Ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, usually in the fallopian tubes. There are several types of ectopic pregnancies classified by location, with tubal pregnancies making up about 90% of cases. Risk factors include previous ectopic pregnancy, PID, tubal ligation or surgery. Symptoms include abdominal pain and vaginal bleeding. Diagnosis involves ultrasound, serum hCG levels, and sometimes laparoscopy. Treatment options range from expectant management for very early, low risk cases to surgical intervention like salpingectomy for ruptured ectopic pregnancies.

1. ECTOPIC PREGNANCY
PRESENTED TO: PRESENTED BY:
PROF. CUM VICE PRINCIPAL
H.O.D OF OBG NURSING NIKITA SHARMA
PROF. (MRS.) NIDHI SAGAR M.SC(N) 2ND YEAR

2. NORMAL
PREGNANCY
IMPLANTATION

3. ECTOPIC
PREGNANCY
IMPLANTATION

4. CLASSIFICATION
Tubal
pregnancy
Ampulla
80%
Isthmus
10%
Rudiment
ary horn
of
bicornuate
uterus
2%
Interstitial
2%
Fimbria
5%

5. CLASSIFICATION

6. CLASSIFICATION
NON TUBAL ECTOPIC
PREGNANCY (2-5% RARE)
OVARIES
BROAD
LIGAMENTS
CERVIX
ABDOMINAL
CAVITY &
PERITONEUM

7. HETEROTOPIC
PREGNANCY
When pregnancy occur in
both the womb and the
tube at the same time.

8. ETIOLOGY/ RISK FACTORS
HISTORY OF PID
PREVIOUS ECTOPIC PREGNANCY
HISTORY OF TUBAL LIGATION
TUBAL RECONSTRUCTIVE SURGERY
CONTRACEPTIVE FAILURE

9. ETIOLOGY/RISK FACTORS
ART WHEN TUBES
ARE DAMAGED
IUD USE
PREVIOUS INDUCED
ABORTION
TUBAL
ENDOMETRIOSIS
HISTORY OF
INFERTILITY

10. OTHER RISK FACTORS
 Age 35-45 yrs
 Previous induced abortion
 Previous pelvic surgeries
 Cigarette smoking
 DES Exposure in Utero
 Infertility
 Salpingitis Isthmica Nodosa
 Genital Tuberculosis
 Fundal Fibroid & Adenomyosis of tube
 Transperitoneal migration of ovum

11. Iffy hypothesis –
“Theory of reflux” menstural fluid throw the fertilised ovum into the tube
Factors facilitating nidation of ovum in tube:
- Premature degeneration of zona pellucida
- Increased decidual reaction
- Tubal endometriosis

12. EVOLUTION
 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:

13. MORBIDANATOMY
Changes
 Implantation- intercolumnar or between mucosal flods
 Decidual change minimal
 Muscle hyperplasia & Hypertrophy min.
 Intramuscular implatation
 Pseudocapsule formation
 Trophoblast invasion-erosion of blood vessel
 The pregnancy is unable to survive owing to its poor blood supply,
thus resulting in a
 tubal abortion and
 resorption, (rare)
 Tubal Rupture
 Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months
 Abortion is common in ampullary pregnancies,whereas rupture is in
isthmic.

14. ARIAS – STELLA
REACTION
Arias – Stella reaction is charecterised by a benign, focal and
unusual decidual changes in the presence of chorionic tissue,
 Loss of polarity
 Pleomorphism
 Hyperchromatic nuclei
 Vacuolated cytoplasm
 Intraluminal budding
Though seen in Ectopic Pregnancy but is not specific for it
and can also be seen in uterine pregnancy.
• It occurs due to the effect of progesterone.

