ECTOPIC

1. ECTOPIC PREGNANCY
Dr. Faryal Wahab
R1 .DUHS
OBS, GYNECOLOGY
& REPRODUCTIVE MEDICINE

2. Headings
• Definition
• Incidence and epidemiology
• Types of ectopic pregnancy
• Risk factors
• Clinical presentation
• Diagnosis
• Management
• Recent advances in management

3. Definition
“Any pregnancy where the fertilized ovum gets implanted & develops in a site
other than normal uterine cavity”.
 Ectopic pregnancy occurs around 1-2% of all pregnancies
 Recurrence rate 15% after 1st , 25 % after 2nd ectopic pregnancy.
 The most recent MBRRACE report (2016) reveals almost 5% of all maternal
deaths in reporting period are directly related to ectopic pregnancy
 Between 6-16% of women who attend emergency departments in the first
trimester with pain or vaginal bleeding with have an ectopic pregnancy
Incidence epidemiology

4. Types of ectopic pregnancy
• Tubal ectopic pregnancy: over 98%
• Nontubal Ectopic preg:
Ovarian (0.5-2%)
Interstitial (2-3%)
Cervical (0.1-1%)
Caesarean scar pregn:(<1%)
Cornual (1:1lakh)
Abdominal pregnancy(0.3-0.5%)
Heterotopic pregnancy

5. Heterotopic pregnancy

6. RISK FACTORS
Congenital
• Tubal hypoplasia
• Tortuosity
• Congenital diverticula
Acquired
• Previous Ectopic Pregnancy
• History of any pelvic surgery e.g.Appendictomy
• Past, present chlamydia trachomatis infection
• Cigarette smoking
• Tubal (pelvic) Surgery
• Previous salpingitis
• DES (diethylstilboestrol)Exposure
• Contraceptives (intra uterine contraceptive use)
• Assisted reproduction

7. Classical symptoms
• 3 A’s

8. Non-classical symptoms
• Dizziness, fainting or syncope
• Breast tenderness
• Gastrointestinal symptoms
• Shoulder tip pain (danforth sign)
• Urinary symptoms
• Passage of tissue
• Rectal pressure or pain on defecation

9. Signs
• Pallor
• tachycardia(>100bpm)or hypotension (<100/60mmHg)
• Shock or collapse
• Orthostatic hypotension
• Pelvic, abdominal, or adnexal tenderness.
• Cervical motion tenderness
• Rebound tenderness
• Abdominal distension +Cullen sign??

10. DIFFERNTIAL DIAGNOSIS
• septic/ threatened abortion
• Pyosalpinx, pelvic abscess
• Rupture of follicle or corpus lutuem
• Acute PID
• Twisted ovarian cyst
• Degenerated leiomyoma
• Retroverted gravid uterus

11. Investigations
 Urine pregnancy test
Culdocentesis
Transvaginal ultrasonography
Serum beta hcg
Urine beta hcg
Serum progesterone
Uterine curettage
Diagnostic Laparoscopy/laparotomy

12. IF PREGNACY TEST TURNS Negative(-ve)
MBRRACE Report
Massive
pulmonary
embolus
Thrombolysis

13. Diagnosis
Proper history (cycle, pregnancy, PID, infertility, gynecological
surgery, contraception).
Clinical examination (Proper general,abdominal, vaginal and
vitalsigns).
Judicious use of investigation.

14. Investigations
• The mainstay for diagnosis of ectopic pregnancy
 Transvaginal ultrasound
 Quantitative serum HCG
• TV USS had a sensitivity 87-99% and specificity of 94 -99%
• Correlation of less conclusive scan findings with quantitative measurement
of serum Hcg can be helpful.
• Ectopic pregnancy in modern practice are diagnosed with a hcg under
1000iu/l.
• Serum progesterone level is not useful in predicting ectopic pregnancy .

15. • Ectopic pregnancy are associated with a below optimal < 66% rise Hcg
over 48 hours or a largely static HCG.
• Miscarriage may become clinically apparent due to the amount of
vaginal bleeding and would correspond to a fall in hcg levels, with a
50% decrease over 48hours meaning viable pregnancy is very
unlikely.

17. Transvaginal ultrasound
Positive β-hCG test + empty
uterus by sonar± adnexal mass
=Ectopic pregnancy.

18. Blob sign Begel sign

19. PREGNANCY OF UNKNOWN LOCATION
INTRAUTERINE
PREGNANCY
“It used to classify a pregnancy when a woman has
+ve pregnancy test but no pregnancy can be seen
on ultrasound’’
 7-20% proved to be ectopic pregnancy.

20. In cases where
imaging is suboptimal
TRANSABDOMINAL
ULTRASOUND
Uterine fibroid Congenital uterine
abnormalities

21. DIAGNOSTIC LAPROSCOPY
Gold standard
for diagnosis of
ectopicpregnancy
Diagnosis &
removal of ectopic
mass can be done
at the sametime

22. Expectant Management
Criteria for selection….(RCOG-greentop-21-guideline)
 Asymptomatic pt
 Hemodynamically stable
 Lower beta hcg value<1000IU/ml
 Adnexal mass <3cm without cardiacactivity
 Pregnancy of unknown location
SUCCESS RATE =57-100%
• Repeat B-HCG = weekly until <20iu/l or NIL

23. Medical Management
• Minimal symptoms/ hemodynamically stable
• No signs or symptoms ofactive bleeding / haemoperitoneum.
• HCG<3000(RCOG)
• Normal CBC,RFT,LFT
• Size<4cm
• Absence of cardiac activity
• Good compliance and follow up can be assured(RCOG)
• Women should be given clear information(preferably written)about
the possible need for further Tt and adverse effects following Tt
(RCOG)

24. Single dose regimen
If B-hcg levels drop by >15%
monitor B-hCG weeklyuntil non pregnant level
If b-hcg level drops by <15%
repeat dose of MTX on day 4 and if needed on D7
 MTX 50mg/m2 on day 0
Measure B-hCG level on days 4 & 7
23-30% success rate


25. • Medical management of non tubal EP is preferred for cervical
pregnancy as surgery has high failure rate , it is also an option for
table women where the avoidance of surgery is preferred with an
interstitial pregnancy ,ovarian , and small abdominal pregnancy.
• Caesarean scar pregnancy is amenable to both medical an surgical
treatment.

26. Surgical management
• Aim of surgical management
Confirm the diagnosis
Stop intraperitoneal bleeding
Remove ectopic pregnancy tissue

27. LAPROSCOPY V/S LAPROTOMY

28. • Salpingectomy
If no any future fertility
is desired
• Salpingectomy
Should the woman wish to
concave naturally &
contralateral tube appears
healthy
• Salpingotomy
If woman wish to conceive
naturally in future &
contralateral tube appears
unhealthy

29. Salpingotomy

31. • All unsensitised woman of rhesus –ve blood group with any form of
surgical management of EP, bleeding is repeated or is heavy …..
receive a prophylactic dose of Anti D ANTIBODIES 250IU I/M to avoid
in advertent rhesus sensitization

32. Take home massage and recent
advancements
• Refinements in risk stratification at first point of contact in antenatal
visit
• Tvs and quantitative serum hcg measurements are mainstay in
diagnosis
• Management is highly case dependant .
• A randomized controlled trial of placebo or gefitinb(on oral epidermal
growth factor receptor agent )used in combination with MTX to
hasten resolution of EP is underway

33. THANK YOU