Pathophysiology and epidemiology Implantation of a fertilised egg outside of the uterus. Almost uniformly unviable. Affects 1/100 pregnancies. 98% are tubal, usually in the ampulla. Remainder are in the ovaries, cervix, and peritoneum, the latter sometimes carrying to the 3rd trimester. Eventually, trophoblast invasion of the tubal wall can cause tubal rupture and potentially major haemorrhage. However, many cases resolve spontaneously without rupture. Presentation Typical presentation: Patients usually present 6-8 weeks after last period, though 30% present before a missed period. Common symptoms are PV bleeding (dark or fresh) – which can occur with or without rupture – and/or abdominal or pelvic pain. However, many patients are asymptomatic. Other possible features: Syncope and dizziness. Shoulder tip pain. Painful defecation and urination. Diarrhoea and vomiting. Adnexal mass or big uterus. Cervical excitation Sudden rupture: peritonism and shock.

1. Ectopic pregnancy
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2. Pathophysiology and
epidemiology
•Implantation of a fertilised egg outside of the uterus. Almost uniformly unviable.
•Affects 1/100 pregnancies.
•98% are tubal, usually in the ampulla. Remainder are in the ovaries, cervix, and
peritoneum, the latter sometimes carrying to the 3rd trimester.
•Eventually, trophoblast invasion of the tubal wall can cause tubal rupture and
potentially major haemorrhage. However, many cases resolve spontaneously
without rupture.

3. Presentation
Typical presentation:
•Patients usually present 6-8 weeks after last period, though 30% present before
a missed period.
•Common symptoms are PV bleeding (dark or fresh) – which can occur with or
without rupture – and/or abdominal or pelvic pain. However, many patients are
asymptomatic.

4. Presentation
Other possible features:
•Syncope and dizziness.
•Shoulder tip pain.
•Painful defecation and urination.
•Diarrhoea and vomiting.
•Adnexal mass or big uterus.
•Cervical excitation
•Sudden rupture: peritonism and shock.

5. Medical Slide

6. Risk factors
ecTOPIC:
•Tubal ligation or surgery.
•Ovulation induction: fertility treatment.
•Past history of ectopic pregnancy.
•Inflammation: PID.
•Coil (IUCD) in situ.

7. Investigations
•Urine β-hCG: +ve.
•Transvaginal ultrasound (TVUS) is the most sensitive test to confirm a viable
intrauterine pregnancy or visualise an ectopic embryo. If neither can be seen in
presence of positive pregnancy test, known as 'pregnancy of unknown location'.
•Abdominal US is an alternative to TVUS.
•Serum β-hCG: serial tests if no intrauterine pregnancy confirmed on imaging.
Falling values suggest miscarriage, while slow rising values – <63% in 48h –
suggests ectopic and should be re-reviewed 24h later.

8. TUBAL ECTOPIC PREGNANCY

9. Management
Conservative:
• If no acute symptoms, ectopic mass consider at 1,000-1,500) and falling.
• Follow up and ensure adnexal mass shrinks and β-hCG drops.
Medical:
• Methotrexate IM.
• Indications: as for conservative (ectopic mass consider at 1,500-5,000).
• Contraindications: if above indications not met (due to ↑risk of rupture) plus usual MTX
contraindications e.g. cytopenia, peptic ulcer, liver disease.
• Side effects: abdominal pain.

10. Management
Surgical:
•Indications: unstable, significant pain, methotrexate contraindicated.
•Procedure: laparoscopic if possible, either salpingectomy (tube removal), or
salpingotomy (dissecting the ectopic) if there is only one healthy tube remaining.
•Anti-D prophylaxis if Rh -ve and surgcially managed.

11. Complications
Maternal mortality in 1/5000 ectopic pregnancies.

12. Thank You
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