This document discusses ectopic pregnancy, beginning with definitions and epidemiology. It describes risk factors, common sites of ectopic implantation, and the natural history if untreated. Clinical presentation is outlined, including symptoms, signs on examination and differential diagnosis. Investigations including ultrasound findings are covered. Management options of methotrexate or surgery are presented for unruptured ectopics, as well as surgical treatment for ruptured cases. Post-treatment follow up with hCG monitoring is also summarized.

1. ECTOPIC PREGNANCY
Dr Isameldin Elamin MD DOWH MBBS
Assistant Professor
Obstetrics & Gynaecology department

2. Objectives
• Discuss the epidemiology, aetiology and
deferential diagnosis of ectopic pregnancy.
• Describe the clinical picture and examination of a
patient with ectopic pregnancy.
• Discuss the investigations and the management
options of an ectopic pregnancy.

3. Definition
• Ectopic pregnancy is defined as implantation of a
conceptus outside the normal uterine cavity.
• Heterotopic pregnancy is simultaneous
development of a conceptus within and outside
the uterine cavity.

4. Epidemiology
• The incidence of ectopic pregnancy in the UK is
11.1/1000 pregnancies.
• Approximately 11 000 cases of ectopic
pregnancies are diagnosed each year in the UK.

5. Risk Factors
• Tubal Disease Due To Previous Pelvic Infection
Commonly with chlamydial infection.
• Previous Ectopic Pregnancy.
• Previous Tubal Surgery.
• Subfertility.
• Use Of Assisted Reproductive Techniques.
• Use Of IUCD.

6. Common Sites of Ectopic Pregnancy
Fallopian tubes (95 percent).
ovaries (3 per cent).
peritoneal cavity (1 percent).
In the Fallopian tubes:
• ampulla (74 per cent).
• isthmus(12 per cent).
• fimbrial end of the tube (12 per cent).
• interstitium (2 per cent).

8. Natural history of untreated Ectopic
• Tubal rupture.
• Pregnancy resorption.
• Tubal abortion into the peritoneal cavity.

9. Clinical presentation
• Sub acute abdominal pain and vaginal
bleeding in early pregnancy.
• Vaginal bleeding is usually dark red.
• The abdominal/pelvic pain may be localized to
the iliac fossa.
• shoulder tip pain

10. Symptoms and signs
Can resemble the symptoms and signs of other
conditions.
Pregnancy tests should be available to all women
in reproductive age

11. Symptoms and signs…CONT.
common symptoms:
• abdominal pain.
• Amenorrhoea.
• vaginal bleeding.
other symptoms:
• breast tenderness
• gastrointestinal symptoms
• dizziness, fainting or syncope
• shoulder tip pain

12. Symptoms and signs…CONT.
urinary symptoms.
passage of tissue.
rectal pressure or pain on defecation.
Common signs of ectopic pregnancy:
• pelvic tenderness
• adnexal tenderness
• abdominal tenderness

13. Symptoms and signs…CONT.
other reported signs:
• cervical motion tenderness.
• rebound tenderness or peritoneal signs.
• Pallor.
• abdominal distension.
• enlarged uterus.
• Tachycardia.
• Hypotension.
• shock or collapse.
• orthostatic hypotension.

14. Pelvic examination
Bimanual examination:
• tenderness in the fornixes.
• cervical excitation,
• in ruptured ectopic there are signs of
hypovolaemic shock and acute abdomen.

15. Differential diagnosis ectopic pregnancy
 Gynecologic problems:
• Threatened or incomplete miscarriage
• Ruptured corpus luteum
• Acute PID
• Adnexal torsion
• Red degeneration of fibroid

16. Differential diagnosis…CONT.
Nongynecologic problem
• Acute appendicitis
• Pyelonephritis
• pancreatitis

17. Investigations
Investigations for suspected ectopic:
• Pregnancy test.
• CBC.
• Blood group.
• Transvaginal ultrasound (TVS).
• serial βhCG.

18. Investigations..CONT.
• Identification of an intrauterine pregnancy
excludes the possibility of an ectopic pregnancy
in most patients.
• In IVF incidence of heterotopic pregnancy is high
(1 per cent)

19. Investigations
Transvaginal ultrasonography should be the
initial investigation
Ultrasonographic features:
• extra uterine sac with a live embryo.
• adnexal mass
• empty uterus.
• pseudo sac .
• free fluid in the pelvis

20. Us pictures

21. Important
• All women of reproductive age are pregnant until
proved otherwise and it is ectopic until clearly
demonstrated to be intra uterine.

22. BhCG Discriminatory zone
• Visualization of an intrauterine gestation sac
above that βhCG level.
• βhCG level greater than 1500 IU (TVS).
• It depends on the user-and machine.

