It's helpful for learning ectopic pregnancy.

1. ECTOPIC
PREGNANCY

2. DEFINITION
• “Any pregnancy where the fertilised ovum gets
implanted & develops in a site other than
normal uterine cavity”.
It represents a serious hazard to a woman’s health and reproductive
potential, requiring prompt recognition and early aggressive
intervention.

7. Risk factor #1
• History of pelvic infection is the most common risk factor for
ectopic pregnancy folds increases the risk, due to destruction of the
fallopian tubes. Chlamydia (a common sexually transmitted disease) and
Gonorrhea are both able to grow within the fallopian tubes and cause-
tremendous damage to the endosalpinx (lining of the inner tubal lumen) 2-
agglutination (sticking together) of the mucosal folds in the tube 3-
peritubal adhesions (scar tissue)
The risk of an ectopic pregnancy is greater when the woman with the
infection is younger. Other pelvic or lower abdominal infections can also
result in pelvic adhesions and an increase in the ectopic pregnancy rate (such
as appendicitis).The chances of another ectopic in the same fallopian tube
also in the other tube are increased 5x

8. Risk factor #2
History of surgery on the fallopian tubes or within the
pelvis:Tubal ligation in the past 2 years, When a bilateral tubal ligation
(tubes tied) is followed by either an unexpected pregnancy (failed tubal
ligation) or is "reversed" with a tubal reanastomosis (tubal
reconstruction) there is an increased risk of a tubal ectopic pregnancy.
When a woman has a history of pelvic surgery that is associated with
significant adhesion formation (such as myomectomy) there is also an
increased risk of an ectopic pregnancy.

9. Risk factor #3
• Prior history of ectopic pregnancy. When an ectopic pregnancy
in the fallopian tube is treated conservatively (by preserving the
tube), there is a roughly 10 fold increase the risk of recurrence in the
same tube.

10. Risk factor #4
• History of IUD use. The use of an IUD is a classic "risk factor" for
ectopic pregnancy. Actually, all but the progesterone containing IUDs
are relatively protective against ectopic pregnancy while the IUD is in
place. That is, the number of ectopic pregnancies in women using an
IUD for contraception is about one half that of women using no
contraception. However, of IUD pregnancies there is a greater chance
of an ectopic location (3-4%) since the number of intrauterine
pregnancies with an IUD in place is markedly reduced.

11. Risk factor #5
• History of destruction of the uterine cavity or lining. Such as history
of uterine synechiae (scar tissue) from previous surgery (like
endometrial ablation for dysfunctional bleeding ) or presence of
multiple submucosal fibroid tumors this cause a larger percentage of
the pregnancies to implant in a space other than the uterine cavity.
Similar to the situation with IUDs, the total ectopic pregnancy rate
may not be increased but when a pregnancy does occur the reduced
likelihood of an intrauterine pregnancy increases the relative
percentage of ectopic pregnancies.

12. Risk factor #6
• History of non-infectious pelvic inflammation (endometriosis,
foreign body). Inflammation of the delicate tubal structures can result
in adhesion formation (scar tissue), which will then increase the risk
of an ectopic pregnancy.
• This inflammation may be due to endometriosis or the presence of a
foreign body, either of which are strongly associated with scar tissue
formation.

13. Risk Factor #7
Use of assisted reproductive technology (such as IVF (in vetro
fertilization) and GIFT (gamete intrafallopian transfere). When multiple
embryos or gametes are placed into the uterus or the fallopian tubes,
the risk for multiple pregnancy rises significantly. The risk of twins and
heterotopic pregnancy is generally thought to be about 1 / 30,000
pregnancies . With ARTs the rates of ectopics and dizygotic twins have
increased to 1/10,000 . The incidence of heterotopic pregnancy may
increase to as frequently as 1 /100 pregnancies.

14. Tubal pregnancy
• Pathophysiology. The trophoblast develops in the fertilized ovum
and invades deeply into the tubal wall. Following implantation, the
trophoblast produces hCG which maintains the corpus luteum. The corpus
luteum produces oestrogen and progesterone which change the secretory
endometrium into decidua. The uterus enlarges up to 8 weeks and
becomes soft. The tubal pregnancy does not usually proceed beyond 8-
10weeks 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.
• Separation of the gestational sac from the tubal wall leads to its
degeneration, and fall of hCG level, regression of the corpus luteum and
subsequent drop in the oestrogen and progesterone level.This leads to
separation of the uterine decidua with uterine bleeding

15. Fate of tubal pregnancy
• 1- Tubal mole: The gestational sac is surrounded by a blood clot and
retained in the tube. This may remain for long period in the tube and
forms so called (chronic ectopic pregnancy),or they may be gradually
absorbed (involution)
• 2-Tubal abortion: This occurs more if ovum had been implanted in
the ampullary portion of the tube. Separation of the gestational sac is
followed by its expulsion into the peritoneal cavity through the tubal
ostium. Rarely, reimplantation of the conceptus occurs in another
abdominal structure leads to secondary abdominal pregnancy.

17. Tubal Abortion

18. Tubal rupture
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. Usually profuse bleeding occurs intraperitoneal
haemorrhage. If rupture occurs in the mesenteric border of the tube,
broad ligament haematoma will occur

19. Clinical Features

23. SIGNS :
• General examination: signs of early pregnancy (Breast tenderness,
nausea and vomitig, change of apettite) … Weakness, pallor, hypotension
and tachycardia, tachypnoea due to bleeding.
• Abdominal examination: Lower abdominal tenderness and rigidity
especially on one side may be present.
• Vaginal examination. Bluish vagina and bluish soft cervix. Uterus is
slightly enlarged and soft. Marked pain in one iliac fossa on moving the
cervix from side to side. Defined tender mass may be detected in one
adnexa in which arterial pulsation may be felt. Speculum or bimanual
examination should not be performed unless facilities for resuscitation are
available, as this may induce rupture of the tube.

