1. By Amielia Mazwa Rafidah
Obstetric and Gynecology
Department

2.  An ectopic pregnancy is a gestation that
implants outside of the endometrial cavity.
@
 defined as pregnancy occurring outside the
endometrial lining of the uterus
 It represents a serious hazard to a woman’s
health and reproductive potential, requiring
prompt recognition and early aggressive
intervention.

3.  95% occur in the tubes: the commonest site is the Ampulla
(85%), followed by the Isthmus.
 The uterus:
 I. Intramural.
 II. Angular
 III. Cervical
 IV. Rudimentary Horn
 The Ovary
 Broad Ligament
 Abdominal:
 I. Primary: first implantation occurs in a peritoneal surface.
 II. Secondary: original implantation occurs first in the tube-ostia,
aborted subsequently then reimplanted into a peritoneal surface.
 Multiple Ectopic: may occur:
 Involving both tubes
 Combined intra- & extra-uterine pregnancy

7.  Since the early 1970s, the incidence of ectopic
pregnancy has tripled, and currently this
condition represents the fourth leading cause
of maternal mortality overall (4%) and the most
common cause of maternal mortality in the first
trimester.
 The overall incidence of ectopic pregnancy is
estimated to be at least one in every 200
pregnancies.

8.  Probably as many as 50% of cases result from
alteration of tubal transport mechanisms
secondary to damage to the ciliated surface of
the endosalpinx caused by infections such as
Chlamydia and gonorrhea.
 Others are the result of intrinsic abnormalities
of the fertilized ovum and possibly
transmigration of the oocyte to the contralateral
tube, with resulting delays in passage.

9.  Tubal pregnancies rapidly invade the mucosa,
feeding from the tubal vessels, which become
enlarged and engorged.
 The segment of the affected tube is distended
as the pregnancy grows.
 Possible outcomes of such abnormal gestations
are as follows:

10.  The pregnancy is unable to survive owing to its
poor blood supply, thus resulting in a tubal
abortion and resorption , or it is expelled from
the fimbriated end into the abdominal cavity.
 The pregnancy continues to grow until the
overdistended tube ruptures, which resulting
profuse intraperitoneal bleeding.

11.  In rare instances, a tubal pregnancy will be
expelled from the tube and seed onto sites in
the abdominal cavity (e.g. the omentum, the
small/large bowel, or the parietal peritoneum),
and gives rise to a viable abdominal pregnancy

12. High risk factors can be summarized as follows:
 A history of tubal infection (ectopic rate of 1:24,
as opposed to 1:200 in non infected patients)
 Prior ectopic pregnancy (15% to 50% increase
in incidence of ectopic gestation in subsequent
pregnancies)
 History of tubal sterilization within the past 1
to 2 years (higher incidence if cauterization was
used)

13.  History of tubal reconstructive surgery
(tuboplasty or end-to-end reanastomosis for
sterilization reversal)
 Pregnancy with an IUD in place or a history of
IUD use.
 Infertility.
 More than one therapeutic abortion
(controversial)
 Pregnancy resulting from failed postcoital
contraception (probably associated with
abnormal tubal transport)

15.  The classic symptom triad
 amenorrhea,
 vaginal
bleeding,
 abdominal pain
 normal pregnancy findings like breast
tenderness, nausea and urinary frequency are
also found.

16.  Abdominal pain, usually in the lower abdomen
in early cases, or generalized in ruptured
ectopics with a hemoperitoneum.
 Amenorrhea or a history of an abnormal last
menstrual period is found in 75% to 90% of
ectopic pregnancies.
 Vaginal bleeding, from spotting to the
equivalent of a menstrual period, results from a
low human chorionic gonadotropin (hCG)
production by the ectopic trophoblast and is
seen in 50% to 80% of patients.

17.  Making the diagnosis of an acutely ruptured
ectopic pregnancy is fairly straightforward.
 The patient presents with symptoms of
increasing abdominal pain, abdominal
distention, and hypovolemia.
 The entire abdomen is acutely tender with
guarding and rebound tenderness

18.  in patients with an unruptured ectopic pregnancy
may be extremely variable.
 90% have abdominal tenderness, but
 only 45% have positive rebound tenderness, and
 only 50 % have an adnexal mass on pelvic examination.
 In half the cases, the mass is contralateral to the
ectopic pregnancy and represents the corpus
luteum.
 20%present with bilateral adnexal masses owing to
the presence of a contralateral coupus luteum cyst.
The uterus is soft and either of normal size or
slightly enlarged.

19.  Many gynecologic and nongynecologic
disorders have symptoms in common with
ectopic pregnancy.
 Gynecologic disorders to be considered include :
 Threatened or incomplete abortion
 A ruptured corpus luteum cyst
 Acute pelvic inflammatory disease with fever,
abdominal pain, leukocytosis, and, at times, adnexal
masses.
 Adnexal torsion
 Degenerating leiomyoma (common in pregnancy)

20.  The key to the successful management of
ectopic pregnancy is early diagnosis.
 Although the number of new cases has
increased threefold, fewer are arriving at the
hospital ruptured, with the patient already in
hemorrhagic shock.
 This decrease is evidence that a high index of
suspicion and vigorous efforts at early
diagnosis are effective.

