بسم ال الرحمن الرحيم
KHARTOUM NORTH TEACHING HOSPITAL
Ectopic Pregnancy is one of the direct causes of maternal death, and
is an important cause of maternal mortality in the 1st trimester. It is the 8th
out 129 direct causes of maternal death in UK. It accounts for 9% of all
Previously, it was 1 per 150 mature birth in UK, but the incidence is
rising all over the world. It has increased from 4.9/1000pregnancies up to
9.6/1000, but the case fatality rate has decreased. It has high incidence in
races other than white.
It is defined as pregnancy occurring outside the endometrial lining of
1) 95% occur in the tubes: the commonest site is the Ampulla,
followed by the Isthmus.
2) The uterus:
IV. Rudimentary Horn
3) The Ovary.
4) Broad Ligament
I. Primary: first implantation occurs in a peritoneal
II. Secondary: original implantation occurs first in the
tube-ostia, aborted subsequently then reimplanted
into a peritoneal surface.
6) Multiple Ectopic: may occur:
a) Involving both tubes
b) Combined intra- & extra-uterine pregnancy
(Heterotopic Pregnancy): accounts for 1 in 4000 to 1
in 7000 pregnancies.
3. previous Ectopic
4. Abdominal Surgery
5. Congenital tubal abnormalities
6. Assisted Reproductive Technology
7. Salpingitis Isthmica Nodosa
8. Endometriosis & lieomyomata
9. Diethyl Stilbesterol (DES)
Inflammation and infection may cause damage of the tube without
Sexually Transmitted Diseases, mainly Chlamydia Trachomatis
infection, are common and major cause of PID. Difficulties occur in
diagnosing C. trachomatis due to its obligate intracellular life cycle
which makes lab. Isolation and diagnosis difficult.
Gonococcus and Tuberculosis infection.
in form of IUD Progesterone and Progesterone Only pills. Women
who use IUDs are 6 to 10 times more likely to suffer Tubal pregnancy.
Minipills and Subdermal implants (Norplant) protect against both
intrauterine and Ectopic pegnancy when compared with no
contraception, but if pregnancy occurs, the chance of it being ectopic is
10% with minipills and 30% in Norplant.
~Ectopic Pregnancy was also reported after Emergency contraception
1. Tubal Repair or reconstruction to correct obstruction-Lyses of
2. Sterilisation: this depends on the method used:
Site of tubal occlusion.
Residual tube length.
Associated conditions, e.g.: infection.
CONGENITAL ANOMLIES OF THE TUBES:
o Accessory Ostia
o Congenital anomalies of the cilia,e.g.: Young Syndrome and
o Ovarian Cystectomy
o Wedge resection.
This results in Peritubal scarring (adhesions interfere with
passage of the ovum).
IVF accounts for 10-15% of Ectopic pregnancy.
SALPINGITIS ISTHMICA NODOSA:
It is non inflammatory pathological condition of the tubes in which the
tubal epithelium extends into the myosalpinx and forms a true
diverticula. These diverticulae interfere with the myometrial electrical
activity over the divrticula.
Exposure in utero causes tubal hypoplasia.
Includes the following:
Smoking: strongly associated with : Abruptio Placentae;
Placenta Previa; and Ectopic pregnancy. Smokers have 2 times
higher than non-smokers. Smoking affects the cilia in the
nasopharynx as well as the cilia of the genital tract.
Multiple sexual partners.
Early age of first intercourse
Most likely reason for Ectopic pregnancy is delay in passage of the
fertilized ovum down the tube due to damaged ciliated epithelium and
peristaltic activity of myosalpinx.
Implantation occurs in the muscle and connective tissues next to the
tubal serosa. There a decidual reaction (Areas Stella Phenomenon).
Hematoma is frequently seen surrounding the distal end of the tube.
Hemoperitoneum nearly always occur.
♣ About 75% of patients present with subacute symptoms, while
25% or less present with acute abdomen.
♣ Symptoms: the TRIAD of:
1. abdominal pain
2. irregular menses
3. followed by vaginal bleeding or brown discharge ±
♣ The vaginal bleeding is due to shedding of the decidua or decidual
cast when pregnancy fails.
♣ The diagnosis of Ectopic pregnancy is overshadowed by a wide
spectrum of clinical presentations ranging from acute abdomen to
hemodynamic shock. Therefore, it requires a high degree of
suspicion specially in areas where the prevalence of Ectopic
pregnancy is high, like in Sudan.
♣ This depends on history and examination.
♣ The presentation may be : Acute; Subacute; or Chronic
⇒ ACUTE PRESENTATION:
In women with tubal rupture.
There will be acute abdominal pain and cardiovascular
Pain is typically referred to shoulder tip or interscapular
region due to irritation of the diaphragm by blood (this may be
provoked by raising the foot of the bed-Kehr sign).
o Shock: tachycardia+hypotension
o Peritoneal irritation
o PV.: cervix soft, uterus enlarged, Excitation Test +ive.
⇒ SUBACUTE PESENTATION:
1. abdominal pain localized to one of the iliac fossae.
2. delayed menstruation
3. episodes of vaginal bleeding
signs of peritoneal irritation are less marked than in the acute
⇒ CHRONIC PRESENTATION:
There is usually history of PID→infertility.
Irregular vaginal bleeding
On-and-Off abdominal pain.