15. PicturesshowingTUBALABORTION
Ruptured ectopic

16. TUBAL PREGNANCY

17. PATHOPHYSIOLOGY
The trophoblast develops in the fertilized ovum and invades deeply
into the tubal wall.
Following implantation, the trophoblast produces hCG which maintains the corpus luteum.
The corpus luteum produces oestrogen and progesteronewhich change the secretory endometrium into decidua.
The uterus enlarges up to 8 weeks and becomes soft.
The tubal pregnancy does not usually proceed beyond 8-10weeksdue to:
> lack of decidual reaction in the tube,
> the thin wall of the tube,
> the inadequacy of tubal lumen,
> bleeding in the site of implantation as trophoblast invades.

18. PATHOPHYSIOLOGY
Separation of the gestational sac from the tubal wall leads to its degeneration, and
fall of hCG level, regression of the corpus luteum and subsequent drop in the
oestrogen and progesteronelevel.
This leads to separation of the uterine decidua with uterine bleeding
Fate of tubal pregnancy
Tubal mole
Tubal abortion
Tubal rupture

19. CHANGES IN UTERUS

20. FATE OF TUBAL PREGNANCY
1 Tubal mole:
The gestational sac is surrounded by a blood clot and retained
in the tube.
This may remain for long period in the tube and forms so called (chronic
ectopic pregnancy),or they may be gradually absorbed (involution)
2 Tubal abortion:
This occurs more if ovum had been implanted in the ampullary portion of the
tube.
Separation of the gestational sac is followed by its expulsion into the
peritoneal cavity through the tubal ostium.
Rarely, reimplantation of the conceptus occurs in another abdominal
structure leads to secondary abdominal pregnancy.

21. Fate of tubal pregnancy
If expulsion was complete the bleeding usually ceases but it may
continue due to incomplete separation or bleeding from the
implantation site.

22. FATE OF TUBAL PREGNANCY
3-Tubal rupture:
More common if implantation occurs in the narrower portion of the tube
which is the isthmus.
Rupture may occur in the
anti-mesenteric border of the tube.
Usually profuse bleeding occurs →
intraperitoneal haemorrhage.
If rupture occurs in the mesenteric border
of the tube, broad ligament haematoma
will occur.

23. PRESENTATION
Early symptoms are either absent or subtle. Clinical presentation of
ectopic pregnancy occurs at a mean of 7.2 weeks after the last
normal menstrual period, with a range of 5 to 8 weeks
The most common presenting symptoms that are suggestive for EP
are:

24. CLINICAL TRAID (3AS)
Amenorhea
Ectopic
pregnancy
Abdominal pain Abnormal vaginal
bleeding

25. SYMPTOMS
Pain and discomfort
• In the Lower back , abdomin, or pelvis.
Usually unilateral
• Pain may be confused with a strong stomach pain, it may also feel like a
strong cramp
• Shoulder pain. This is caused by free blood tracking up the abdominal
cavity and irritating the diaphragm, and is an ominous sign.
• Pain while urinating
• Pain while having a bowel movement

26. SYMPTOMS
Bleeding
• Vaginal (external)bleeding usually mild. An ectopic pregnancy is usually a failing
pregnancy and falling levels of progesterone from the corpus luteum on the ovary
cause withdrawal bleeding.
• Internal bleeding (hematoperitoneum) is due to hemorrhage from the
affected tube.
• Dizziness, headache, weakness, fainting all may happen due to bleeding.

27. SIGNS
General examination:
• signs of early pregnancy (Breast tenderness, nausea and
vomitig, change of appetite …)
• Weakness, pallor, hypotension and tachycardia,
tachypnea due to bleeding.
Abdominal examination: most constant feature. It is acute, agonizing
or colicky. Pain is located at lower abdomen: unilateral, bilateral or may
be generalized.
Shoulder tip pain (25%) – referred pain due to diaphragmatic irritation
from haemoperitoneum may be present ( DANFORTH’S SIGN)

28. SIGNS
Vaginal examination:
• Vaginal spotting
• Bluish vagina and bluish soft cervix.
• Uterus is slightly enlarged and soft.
• Marked pain in one iliac fossa on moving the cervix from side to
side.
• Ill defined tender mass may be detected in one adnexa in which
arterial pulsation may be felt.
• Speculum or bimanual examination should not be performed
unless facilities for resuscitation are available, as this may induce
rupture of the tube