24. DIAGNOSIS:
• Hormonal assay. Serum β-Hcg. Urine pregnancy tests are positive in only
50-60% of ectopic. Detection of β-hCG in the serum by ELISA or
radioimmunoassay are more sensitive and can detect very early pregnancy
about 10 days after fertilization i.e. before the missed period.
• If the test is negative (generally less than 5 IU/L), normal and abnormal
pregnancy including ectopic are excluded.
• If the test is positive , and doubles every 36-48 hour till reaching 1500 IU/L
which is The threshold of discrimination for intrauterine pregnancy, this
indicates a normal intrauterine pregnancy, An abnormal rise in blood β-
hCG levels may indicate an ectopic pregnancy and ultrasonography is
indicated.

25. DIAGNOSIS
• The second most common hormone after hCG in pregnancy is
progesterone. Generally, a progesterone concentration of greater
than 25 ng/ml is highly correlated with a normal intrauterine
pregnancy while a concentration of less than 5 ng/mL is highly
correlated with an abnormal and nonviable pregnancy

26. DIAGNOSIS
• 2 - Ultrasound scan. In general, a positive β-hCG test with empty
uterus by sonar ± adnexial mass indicates ectopic pregnancy.
Diagnosis of ectopic pregnancy is made if there is: An empty uterine
cavity by abdominal sonography with b -hCG value above 6000
mIU/ml. An empty uterine cavity by vaginal sonography with b -hCG
value above 2000 mIU/ml.

28. DIAGNOSIS
• Culdocentesis. in this test, a needle is inserted into the space at the
top of the vagina, behind the uterus and in front of the rectum to
aspirate fluid and Determines if there is blood in the space behind the
uterus. If non-clotting blood is aspirated from the Douglas pouch ,
intraperitoneal haemorrhage is diagnosed. But if not, ectopic
pregnancy cannot be excluded.

30. DIAGNOSIS
• Laparoscopy or laparotomy can also be performed to visually confirm
an ectopic pregnancy. Often if a tubal abortion or tubal rupture has
occurred.
Laparoscopy: an endoscope is inserted through a small incision in the
woman’s abdomen.This allows you to see the fallopian tubes and other
organs. This takes place in an operating room with anaesthesia.

32. Uncommon Sites of Ectopic Pregnancy
• 1-Cornual angular pregnancy
• 2-Pregnancy occurs in the blind rudimentary horn of a bicornuate
uterus.
• 3-Cervical pregnancy
• 4-Ovarian pregnancy
• 5-Abdominal (peritoneal) pregnancy

33. Cornual angular pregnancy
• It is implantation in the interstitial portion of the tube.It is uncommon
but dangerous because when rupture occurs bleeding is severe and
disruption is extensive that needs hysterectomy. In some cases, the
pregnancy is expelled into the uterus and rupture does not occur.

34. Pregnancy in a rudimentary horn
• Pregnancy occurs in the blind rudimentary horn of a bicornuate
uterus. As such a horn is capable of some hypertrophy and distension,
rupture usually does not occur before 16-20 weeks.

35. Cervical pregnancy
• Implantation in the substance of the cervix below the level of uterine
vessels. May cause severe vaginal bleeding. Can be diagnosed by
trans vaginal ultrasound

36. Ovarian pregnancy
• Criteria for diagnosis of ovarian pregnancy:
• * The gestational sac is located in the region of the ovary,
• * the ectopic pregnancy is attached to the uterus by the ovarian
ligament,
• * ovarian tissue in the wall of the gestational sac is proved
histologically,
• * the tube on the involved side is intact.

37. Abdominal (peritoneal) pregnancy
• Types: Primary: implantation occurs in the peritoneal cavity from the start.
• Secondary: usually after tubal rupture or abortion
- Intraligamentous pregnancy: is a type of abdominal but extraperitoneal pregnancy. It
develops between the anterior and posterior leaves of the broad ligament after rupture of
tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the
myometrium) pregnancy.
Abdominal (peritoneal) pregnancy. Diagnosis: History: of amenorrhoea followed by an
attack of lower abdominal pain and slight vaginal bleeding which subsided spontaneously.
Abdominal examination: Unusual transverse or oblique lie. Fetal parts are felt very
superficial with no uterine muscle wall around. Vaginal examination: The uterus is soft,
about 8 weeks and separate from the fetus. No presenting part in the pelvis.
• Abdominal (peritoneal) pregnancy Special investigations: Plain X-ray: shows abnormal
lie. In lateral view, the fetus overshadows the maternal spines .Ultrasound: shows no
uterine wall around the fetusMagnetic resonance imaging (MRI): has a particular
importance in preoperative detection of placental anatomic relationships.

39. Treatment
 Watchful waiting if – asymptomatic
- detected eary
 Methotrexate – inhibits rapidly dividing cells, can stop proliferating of
ectopic pregnancy in some cases
 Surgical treatment – usually performed emergency – laparoscopic
- laparotomy
- Salpingectomy (all fallopian tube removes)
- Salpingostomy (part of fallopian tube removes)

40. COMPLICATIONS:
 Rupture of ectopic pregnancy – shock
 Reccurent ectopic pregnancy
 Metotrexate side effects (dizziness, headache, swollewen gums,
reddened eyes and others)
 Surgical complications