Patient is Hemodynamically Stable.
URINE FOR PREGNANCY TEST:
This is the standard test, it is 99% specific and 99% sensitive. It is
mainly a qualitative rather than a quantitative.
SERUM HCG DOUBLING TIME:
Usually in chronic cases. HCG Doubling time can differentiate an
Ectopic pregnancy from an intrauterine one. Normal pregnancy
causes HCG level to rise by 66% in 48hr.
If the serum HCG level is rising but the douling time is increased
then the likelihood of an extrauterine pregnancy is high.
Most omen with an HCG half life more than 7 days have an Ectopic
SERIAL PROGESTERONE ESTIMATIONS:
The mean serum level of progesterone in patients with Ectopic
pregnancy is lower than in those with normal pregnancy. In normal
viable intrauterine pregnancy the level is 25ng/ml, wile in Ectopic
pregnancy it is less than 5ng/ml.
OTHER ENDOCRINE & PROTEN MONITORS:
1) MATERNAL SERUM CREATININE KINASE LEVEL:
significantly higher in all patients with tubal pregnancy when
compared to missed abortion and normal pregnancy.
2) PREGNANCY ASSOCIATED PLASMA PROTEIN C
(PAPPC)- SCHWANGER CHAFT’S PROTEIN: this is a β-
glycoproteinproduced by syncytiotrophoblasts, its level is low
in Ectopic pregnancy.
3) RELAXIN: is a hormonal protein produced by the corpus
luteum of pregnancy. It is signicantly lower in Ectopic
pregnancy and spontaneous abortion. A single reading of
33pg/ml excludes Ectopic pregnancy.
4) MATERNL SERUM α-FETO-PROTEIN: elevated in Ectopic
5) C-REACTIVE PROTEIN: is low in Ectopic pregnancy, but
high in infections like PID (enables differentiation).
includes the following:
Trans-Vaginal Scan: shows the following:
♦ Empty uterine cavity.
♦ In live Ectopic:intact tubal ring with a heart action
(in 20% of cases).
♦ In tubal abortion: pooly defined tubal ring ±fluid in
the pouch of Douglas.
♦ In ruptured Ectopic: fluid in the pouh of Douglas.
Trans-Abdominal Scan: may show:
♦ Life embryo in the adenexae (in 10% of cases).
♦ Pseudo-gestational sac in the uterus.
♦ Empty uterus ± adenexal sac ± fluid in the pouch
♦ The purpose is to find non-clotted blood
♦ METHOD: apply bivalve speculum, grip the posterior
cervical lip with a volsellum, then the pouch of Douglas
(Cul De Sac) is entered via the posterior vaginal fornix
by a needle through which the intraperitoneal content is
♦ This is the gold standard for diagnosis and treatment of
♦ The tubes are easily visualized and evaluated: Ectopic
pregnancy distorts the normal tube architecture.
♦ Small ectopics may be missed.
DEPENDS ON THE PRESENTATION:
ACUTE PRESENTATION - RESUSCITATION:
2 wide bore cannulae
Immediate IV fluids and blood as necessary.
As soon as possible: Video-Laparascopy or Lparatomy
should be done followed by Simple Salpingectomy with
conservation of the ovaries.
SUBACUTE & ASYMPTOMAIC PRESENTATION:
I. If the Δ is made BEFORE TUBAL RUPTURE:
it may be treated medically with methotrexate or by local
injection of drugs by laparscopy via tranvaginal or
transcervical tubal canulation.
II. Laparoscopic Surgery in both Ruptured & Intact Ectopic:
# Major contraindications to this are:
1. Massive intra-abdominal adhesions
2. Massive bleeding.
# Advantages include:
a) Reduced operating time
b) Reduced hospital stay
c) Reduced cost
d) Early return to activity
e) Cosmetically acceptable
III.Linear Salpingotomy: when the tube’s is intact. The tube
is left open after incision to heal by secondary intension.
IV.Fimbrial Evacuation: ONLY if pregnancy already is
aborting through the tube.
V. Radical Surgery (Salpingectomy without corneal resection
± Oopherectomy): in case of irreparably damaged tube
with heavy bleeding. After this procedure the rate of
intrauterine pregnancy is 45% and of repeated Ectopic is
ABDOMIAL ECTOPIC PREGNANCY:
It is a rare condition with high maternal mortality.
It is always secondary to implantation of a primary tubal
If the fetus died & and retained: it may become infected or
calcified(Lithopedion) or it may form a fatty mass
In most cases the fetus should be delivered in which case
the placenta should left to avoid hemorrhage.
OVARIAN ECTOPIC PRGNANCY:
Is the commonest Extra-Tubal Ectopic.
Early on, it may confused with the corpus luteum.
a. Wedge resection of that part of the ovary containing
b. Laser therapy
d. Use of Methotrexate.
Very rare, 0.1%of all cases.
U/S shows an empty uterus with Hour-Glass appearance of
Treatment: Suction Curettage after vascular ligation by
Implantation occurs in an Atretic horn of a Bicornate Uterus.
Implantation occurs in the myometrium.
Occurs in cases of;
1. Women who had uterine perforation
2. After IVF.
Combination of intra- & extra-uterine pregnancy.
More common now after IVF-ET.
Up to 75% of intrauterine ones reach term.
Treatment of the Ectopic one is: injection of Potassium
Chloride or Methotrexate.