Document tubal gestation as defined by BhCG &T.V.S.
I. Ensure the following criteria are met:
BhCG <10,000 mIu/ml
Tubal diameter <3.5 cm
Absence of fetal heart
II. Inform the patient about:
Alternative therapeutic options
Possible side effect
Risk of treatment failure
Prospect of future fertility
III. If medical treatment is chosen:
Day 1: FBC, LFT, KFT, If Rh – Ve, Anti D
Do not start medical treatment if unsatisfactory
If BhCG <5,000 mIu/ml
Single dose methotrexate regimen
If BhCG >5,000 mIu/Ml
Two doses methotrexate regimen
IV. On discharge: Inform patient:
If abd pain {as the pregnancy resolves}: simple analgesia
Avoid intercourse until follow is complete
Contraception for 3 ms.
Avoid herbal remedies &vit preparation containing folate.
Contact ER if concerns regarding pain or bleeding.
Aboubakr Elnashar
81. Single dose methotrexate regimen:
Day 1: Methotrexate 50 mg/m2 I.M.
Day 4: BhCG
Day 7: FBC, BhCG, LFT, KFT
D14: FBC, BhCG
Weekly BhCG unitl BhCG <25 mIu/ml
If BhCG doesn’t fall by more than 15% between D4 –
D7 administer 2nd dose
If 2nd dose is administered:
Day 7: have NL LFT, injection should be given in
opposite gluteal.
Day 11: BhCG
Day 14: FBC, BhCG, LFT, KFT
Aboubakr Elnashar
82. Two doses methotrexate regimen:
Day 1: Methotrexate 50 mg / m2 IM
Day 4: Methotrexate 50 mg / m2 IM other gluteal BhCG
Day 7: BhCG, FBC, LFT, KFT
Weekly BhCG until BhCG <25 mIu/ml
If BhCG doesn’t fall by more than 15% between day 4 –
day 7 administer Methotrexate on day 7 and day 11
Day 11: BhCG
Day 14: BhCG, LFT, KFT, FBC
Aboubakr Elnashar
83. 2. Local:
A. Laparoscopic
B. Transvaginal
There is no place for local methotrexate under
laparoscopic guidance (Cochrane library,2002):
1.less effective than laparoscopic salpingostomy in
the elimination of tubal pregnancy.
2. The risks of anesthesia and trocar insertion
Aboubakr Elnashar
84. • Compared to laparoscopic adminstration of
methotrexate, transvaginal administration of
methotrexate under sonographic guidance is:
1- less invasive and
2- More effective
3- Requires visualization of an ectopic gestational
sac and specific skills and expertise of the clinician.
Aboubakr Elnashar
86. Indications (RCOG, 2004 Grade C)
1. Patient:
Clinically stable or asymptomatic
2. US:
Unruptured mass <4 cm
3. HCG:
Initially < 1000 iu/l
Decreasing level
Clear information (preferably written) about the
importance of compliance with follow-up
Should be within easy access to the hospital
treating them.
Aboubakr Elnashar
87. Follow up:
1. HCG:
Twice weekly (< 50% of its initial level within 7d)
Then weekly until < 20 iu/l
2. TVS: weekly (reduction in the size) .
Indication of active intervention
(RCOG 2004)
If symptoms of ectopic pregnancy occur
Serum hCG levels rise above 1000 iu/l
Levels start to plateau.
Aboubakr Elnashar
88. Results:
25% can be managed expectantly.
70% of this will avoid surgery (Ylostalo et al, 1992;
Speroff et al, 1999)
The long term outcome is similar to that with active
treatment (Rantala/Makinen, 1997).
Aboubakr Elnashar
89. The 18- month cumulative rate
of IU Pregnancy (Bouyer et al 2000)
Salpingectomy * 57
Salpingostomy
Salpingotomy
Methotrexate (systemic)
% of IUP
}* 73
80
P < 0.01
* Pregnancy was very similar if there is no fertility factor
Aboubakr Elnashar
90. Anti-D immunoglobulin
(RCOG,2004 Grade B)
Nonsensitised women who are rhesus negative with
a confirmed or suspected ectopic pregnancy should
receive anti-D (50 µg)
Aboubakr Elnashar