2. Introduction
• Ectopic pregnancy is a pregnancy in
which the developing blastocyst
becomes implanted at a site other
than the endometrium of the
uterine cavity.
• The fallopian tube is the most
common location of ectopic
implantation, accounting for more
than 90% of cases.
3. Sites of Implantation
• Ampulla - 70%
• Isthmus – 12%
• Fimbria – 11%
• Interstitial tubal pregnancies – 2%
• The remaining 5 percent of nontubal
ectopic pregnancies implant in the
ovary, peritoneal cavity, cervix, or
prior cesarean scar.
4. Epidemiology
• According to the Centers for Disease Control and Prevention,
ectopic pregnancy accounts for approximately 2% of all
reported pregnancies.
• Implantation elsewhere accounts for 0.5 to 1.5 percent of all
first-trimester pregnancies in the United States.
• The prevalence of ectopic pregnancy among women presenting
to an emergency department with first-trimester vaginal
bleeding, or abdominal pain, or both, has been reported to be
as high as 18%
5. Risk Factors
• The major cause of
ectopic pregnancy is
disruption of normal tubal
anatomy from factors
such as infection, surgery,
congenital anomalies, or
tumors.
• The highest risk is
associated with a history
of prior ectopic pregnancy
or tubal surgery (10% of
patients)
IVF or ART STI/PID
Peritubal
Adhesions
Pregnancy
with IUD
Smoking
6. Evolution
• With tubal pregnancy, because the
fallopian tube lacks a submucosal layer,
the fertilized ovum promptly burrows
through the epithelium.
• the zygote comes to lie near or within the
muscularis, which is invaded by rapidly
proliferating trophoblast.
• The embryo or fetus in an ectopic
pregnancy is often absent or stunted.
Outcomes
Pregnancy Failure
with regression
Tubal Abortion
Tubal Rupture
7. Clinical Manifestations
• The most common clinical presentation of ectopic pregnancy is first-
trimester vaginal bleeding and/or abdominal pain
• typically appearing six to eight weeks after the last normal menstrual
period
• Vaginal Bleeding – ranges from scant to hemorrhage, is intermittent,
follows a period of amenorrhea
• Abdominal Pain – diffuse or unilateral lower pelvis, Tubal rupture may
be associated with an abrupt onset of severe pain, but rupture may
also present with mild or intermittent pain.
8. Diagnosis
Confirm Pregnancy
by Hx (LMP) and
BhcG
Assess for Rupture
and Shock
(Hypotension,
Tachycardia,
Peritonitis)
Determine
Location of
Pregnancy with
TVUS
Assess Progress of
Pregnancy with
serial BhcG and
Repeat TVUS
9. Investigations
• Initial CBC – Anaemia, Serial Hb can be used to monitor for subclinical rupture
• FAST- Can be used to assess for free fluid in the abdomen of a patient in shock;
suspecting rupture
• Initial hCG –Used to confirm Pregnancy and can be used to rule out IUP when
combined with TVUS
• Trans-Vaginal Ultrasound – Can detect an IU Gestational Sac as early as GA 5
weeks
• Serial hCG - taken every 48 – 72hrs, used to track the progress of pregnancy and
therapy response.
• Diagnostic Laparoscopy
• Progesterone — Serum progesterone concentrations are higher in viable IUPs
than in ectopic pregnancies
10. Serum Human Chorionic Gonadotropin
Measurement
• serum hCG values alone should not be used to diagnose an ectopic
pregnancy and should be correlated with the patient’s history,
symptoms, and ultrasound findings.
• lower limits of detection are 20 to 25 mIU/mL for urine and 5 mIU/mL
for serum
• A positive hCG test confirms the presence of a pregnancy (IUP, PUL,
Ectopic, Molar)
11. hCG Discriminatory Zone
• hCG Discriminatory Zone – minimum hCG level at which an IUP can
be visualized by TVUS, ACOG recommends >/= 3510mUI/L
• If the initial hCG level exceeds the set discriminatory level and no
evidence for an IUP is seen with TVS, then ectopic pregnancy is a
concern.
• The diagnosis is narrowed in most cases to a failing IUP, a recent
complete abortion, or an ectopic pregnancy.
• If <3510mUI/L with no TVUS findings, repeat every 48 hours in a
stable patient.