29. UNRUPTURED ECTOPIC
 High degree of suspicion & ectopic conscious clinician can
diagnose.
 Diagnosed accidentally in Laparoscopy or Laparotomy
C/F – delayed period, spotting with discomfort in
lower abdomen.
P/A – tenderness in lower abdomen
P/V
 should be done gently
 uterus is normal size, firm
 small tender mass may be felt in the fornix
Investigations- TVS, radioimmunoassay of β-HCG and
Laparoscopy

30. DIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb%, CBC, blood grouping and cross
matching,.Serology and Coagulation profile.
 Should be catheterized to know urine output.
Bed side test:-
1. Urine pregnancy test:- positive in 95% cases.
ELISA is sensitive to 10-50 mlU/ml of β hCG and
can be detected on 24th day after LMP.
2. Culdocentesis:- (70-90%)
 Can be done with 16-18 G lumbar puncture needle through posterior
fornix .
 Positive tap is 0.5ml of non clotting blood.

31. DIAGNOSIS
▪ Imaging:-
1. Ultra Sonography-
a) Transvaginal Sonography (TVS):
Is more sensitive
It detect intrauterine gestational sac at 4-5wks and at S-β
hCG level as low as 1500 IU/L .

32. ENDOMETRIAL CAVITY
-A trilaminar endometial pattern seen
-pseudogestational sac
-decidual cyst may be seen
PSEUDOSAC – All pregnancies induce an endometrial
decidual reaction, and sloughing of the decidua can create an
intracavitary fluid collection called a pseudosac
Early Gestational Sac Pseudosac
Location Eccentrically located Midline within E.cavity
Shape Round-shape Irregular
Border Double Ring sign
Vascularity High Avascular
Pattern Peripheral -

33. b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
- Identify the placental shape
(ring-of-fire pattern) and blood flow
outside the uterine cavity.
c) Transabdominal Sonography:
- can identify gestational sac at 5-6 wks
- S-β hCG level at which intrauterine gestational
sac is seen by TAS is 1800 IU/L.

34. USG PICTURE
1.‘Bagel’ sign – Hyperechoic ring around gestational sac
in adnexal region
2. ‘Blob’ sign – Seen as small inconglomerate mass next
to ovary with no evidence of sac or embryo.
3. Adnexal sac with fetal pole and cardiac activity is most
specific.
4. Corpus luteum is useful guide when looking for EP as
present in 85% cases in Ipsilateral ovary.

35. Hyperechoic ring around
gestational sac in adnexal region

36. Ring sign — a hyperechoic ring around an
extrauterine gestational sac.

37. 2. β-HCG Assay-
a) Single β-HCG: little value
b)Serial β-HCG: is required when result of
initial USG is confusing.
- When hCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.
-Rise of β-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .
Biochemical pregnancy is applied to those
women who have two β-HCG values >10 IU/L

38. 3. SERUM
PROGESTERONE –
 level >25 ngm/ml is suggestive of normal intrauterine pregnancy.
 level <15 ngm/ml is suggestive of ectopic pregnancy.
 level <5 ngm/ml indicates nonviable pregnancy, irrespective of its
location.
4. Diagnostic Laparoscopy (Gold standard)–
Can be done only when patient is haemodynamically stable.
-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.

39. DIAGNOSIS
5. Dilatation & Curettage –
 Is recommended in suspected case of incomplete
abortion vs ectopic pregnancy.
 Identification of decidua without chorionic villi is
suggestive of extra uterine pregnancy.
 “Arias-Stella” endometrial reaction is suggestive but not
diagnostic of ectopic pregnancy.

40. SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive
Transvaginal USG
IU sac No IU sac
Quantitative S-hCG
+ S progesterone
< 66% rise in 48 hr or
S progesterone < 5-10 ng/ml
D & C
Villi present
Incomplete
abortion
Villi absent
Laparoscopy
>66% rise in 48 hr or
S progesterone > 5-10 ng/ml
Repeat S-hCG in 48 hrs
till USG discrimination zone
No sac IU sac
Continue to monitor

41. DIFFERENTIAL DIAGNOSIS
Acute Ectopic
1. Rupture corpus luteum of pregnancy
2. Rupture of chocolate cyst
3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion
6. Acute Appendicitis
7. Perforated peptic ulcer
8. Renal colic
9. Splenic rupture

42. MANAGEMENT
Expectant
management
Medical
management
Surgical
management
SystemicLocal
(USG or Laparoscopic)
salpingocentesis
- Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Actinomycin D
- Mifepristone
Methotrexate
Radical
Salpingectomy
Conservative
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbria
expression

43. MANAGEMENT OF ECTOPIC-
PRINCIPLE: Resuscitation and Laparotomy/Laparoscopy
ANTI SHOCK TREATEMENT:
- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching, BT
- Folley’s catheterization done
- Colloids for volume replacement
LAPAROTOMY:
Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given
- Autotransfusion only when donated blood not available.

44. MANAGEMENT OF ECTOPIC PREGNANCY-
Laparoscopy
 Preferred method if haemodynamically stable
 Tubal Patency no significant difference
 Followed by similar number of uterine pregnancy
 Shorter operative time
Salpingostomy
 Less than 2cm size
 10-15mm incision

46. MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
 SURGICAL-
 SURGICALLY ADMINISTERED MEDICAL(SAM)
TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT

47. EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA - :
1. Tubal ectopic pregnancies only
2. Haemodynamically stable
3. No rupture or bleeding
4. Adnexal mass of < 3.5 cm without heart beat.
5. Initial β HCG <1000 IU/L and falling in titre (single best)
SUCCESS RATE - Upto 60%
PROTOCOL:
- Hospitalization with strict monitoring of clinical symptom
- Daily Hb estimation
- Serum β HCG monitoring 3-4 days until it is <10 IU/L
- TVS to be done twice a week.

48. EXPECTANT MANAGEMENT
 Spontaneous resolution occurs in 72%,while 28%
will need laparoscopic salpingostomy
 In spontaneous resolution, it may take 4-67 days
(mean 20 days) for the serum HCG to return to non
pregnant level.
 The percentage fall in serum HCG by day 7 is a
better indicator than the percentage fall by day 2.
 Warning: - Tubal pregnancies have been known to
rupture even when Serum HCG levels are low.

49. MEDICAL MANAGEMENT
Surgery is the mainstay of T/t worldwide
Medical M/m may be tried in selected cases
CANDIDATES FOR METHOTREXATE (MTX)
 Unruptured sac < 3.5cm without cardiac activity
 S-hCG < 10,000 IU/L
 Persistant Ectopic after conservative surgery
PHYSICIAN CHECK LIST
 CBC, LFT, RFT, S-hCG
 Transvaginal USG within 48 hrs
 Obtain informed consent
 Anti-D Ig if pt is Rh negative

50. MEDICAL MANAGEMENT
METHOTREXATE:
 It can be used as oral,intramuscular ,intravenous usually along with
folinic acid.
 Resolution of tubal pregnancy by systemic administration of
Methotrexate was first described by Tanaka et al (1982)
 Mostly used for early resolution of placental tissue in abdominal
pregnancy.Can also be used for tubal pregnancy.
 Mechanism of action-Methotrexate is a folic acid antagonist that
inactivates the enzyme dihydrofolate reductase.Interferes with the
DNA synthesis by inhibiting the synthesis of pyrimidines leading to
trophoblastic cell death. Auto enzymes and maternal tissues then
absorb the trophoblast.

