ectopic pregnancy

2. An “ectopic” or “ectopic pregnancy”
(graviditas extrauterine, S.ec-topica)
implies the development of a fetal
egg not in the uterine cavity, but
outside it.

3. An ectopic pregnancy is an extrauterine pregnancy.Almost all ectopic pregnancies occur
in the fallopian tube (>95%).

5. Sites of implantation of 1800 ectopic pregnancies from a 10-year population-based
study. (Data from Callen, 2000; Bouyer, 2003.)

6. Two national guidelines are available covering the diagnosis
and management of ectopic pregnancy:
•RCOG/AEPU Joint Guideline: Diagnosis and Management
of Ectopic Pregnancy, Nov 16.
•NICE Guideline 126: Ectopic pregnancy and miscarriage:
diagnosis and initial management, Apr 19

8. The cause of ectopic pregnancy is either the delayed advancement of the egg or its
accelerated maturation. The following factors contribute to this:
• Inflammatory diseases of the genital organs(PID SIN);
• Reconstructive plastic surgery on the fallopian tubes;
• In vitro fertilization;
• Tumors and tumor-like formations of the uterus and its appendages;
• Endometriosis;
• Tuberculosis
• Sexual infantilism;
• Anomalies in the position and development of the genital organs;
• Irregularities in the migration of the fetal egg(migracio ovi externum);
• Increased proteolytic activity of trophoblast;
• Endocrine diseases.
• Previous ectopic pregnancy (15% chances of next)
ETIOLOGY

9. •Previous ectopic
pregnancy (risk is around
15-18.5%)
•IVF
•Fallopian tube
damage (may be secondary
to infection, surgery)
•Adhesions
•Smoking
•Intrauterine contraceptive
device
•Progestogen-only pill
RISK FACTORS

10. Ectopic Pregnancy Triad: amenorrhea, vaginal spotting, and
abdominal pain.
NB!!
Clinical Presentation differs if the patient has an ectopic or an ruptured ectopic
Women has dubious
and probable signs of
pregnancy, there are
changes in taste and
appetite, nausea,
salivation or vomiting,
delayed menstruation,
engorgement of the
mammary glands may
be observed !!

11. Symptoms
• Abdominal/pelvic pain
• Vaginal bleeding
• Amenorrhoea
• Shoulder tip pain (a sign of
rupture and intra-abdominal
bleeding, indicative of blood
irritating the diaphragm)
• Urinary discomfort
• GI upset
• Syncopal attacks
Signs
• Abdominal/pelvic tenderness
• Rebound tenderness, peritonism
• Abdominal distention
• Pallor
• Cervical motion tenderness (refers to
pain on movement of the cervix during a
bimanual examination, indicative of pelvic
inflammation)
• Cullen Sign Bruising around the
umbilicus’s
Turner sign  Bruising around flanks
Evidence
of
Hemoperitoneum

12. PRIMARY OVARIAN ECTOPIC
Spiegelberg’s criteria

13. A. Transvaginal sonogram shows a gestational sac containing fetal parts of a 16-week gestation.
The placenta is marked by a red asterisk.

14. B. Due to concern for extensive parasitic blood supply to the pregnancy, exploratory laparotomy
was performed. Here, the right ovary is lifted by the surgeon, and the fallopian tube is the cordlike structure stretched across
the top of the mass. Due to mass size and vascularity and scant normal ovarian stroma, this patient was treated by right
salpingo-oophorectomy.
(Photograph contributed by Dr. Kyler Elwell.)

15. PRIMARY ABDOMINAL ECTOPIC
 Studdiford criteria

16. Sagittal view of an abdominal
pregnancy at term. The
placenta is implanted on the
posterior surface of the uterus
and broad ligament.
The enlarged, flattened uterus
is located just beneath the
anterior abdominal wall and to
the level of the umbilicus. The
cervix and vagina are pulled up
and are dislodged anteriorly
and superiorly by the large fetal
head in the cul-de-sac.
Placenta
Uterus
Bladder

17. NB! Primary ovarian/abdominal are much rarer as compared to
secondary ovarian and abdominal ectopic
Secondary ovarian ectopic 
Pregnancy coming out from uterus and settling in the ovary
Secondary abdominal ectopic 
Pregnancy coming out from tube and settling in the abdomen
#Term abdominal pregnancy is very rare- Delivered by laparotomy

18. CERVICAL ECTOPIC
Cervical pregnancy. Transvaginal sonographic findings
may include:
(1) an hourglass uterine shape and ballooned cervical canal;
(2) gestational tissue at the level of the cervix (black arrow);
(3) absent intrauterine gestational tissue (white arrows); and
(4) a portion of the endocervical canal seen interposed
between the gestation and the endometrial canal

19. CESAREAN SCAR ECTOPIC
A. Transvaginal sonogram of a uterus with a cesarean scar pregnancy (CSP) in a
sagittal plane. An empty uterine cavity is identified by a bright hyperechoic
endometrial stripe (long, white arrow). An empty cervical canal is similarly identified
(short, white arrow). Last, an intrauterine mass is seen in the anterior part of the
uterine isthmus (red arrows).
Healthy myometrium between the bladder and gestational sac is absent.