12. Serial hCG Monitoring
hCG is Rising
Normally
• >35% in 48 hrs or
Doubling in 72hrs
= Advancing
Pregnancy
• Repeat until
>3510mUI/L then
TVUS
hCG is Rising
Abnormally
• Slow rising or
plateau after 3
serial hCG = Failing
IUP vs Ectopic
• Repeat TVUS or
Diagnostic Uterine
Aspiration
hCG is Decreasing
• Associated with
Failing Pregnancy
• Spontaneous AB,
Tubal AB or
Resolving Ectopic
• Weekly hCG until
undetectable
13. Management
• Approach to a patient with an Ectopic Pregnancy is based on location
of Pregnancy, hemodynamic stability, hCG trend, and TVUS findings as
well as future fertility concerns.
• Management is as follows
• Conservative/ Expectant
• Surgical
• Medical
14. Expectant Management
• The indication for expectant management of
ectopic pregnancy is a suspicion of ectopic
pregnancy in a woman who meets the selection
criteria for expectant management.
• Involves close follow up with weekly hCG
monitoring until levels are <5mUl/L
• Switch to Active Management if
• hCG levels stop declining or isnt <5mUI/L at 10
weeks
• Increasing Abdominal Pains or Hemodynamic
instability
Criteria for Expectant Management
of Ectopic Pregnancy
Asymptomatic
Understand Risks associated with
Ectopic Pregnancy
Able to access emergency and
surgical care rapidly
Willing to Follow Up Closely and
Comply
TVUS does not show GS or Adnexal
Mass
hCG <200mUl/L and declining
15. Medical Therapy
• Pharmacologic therapy is the
preferred treatment for ectopic
pregnancy, and Methotrexate (MTX)
is the main agent used.
• Pre-Treatment Testing – CBC, RFTs,
LFTS, Must rule out Viable IUP
Criteria for MTX use in Ectopic Pregnancy
Hemodynamically stable
No Contraindications to MTX use (
Immunosuppression, PUD, Renal
Impairment, Breast Feeding)
Serum hCG Levels < 5000mUl/L
No Fetal Heart activity on TVUS
Able to Comply with close monitoring and
Follow Up
Rapid Access to Surgical Care
+/- Ectopic Mass < 3-4cm
16. Methotrexate Therapy
• Treatment of ectopic pregnancy uses an intermediate MTX dose (50
mg/m2 or 1 mg/kg).
• reduced folates can be given in combination with MTX to bypass the
metabolic block thus rescue normal cells from toxicity.
• Single Dose vs Multi-Dose Protocols
• The overall rate of resolution of ectopic pregnancy reported in the literature is
approximately 90 percent for both single- and multiple-dose protocols
• Single Dose is preferred due to reduced cost and simplicity
• However, 20% of patients may require a second dose of MTX
17.
18.
19. Medical Therapy
• Mild to moderate abdominal pain of short duration (one to two days)
at six to seven days after receiving the MTX is common.
• The pain may be due to tubal abortion or tubal distention from
hematoma formation and can usually be controlled with Panadol or
NSAIDs
• A patient with severe pain should be further evaluated with
transvaginal ultrasonography.
20. Surgical Management
• Laparoscopy is the preferred surgical treatment for ectopic pregnancy
unless a woman is hemodynamically unstable.
• Salpingostomy — consists of making an incision in the fallopian tube and
removing the ectopic gestation.
• Salpingectomy - Total or partial salpingectomy may be performed for the
tube with the ectopic gestation.
• The decision for partial versus total salpingectomy depends upon the
patient's age, whether she has one or two tubes, the condition of the tube,
and plans for future fertility.
• Open Laparotomy with Salpingectomy is preferred in ruptured Ectopic
tubal with shock.
21. Follow Up
• Patients who receive Surgical Management should have weekly hCG
measurements until undetectable.
• If the hCG level does not decline with each measurement or does not
reach an undetectable level within a reasonable time period, treat
with methotrexate.
• The regimen of methotrexate is the same as for primary medical
treatment of ectopic pregnancy.
• Future Fertility = tubal damage is associated with a decreased rate of
future pregnancy compared with controls with normal-appearing
tubes (pregnancy rate 42 and 79 percent, respectively)
22. References
• ACOG Practice Bulletin No. 191. (2018). Obstetrics & Gynecology, [online]
131(2), pp.e65-e77. Available at: https://www.acog.org/Clinical-Guidance-
and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-
Gynecology/Tubal-Ectopic-Pregnancy?IsMobileSet=false.
• Cunningham, G., Leveno, K. and Gilstrap, L. (2005). Williams Obstetrics
(22nd Edition). Blacklick, USA: McGraw-Hill Professional Publishing.
• Uptodate.com. (2020). UpToDate; Ectopic Pregnancy. [online] Available at:
https://www.uptodate.com/contents/ectopic-pregnancy-choosing-a-
treatment [Accessed 1 Jan. 2020].