51. MEDICAL MANAGEMENT
Single dose
Mtx 50mg/m² IM
βHCG levels at days 4 & 7
•If difference ≥15% repeat weekly till ≤5IU/ml
•If difference ˂15% between day 4 & 7 repeat dose & begin D₁
•If fetal Cardiac +ve at D₇ repeat D₁ Mtx
•Surgical management if βHCG not ↓ or fetal cardiac +ve after 3
doses
Two dose on Day
0, 4
Follow-up same as One dose regimen
Variable doses
1. Mtx 1gm/kg IM
D₁₃₅₇
2. Leucovorin
0.1mg/kg IM
D₂₄₆₈
Measure βHCG levels at D₁₃₅₇ . Continue alternate day regimen
until βHCG levels decrease ≥15% in 48hrs, or 4 doses of Mtx given.
Then, weekly βHCG levels until <5iu/ml

52. CONTD……
 Advantages –
 Minimal Hospitalisation.Usually outdoor treatment
 Quick recovery
 90% success if cases are properly selected
 Disadvantages-
 Side effects like GI & Skin
 Monitoring is essential-
 Total blood count,
 LFT &
 Serum HCG once weekly till it becomes negative

53. SURGICALLYADMINISTERED MEDICALTT
(SAM)
 Aim- trophoblastic destruction without systemic
side effects
 Technique- Injection of trophotoxic substance into
the ectopic pregnancy sac or into the affected tube
by-
 Laparoscopy or
 Ultrasonographically guided
 Transabdominal (Porreco, 1992)
 Transvaginal (Feichtingar, 1987)
 With Falloposcopic control (Kiss, 1993)

54. SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2 (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
Advantage of local MTX :
- Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up: - Serum β HCG twice weekly till < 5 IU/L
- TVS weekly for 4-6 weeks
- HCG after 6 months for tubal patency

55. INSTRUCTION TO THE PATIENTS
 If T/t on outpatient basis rapid transportation should be
available
 Refrain from alcohol, sunlight, multivitamins with folic acid,
and sexual intercourse until S-hCG is negative.
 Report immediately when vaginal bleeding, abdominal pain,
dizziness, syncope (mild pain is common called separation
pain or resolution pain)
 Failure of medical therapy require retreatment
 Chance of tubal rupture in 5-10 % require emergency
Laparotomy.

56. ECTOPIC
CONSERVATIVE SURGERY
Can be done Laparoscopically or by microsurgical laparotomy
INDICATION:
- Patient desires future fertility
- Contralateral tube is damaged or surgically removed
previously
CHOICE OF TECHNIQUE: depends on
- Location and size of gestational sac
- Condition of tubes
- Accessibility

57. VARIOUS CONSERVATIVE SURGERIES
1.Linear Salpingostomy:
- Indicated in unruptured ectopic <2cm in ampullary region.
- Linear incision given on antimesentric border over the site
and product removed by fingers, scalpel handle or gentle
suction and irrigation.
- Incision line kept open (heals by secondary intention)
2. Linear Salpingotomy :
- Incision line is closed in two layers with 7-0 interrupted
vicryl sutures.
3. Segmental Resection & Anastomosis:
- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at
later date

58. 4. Milking or fimbrial Expression:
- This is ideal in distal ampullary or infundibular pregnancy.
- It has got increased risk of persistent ectopic pregnancy.
ADVANTAGES OF LAPAROSCOPY
- It helps in diagnosis, evaluation, and treatment .
- Diagnose other causes of infertility.
- Decreased hospitalization, operative time, recovery period,
analgesic requirement.
Follow up after conservative surgery
- With weekly Serum β HCG titre till it is negative.
- If titre increases methotrexate can be given.

59. CE
1.Gynecology & obstetrci by Ten
teachers 19th edition
2.RCOG guidelines (Royal college of
obstetric & gynecology)
3.ACOG(American college of
obstetric & gynecology)
4.ASRM(American society of
reproductive medicine)
5.Wikipedia .com
6.Livemedicine.co
m

60. THANK
YOU