20. CESAREAN SCAR
B. Hysterectomy specimen containing a cesarean scar
pregnancy.
C. This same hysterectomy specimen is transversely
sectioned at the level of the uterine isthmus and through
the gestational sac. The uterine body lies to the left, and
the cervix is on the right. A metal probe is placed through
the endocervical canal to show the eccentric development
of this gestation. Only a thin layer of myometrium overlies
this pregnancy, which pushes anteriorly through the uterine
wall

21. CORNUATE ECTOPIC

22. HETEROTYPIC ECTOPIC

23. INTERSTITIAL ECTOPIC

24. OTHER RARE PARTS

25. Time of rupture:
• Isthmus ectopic-
4-6 weeks
• Ampullary ectopic-
6-8 weeks
• Interstitial/
Cornual ectopic-
12-16 weeks

26. Pain is the most common complaint +/- vaginal
bleeding. A ruptured ectopic will present with signs
of shock and signs of peritonism.
PHYSICAL EXAMINATION

27. DIFFERENTIAL DIAGNOSIS

28. Pain can be divided as being epigastric, umbilical or suprapubic
(hypogastric). Ectopic typically presents as suprapubic pain but
pain but may radiate to other areas, especially if ruptured.

29. Referred pain is important to understand. Certain areas of the
abdomen can refer pain else where. A good example is in ectopic
is in ectopic pregnancy when irritation of the diaphragm can
diaphragm can cause shoulder tip pain.

30. Rapid onset severe constant pain differentials

31. Differential Diagnosis for ectopic pregnancy
•Acute salpingitis
•Abortion
•Ruptured corpus luteum
•Acute appendicitis
•Dysfunctional uterine bleeding
•Adnexal torsion
•Degenerating leiomyomata
•Endometriosis

32. For any pregnant lady presenting with
abdominal pain and/or vaginal bleeding the
most important investigations:
•FBC
•EUC
•Urine analysis
•β-hCG – Pregnancy test is almost always
+ve, but serum β-HCG levels are lower
than expected for normal pregnancy
•Transvaginal Ultrasound/sonography
Remember Levels of hCG that plateau in the first 8 weeks of pregnancy indicate an abnormal pregnancy, which may either be a miscarriage
or an ectopic pregnancy.
INVESTIGATION

33. Other Investigations to support or rule out differentials”
•Progesterone
•Amylase/Lipase
•LFT
•ESR/CRP

34. Hormonal changes in pregnancy. Note First trimester bHCG peaks then drops

35. When the hCG level equals or exceeds 1500 to 2000 mIU/mL, an intrauterine gestational sac is
usually seen on transvaginal ultrasound; in fact, when the hCG level meets or exceeds this
threshold and no gestational sac is seen, the patient has a high Likelihood of an ectopic pregnancy
β-HCG levels and correlation
β-HCG rising normally
β-HCG rising but not normally
β-HCG is decreasing Failed pregnancy (eg, spontaneous
abortion, tubal abortion, spontaneously
resolving ectopic pregnancy).

36. STANDARD INVESTIGATION Transvaginal Ultrasound/sonography

39. GOLD STANDARD LAPAROSCOPY

40. Treatment for ectopic pregnancy should be comprehensive.
It consists of the following stages:
1. Surgery- stopping bleeding;
2. Restoring blood loss and combating shock;
3. Rehabilitation of reproductive function.
TREATMENT

41. MANAGEMENT
Management of ectopic pregnancy falls into three main types;
1.Expectant your condition is carefully monitored to see whether
treatment is necessary
2.Pharmacological  a medicine called methotrexate is used to stop
the pregnancy growing
3.Surgical surgery is used to remove the pregnancy, usually along
with the affected fallopian tube

43. Expectant management
This may be considered in carefully selected patients. They should be well, with only minor
pain and low or declining B-hCG. Patients must also be willing and able to attend follow-up.
NICE guidelines 126 advise the following women are offered expectant management:
•Clinically stable and pain-free and
•Unruptured tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on
transvaginal ultrasound scan and
•Serum B-hCG levels of 1,000 IU/L or less and
•Able to return for follow-up
They also state it may be considered in women with serum B-hCG levels above 1,000 IU/L
and below 1,500 IU/L.
Serum B-hCG should be measured at days 2, 4 and 7 and then weekly. Levels should fall
by 15% at each measurement, if they do not arrange senior review.

44. Pharmacological management
Single-dose methotrexate (though some may require subsequent doses) can be considered as an
alternative to surgery.
NICE guidelines 126 advise the following women are offered methotrexate:
•Have no significant pain and
•Have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible
heartbeat and
•Have a serum B-hCG level less than 1,500 IU/litre and
•Do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and
•Able to return for follow-up
A choice of either methotrexate or surgical management should be offered to women with a B-hCG level
1,500-5,000 IU/litre, who are able to return for follow-up and meet all of these criteria:
•No significant pain
•Unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
•No intrauterine pregnancy (as confirmed on an ultrasound scan)
Those managed with methotrexate should have serum B-hCG measured at days 4 and 7 and then
weekly. If levels plateau or rise arrange senior review.