21.  Human chorionic gonadotropin is consisting of
two linked subunits, α and β
 β-hCG is secreted by both the cytotrophoblast
and the syncytiotrophoblast and has the sole
function of supporting the corpus luteum.
 Abnormal β-hCG could not provide
information on the location of the pregnancy.
 Ultrasonography must be used to locate the
gestation.

22.  its application to the diagnosis of ectopic
pregnancy, alone and in combination with hCG
testing, is now the standard of care.
 Transvaginal ultrasonography has allowed the
detection of an intrauterine gestational sac at as
early as 5 weeks of amenorrhea (2 mm
diameter).

23.  If the sac is not visualized at the uterine cavity,
special attention is needed to differentiate
between a true sac and a pseudosac, which is a
ring-like structure produced on ultrasound by
a prominent decidual echo.
 Evidence of hemoperitoneum may be inferred
by the sonographic description of “free fluid in
the cul-de-sac.”

25.  Culdocentesis is the technique by which a
needle, attached to a syringe, is inserted
transvaginally through the posterior vaginal
fornix into the pouch of Douglas to detect any
fluid within the peritoneal cavity
 Although the procedure is simple, inexpensive,
and rapid, it is quite uncomfortable for the
patient and is of limited use in an unruptured
ectopic pregnancy.
 It is unnecessary when the diagnosis is obvious
and has a high false-negative rate.

28.  Emergency treatment
 Surgical treatment
 Laparotomy
 laparoscopy
 Medical treatment
 Expectant management

29.  Immediate surgery is indicated when the
diagnosis of ectopic pregnancy with
hemorrhage is made.
 Transfusion with whole blood or an
appropriate blood component therapy as soon
possible is indicated when the patient is in
shock.

30.  Rapid entry into the abdomen should be
accomplished, as control of hemorrhage can be
lifesaving.
 Careful, fast exploration of the abdominal
cavity should be done at once.
 Remove products of conception, clots, and free
blood.
 At operation the damaged tube is usually
removed.
 This procedure is the most common for ectopic
pregnancy.

31.  The type of procedure performed by either
laparoscopy or laparotomy will be dictated by
local findings at the time of surgery and the
desire of the woman for future fertility.
 In patients who with to conserve fertility, a
linear salpingostomy is the treatment of choice
in unruptured ampullary pregnancies.
 In ampullary pregnancies that have already
ruptured, a segmantal resection or partial
salpingectomy can be offered, which implies
the removal of only the affected segment of
tube, leaving the rest intact.

35.  Unruptured ectopic pregnancy can be treated
with Methotrexate (MTX).

36.  no contraidications to MTX
 type of unruptured or abortion
 unruptued mass <4 cm at its greastest
dimension
 β-hCG level <2000mIU/ml
 without signs of hemoperitoneum

38.  ABSOLUTE
 Breast feeding.
 Immunodeficiency
 Alcoholism or related Hepatic Cirrhosis.
 MTX sensitivity.
 Active pulmonary disease.
 Peptic Ulcer disease.
 Hepatic, Renal or Hematologic dysfunction.
 RELATIVE
 Gestational Age >3.5 cm,
 Embryonic HR present.

39.  As many as 80% of ectopic pregnancies with
hCG levels of 1000mIU/ml or less will not
rupture spontaneously or bleed profusely but
will undergo spontaneous resolution.
 Expectant management is generally reserved
for reliable, relatively asymptomatic patients in
whom the hCG titers are <200mIU/ml and
delining.

40.  Ectopic pregnancy and tubal pregnancy are
terms used interchangeably because other sites
of ectopic implantation are rare.
 A pregnancy can implant on the surface of the
ovary.
 The treatment is aimed at removing the
pregnancy and sacrificing as little as possible of
the ovarian tissue.

41.  Cervical pregnancy usually presents with
profuse vaginal bleeding, and attempts at
removal of the pregnancy are often
unsuccessful.
 Hysterectomy is frequently indicated and is
usually quite difficult.
 In more recent years, methotrexate have been
used to manage cervical pregnancy.

42.  http://en.wikipedia.org/wiki/Ectopic_pregnancy
 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/
 http://www.google.com/imgres?q=ectopic+pregnancy
 American College of Obstetricians and Gynecologists.
Management of recurrent and early pregnancy loss. ACOG
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 American College of Obstetricians and Gynecologists. Medical
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 ACOG Practice Bulletin No. 67. Obstet Gynecol . 2005;106
(4):871-882.
 American College of Obstetricians and Gynecologists. Medical
Management of tubal pregnancy.
 ACOG Practice Bulletin No. 3. Obstet Gynecol . 1998;92(6):1-7.