2. DEFINITION
“Any pregnancy where the fertilized ovum gets implanted & develops in a site
other than normal uterine cavity”.
Ectopic pregnancy is accounted for 2% of all pregnancies, and is the most
common cause of maternal death during the first trimester (usually week 6-8
of pregnancy )
It represents a serious hazard to a woman’s health and reproductive
potential, requiring prompt recognition and early aggressive intervention.
3. Sites:
1-Fallopian tubes in 95% of the cases -Ampulla ( most common site) which is the
widest part ( 5-6 cm)
-Isthmus
-Fimbria
2-Uterine Cornua or uterine horns. Which is the meeting point of the uterus and
the fallopian tubes. This site of ectopic pregnancy is the most dangerous of all due
to the high risk of rupture. This case needs around 10 weeks to appear.
3- Cervical Implantation ( 0.2%)
4- Ovarian Implantation (0.2%)
5- Abdominal Implantation (2%) This type may reach term.
4.
5. Risk factors
1-The most important risk factor is previous history of ectopic pregnancy.
(30% risk of recurrence)
2-Pelvic inflammatory disease (PID) and STD infections
Any Assisted Reproductive techniques (ART) for eg, IVF
History of any pelvic or tubal surgeryHistory of any pelvic or tubal surgery
Contraceptive methods like Intrauterine device (IUD) .
Smoking.
Any congenital malformations of the tubes or the uterus
6. Signs and symptoms
The classic clinical triad of ectopic pregnancy is as follows:
Abdominal pain
Amenorrhea
Vaginal bleeding
Unfortunately, only about 50% of patients present with all 3 symptoms.
7. Patients may present with other symptoms common to early pregnancy (eg,
nausea, breast fullness). The following symptoms have also been reported:
Painful fetal movements (in the case of advanced abdominal pregnancy)
Dizziness or weakness
Fever
Flulike symptoms
Vomiting
Syncope
Cardiac arrest
8. The presence of the following signs suggests
a surgical emergency:
Abdominal rigidity
Involuntary guarding
Severe tenderness
Evidence of hypovolemic shock (eg, orthostatic blood pressure changes,
tachycardia)
9. Findings on pelvic examination may include
the following:
The uterus may be slightly enlarged and soft
Uterine or cervical motion tenderness may suggest peritoneal inflammation
An adnexal mass may be palpated but is usually difficult to differentiate from
the ipsilateral ovary
Uterine contents may be present in the vagina, due to shedding of
endometrial lining stimulated by an ectopic pregnancy
10. INVESTIGATIONS:
Serum β-HCG levels
In a normal pregnancy, the β-HCG level doubles every 48-72 hours until it
reaches 10,000-20,000mIU/mL. In ectopic pregnancies, β-HCG levels usually
increase less. Mean serum β-HCG levels are lower in ectopic pregnancies than
in healthy pregnancies.
No single serum β-HCG level is diagnostic of an ectopic pregnancy. Serial
serum β-HCG levels are necessary to differentiate between normal and
abnormal pregnancies and to monitor resolution of ectopic pregnancy once
therapy has been initiated.
11. *Progesterone level - greater than 20 micrograms/ml indicates good
pregnancy and
less than 5 micrograms/ml is a bad indicator ( ectopic or abortion)
Anything in between 5-20 microgram/ml is a grey zone and not indicative.
-Ultrasound imaging: it is usually inconclusive but the U/S findings
suggestive of ectopic preg;
- ABSENT intrauterine sac and the presence of ectopic sac
- complex adnexal mass
-Free fluid in cul de sac ( ruptured ectopic pregnancy)
VALUES of discriminatory beta HCG:
On ABDOMINAL U/S 6,000-6,500 m IU/ml
On Transvaginal U/S 1,500-1,800 m IU/ml
13. Differential diagnosis:
Differential diagnosis of first trimester bleeding :
-Ectopic pregnancy
-Recent Abortion
-Molar pregnancy
the symptomatic picture of ectopic pregnancy:
Appendicitis, salpingitis, ruptured corpus luteum…
14. Management:
The method of management depends greatly on the hemodynamic stability of
the patient, so the vital signs indicates instability (hypotension) or decreased
level of consciousness or life threatening bleeding Laparotomy is indicated.
observation:
Indicated when: the patient is stable without any significant bleeding or pain/
the site of implantation is the tube/ size of gestational sac< 4 cm , FALLING
beta HCG levels .
15. Medical management
(METHOTREXATE):
If the patient is stable, no IUP ,gestational sac < 3.5 cm and no FHA, but suffering of
significant pain or bleeding, METHOTREXATE is the drug of choice.
MTX is an antimetabolite (folate antagonist). Usually, it is given as a single shot at a
dose of 50
mg/m2 IM. Then Beta HCG is followed after 3-7 days a drop in the levels of beta HCG
of about 15% indicates successful treatment.
Beta HCG levels should be followed up till levels are 0-5.
If serum levels were in plateau or the drop was less than 15%, a second dose of MTX
should be given after 2 weeks.
However if the level increased or if the patient became symptomatic, Surgery is
indicated.
16. Surgical Management:
It is indicated if the patient was hemodynamically unstable (laparotomy) or failure of
medical treatment, or if FHA is present, or gestational sac size is > 4cm. If the patient is
stable, but has one of these indications, laparoscopy is done.
Salpingectomy; removal of the tube. no need for follow up of beta HCG levels.
Salpingostomy; Incision on the antimesentric portion of the tube is made, then after
removal of products of conception, the tube is sutured. Used for unruptured distal tube
ectopic preg.
Salpingotomy : The same procedure as salpingostomy however the incision is not sutured
and is left to heal by secondary intention.
In Salpingostomy and salpingiotomy, beta HCG levels should be followed up as in medical
treatment. ( till levels are 0-5 )
17. Contraindications of Methotrexate:
-Unstable patient
Beta HCG levels > 5,000
-Fetal heart activity or any intrauterine pregnancy evidence
-free fluid in cul de sac ( indicating ruptured ectopic preg. )
-Active Peptic ulcer disease
-Active pulmonary/ renal/ hepatic disease
-Breast feeding
- MTX sensitivity
- Moderate/severe Anemia/ Thrombocytopenia / Leukopenia
-Leukemia
Note: Do not use MTX with NSAID, since this combination may potentiate
nephrotoxicity