23. Acutely ruptured ectopic pregnancy
Severe abdominal pain and dizziness due to
haemoperitoneal .
Ipsilateral shoulder tip pain.
Hemodynamic instability.
• tachycardia
• hypotension
• shock.
• Distended abdomen.
• Tenderness.

24. Acutely ruptured ectopic pregnancy
• Guarding.
• rebound tenderness.
• cervical motion tenderness.
• Mass.
• free fluids.
• Diagnosis is by urine for pregnancy test.
• Ultrasound although is not necessary would
reveal significant fluids in the cul-de-sac

25. Acutely ruptured ectopic pregnancy
Management:
• It is surgical emergency .
• Two wide bore intravenous lines.
• Resuscitation by IV fluids.
• Blood transfusion but should not delay surgery
• Surgery is by Laparotomy, although
laparoscopy may be appropriate if
hemdynamically stable.

26. Management Of Ectopic Pregnancy
Systemic methotrexate when:
• Able to return for follow-up.
• No significant pain
• Unruptured ectopic pregnancy.
• Adnexal mass smaller than 35 mm.
• No visible heartbeat.
• hCG level less than 1500 IU/litre
• No intrauterine pregnancy.

27. Management …CONT.
surgical treatment if:
• methotrexate is not acceptable.
• significant pain
• adnexal mass of 35 mm or larger.
• fetal heartbeat.
• hCG level of 5000 IU/litre or more.

28. Management …CONT.
• Methotrexate or surgery if:
• hCG level at 1500 IU/litre to 5000 IU/litre.
• able to return for follow-up.
• no significant pain
• unruptured ectopic.
• adnexal mass smaller than 35 mm.
• No visible heartbeat
• no intrauterine pregnancy

29. Management …CONT.
After methotrexate:
• hCG measurements at days (4 and 7).
• hCG weekly until a negative.

30. surgical treatment
Laparoscopic surgery should be done whenever
possible.
Take into account:
• Condition of the woman.
• Competency of the Surgeon.
• complexity of the surgical procedure

31. Laparoscopic surgery
Advantages:
• Shorter hospital stay with quicker post-op
recovery.
• Lower blood loss .
• Lower analgesic requirement.
• Lower cost.
• Lower risk of adhesion formation.

32. Laparoscopic surgery…CONT.
Disadvantages:
risk of visceral injury
• requires specialised equipment.
• additional surgical expertise
• Patient should be haemodnamically stable.
• Cornual ectopics may not be suitable for
laparoscopic treatment

33. Salpingectomy and salpingotomy
salpingectomy if no other risk factors for infertility.
salpingotomy if contralateral tube damage.
After salpingotomy women may need further
treatment like:
• methotrexate.
• salpingectomy.

34. Salpingectomy and salpingotomy
• After salpingotomy measture hCG after 7 days
and weekly until a negative result is obtained.
• Urine pregnancy test after 3 weeks.
• further assessment if the test is positive.

35. hCG measurements in pregnancy of unknown
location (PUK)
• Take 2 serum hCG measurement 48 hours apart.
• Developing intrauterine pregnancy if HCG
increase greater than 63%.
Offer her a transvaginal ultrasound scan between
7 and 14 days later.

36. hCG measurements in PUK
• pregnancy is unlikely to continue if hCG decrease
greater than 50%.
• Do urine pregnancy test after 14 days
• hCG between a 50% decline and 63% rise.
• refer her for clinical review and further
assessment .
• serum progesterone should not be used to to
diagnose either viable intrauterine pregnancy or
ectopic pregnancy.

37. HCG measurements in PUL
• Pregnancy of unknown location (PUL) can be an
ectopic pregnancy.
• Do not use serum hCG measurements to
determine the location of the pregnancy.
• Clinical symptoms more important than serum
hCG results.
• Use serum hCG measurements only for
assessing trophoblastic proliferation to.

38. Anti-D rhesus prophylaxis
Offer anti-D to all rhesus negative after surgical
management of ectopic pregnancy.
Do not offer anti-D to:
• medical management only.
• threatened miscarriage
• complete miscarriage
• pregnancy of unknown location.

39. conclusion
• Management based on the clinical presentation,
bHCG and ultrasound findings
• By TVS An intrauterine gestational sac seen at 4-
5 weeks if bHCG at 1500 mIU/mL.
• intrauterine pregnancy excludes an ectopic
pregnancy except in those with rare heterotopic
pregnancy.

40. Conclusion…CONT.
• Methotrexate for haemodynamically stable and
compliant.
• Surgical treatment will remain the mainstay
treatment modality for ectopic pregnancy in most
units.

41. Further reading
• Ten Teachers Gynaecology 19 editions.
• Essential of obstetrics and gynaecology.
Hacker & Moore, Fifth Edition.
• NICE clinical guideline 154. Ectopic pregnancy
and miscarriage December 2012.
• http://www.uptodate.com.

42. THANK YOU