47. Pharmacology Methotrexate is a folic acid antagonist widely used for treatment of neoplasia, severe psoriasis
and Rheumatoid arthritis. Side effects of methotrexate is conjunctivitis and gastrointestinal upset.
Methotrexate therapyThe optimal candidates for MTX treatment of ectopic pregnancy are
hemodynamically stable, willing and able to comply with post-treatment follow-up, have a human
chorionic gonadotropin (hCG) concentration ≤5000/mL, and no fetal cardiac activity.
Contraindications for ectopic include renal failure, immunodeficiency, allergy, heterotopic pregnancy
heterotopic pregnancy with coexisting viable intrauterine pregnancy, breastfeeding, unable to complete
methotrexate management

48. Surgical management
There are a number of indications for surgery, when indicated the laparoscopic approach
should be used over open surgery when possible.
There are two main terms to be aware of in the surgical management of tubal ectopics:
•Laparoscopic salpingectomy: laparoscopy refers to 'key-hole' surgery. Salpingectomy refers to
the removal of a fallopian tube, in this case, the tube affected by the ectopic pregnancy. This is
generally the preferred treatment.
•Laparoscopic salpingotomy: this refers to a procedure that aims to preserve the fallopian tube.
The tube is opened and the ectopic is removed. It is generally considered if the contralateral tube is
damaged or there are other fertility-based concerns.
NB! The difference
between salpingostomy and salpingotomy!!!
Is that salpingostomy is (surgery) the surgical unblocking of a
blocked fallopian tube while salpingotomy is the operation of
making an incision into a fallopian tube to remove an ectopic.

49. Salpingectomy is removal of the fallopian tube (uterine tube).
Salpingostomy is removing a section of the fallopian tube (uterine tube)
Indications for salpingectomy:
• Recurring ectopic pregnancies or
are > 5 cm
• Severely damage tubes
• No future childbearing is planned

50. Laparoscopic salpingectomy:

51. Laparoscopic salpingostomy:

52. NICE guidelines 126 advise the following women are offered surgery as first-line
management:
•Unable to return to follow up or
•An ectopic pregnancy and significant pain or
•An ectopic pregnancy with an adnexal mass of 35 mm or larger or
•An ectopic pregnancy with a foetal heartbeat visible on an ultrasound scan or
•An ectopic pregnancy and a serum hCG level of 5,000 IU/litre or more
Patients who have required salpingotomy require weekly serum B-HCG
measurements until negative. Approximately 1 in 5 will need further treatment (e.g.
methotrexate, salpingectomy).
Women who have had a salpingectomy should conduct a urinary pregnancy test at
three weeks and contact the gynaecology department if positive.

53. Emergency
Haemodynamically unstable patients (ruptured ectopic)
Signs and symptoms
•Acute abdomen with worsening pain
•Abdominal distention
•Shoulder tip pain (Kehr’s sign)
•Signs of shock
Management - Resuscitation
•Two large-bore IV line and IV fluids
•Cross match 6U blood
•Call senior help and aesthetics assistance urgently
Surgery – Laparotomy with salpingectomy

54. Emergency surgery is indicated in patients with a ruptured ectopic pregnancy. If the patient is
unstable, assess in an ABCDE manner, escalate with peri-arrest and/or major haemorrhage call.

55. Anti-D rhesus prophylaxis
Rhesus D (RhD) negative women may require anti-D rhesus
prophylaxis.
Anti-D immunoglobulin is given to reduce the risk of maternal sensitisation in events
where FMH is likely. The advice from NICE and the Royal College of Obstetricians and Gynaecologists
(RCOG) is as follows (each trust will have local guidelines):
1. NICE guidance 126 states anti-D rhesus prophylaxis should be offered to all RhD-negative women who have
surgery to manage an ectopic pregnancy.
2. RCOG/AEPU Joint Guideline advises anti-D rhesus prophylaxis should be offered to all RhD-negative women who
have surgery to manage an ectopic pregnancy or where bleeding is repeated, heavy or associated with
abdominal pain.
Rhesus (Rh) refers to a group of red cell antigens, the
most important being RhD. Problems arise when RhD-
negative mothers have RhD-positive foetuses. Feto-
maternal haemorrhage (FMH) can expose the mother to
RhD-positive blood. In response, a RhD-negative mother
generates anti(D) antibodies. In subsequent pregnancies
anti(D) antibodies can cross the placenta and lead to
haemolytic disease of the newborn.

56. Side effects of methotrexate is conjunctivitis and gastrointestinal upset.
COMPLICATION AND PROGNOSIS

58. REFERENCES
• https://www.nice.org.uk/guidance/ng126/resources/ectopic-pregnancy-and-
miscarriage-diagnosis-and-initial-management-pdf-66141662244037
• https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14189
• https://app.pulsenotes.com/specialities/gynaecology/notes/ectopic-pregnancy
• https://armandoh.org/disease/ectopic-pregnancy/
• https://www.youtube.com/watch?v=RoBohoUrx4c
• https://meduniver.com/Medical/Akusherstvo/1155.html
• Books- Williams, Saveleva

59. Thanks For Your Attention!