Ectopic pregnancy

Ectopic PregnancyEctopic Pregnancy
Zia ur RehmanZia ur Rehman
Tasbeeh ur RehmanTasbeeh ur Rehman

Ectopic
:
(Ektopos) out of place
Definition
“Any pregnancy where the
fertilised ovum gets implanted
& develops in a site other
than normal uterine cavity”.

SITES OF ECTOPIC PREGNANCYSITES OF ECTOPIC PREGNANCY

EpidemiologyEpidemiology
 It is fourth leading cause of maternalIt is fourth leading cause of maternal
mortality overall (4%) and the most commonmortality overall (4%) and the most common
cause of maternal mortality in the firstcause of maternal mortality in the first
trimester.trimester.
 Acute and chronic salpingitis, inducedAcute and chronic salpingitis, induced
abortion, tubal ligation, tubal reconstructiveabortion, tubal ligation, tubal reconstructive
surgery, and conservative management ofsurgery, and conservative management of
tubal pregnancy result in histologic andtubal pregnancy result in histologic and
structural damage to the tubes.structural damage to the tubes.

 Women with IUDs are four times moreWomen with IUDs are four times more
likely to suffer from an ectopiclikely to suffer from an ectopic
pregnancy.pregnancy.
The overall incidence of ectopic pregnancy
is estimated to be at least one in every 200
pregnancies.

MechanicalMechanical factorsfactors
 Congenital:Congenital: long narrow tube, diverticulae andlong narrow tube, diverticulae and
accessory ostia.accessory ostia.
 Traumatic:Traumatic: operation on the tube as salpingoplastyoperation on the tube as salpingoplasty
and tubal reversal following ligation.and tubal reversal following ligation.
 Inflammatory:Inflammatory: Chronic salpingitis, PIDChronic salpingitis, PID
 Neoplastic:Neoplastic: Narrowing of the tube by a fibroid or aNarrowing of the tube by a fibroid or a
broad ligament tumor.broad ligament tumor.
 Functional:Functional: As tubal spasm or antiperistalticAs tubal spasm or antiperistaltic
contractions.contractions.
 endometriosisendometriosis in the tube. encourages embedding ofin the tube. encourages embedding of
the fertilized ovum.the fertilized ovum.

Other FactorsOther Factors
 Hx of tubal surgeryHx of tubal surgery
 Hx of STD’s (such as chlamydia)Hx of STD’s (such as chlamydia)
 Hx of Assisted Reproductive TechniqueHx of Assisted Reproductive Technique
 Hx of ectopic (esp if conservatively managedHx of ectopic (esp if conservatively managed
without surgery)without surgery)
 SmokingSmoking
 IUD in place at time of conceptionIUD in place at time of conception

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

 The pregnancy is unable to survive owingThe pregnancy is unable to survive owing
to its poor blood supply, thus resulting into its poor blood supply, thus resulting in
a tubala tubal abortionabortion andand resorptionresorption, or it is, or it is
expelled from the fimbriated end into theexpelled from the fimbriated end into the
abdominal cavity.abdominal cavity.
 The pregnancy continues to grow untilThe pregnancy continues to grow until
the overdistended tubethe overdistended tube ruptureruptures, withs, with
resulting profuse intraperitoneal bleeding.resulting profuse intraperitoneal bleeding.

 In rare instances, a tubal pregnancy willIn rare instances, a tubal pregnancy will
be expelled from the tube and seed ontobe expelled from the tube and seed onto
sites in the abdominal cavity (e.g. thesites in the abdominal cavity (e.g. the
omentum, the small or large bowel, or theomentum, the small or large bowel, or the
parietal peritoneum), and gives rise to aparietal peritoneum), and gives rise to a
viableviable abdominal pregnancyabdominal pregnancy..

Symptoms & Signs:Symptoms & Signs:
In a woman of child bearing age with
pelvi-abdominal pain and/ or vaginal
bleeding …… ALWAYS….think

Clinical traid (3As)Clinical traid (3As)
AmenorheaAmenorhea
Abdominal pain Abnormal vaginalAbdominal pain Abnormal vaginal
bleedingbleeding
Ectopic
pregnancy

signssigns
General examination:General examination:
 Signs of early pregnancy (BreastSigns of early pregnancy (Breast
tenderness, nausea and vomitig, changetenderness, nausea and vomitig, change
of apettite …)of apettite …)
 Weakness, pallor, hypotension andWeakness, pallor, hypotension and
tachycardia, tachypnoea due totachycardia, tachypnoea due to
bleedingbleeding
Abdominal examination:Abdominal examination:
 Lower abdominal tenderness andLower abdominal tenderness and
rigidity especially on one side may berigidity especially on one side may be
present.present.

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

The diagnosis can be difficult and it is based onThe diagnosis can be difficult and it is based on
Detailed historyDetailed history of (cycle, pregnancy, PID,infertility,of (cycle, pregnancy, PID,infertility,
gynaecological surgery, contraception…)gynaecological surgery, contraception…)
ExaminationExamination Proper general, abdominal, vaginalProper general, abdominal, vaginal
examination and vital signsexamination and vital signs
InvestigationsInvestigations includingincluding

InvestigationsInvestigations
1.Serum1.Serum β-β-hCGhCG
Urine pregnancy tests are positive in only 50-60% of ectopic. DetectionUrine pregnancy tests are positive in only 50-60% of ectopic. Detection
ofof β-hCGβ-hCG in the serum by ELISA or radioimmunoassay are morein the serum by ELISA or radioimmunoassay are more
sensitive and can detect very early pregnancy about 10 days aftersensitive and can detect very early pregnancy about 10 days after
fertilization i.e. before the missed period.fertilization i.e. before the missed period.
If the test isIf the test is negativenegative (generally less than(generally less than 5 IU/L5 IU/L), normal and abnormal), normal and abnormal
pregnancy including ectopic are excluded.pregnancy including ectopic are excluded.
If the test isIf the test is positivepositive , and doubles every 36-48 hour till reaching 1500, and doubles every 36-48 hour till reaching 1500
IU/L which is The threshold of discrimination forIU/L which is The threshold of discrimination for intrauterineintrauterine
pregnancypregnancy, this indicates a normal intrauterine pregnancy,, this indicates a normal intrauterine pregnancy,
An abnormal rise in blood β-hCG levels may indicate an ectopicAn abnormal rise in blood β-hCG levels may indicate an ectopic
pregnancy and ultrasonography is indicated.pregnancy and ultrasonography is indicated.

2.Progesterone2.Progesterone
The second most common hormone after hCG inThe second most common hormone after hCG in
pregnancy is progesterone.pregnancy is progesterone.
Generally, a progesterone concentration of greater thanGenerally, a progesterone concentration of greater than 2525
ng/mLng/mL is highly correlated with a normal intrauterineis highly correlated with a normal intrauterine
pregnancy while a concentration of less thanpregnancy while a concentration of less than 5 ng/mL5 ng/mL
is highly correlated with an abnormal and nonviableis highly correlated with an abnormal and nonviable
pregnancypregnancy

3.Ultrasound3.Ultrasound
In general, a positive β-hCG test with empty uterus byIn general, a positive β-hCG test with empty uterus by
sonar ± adnexial mass indicates ectopic pregnancy.sonar ± adnexial mass indicates ectopic pregnancy.
Discriminatory hCG zones:Discriminatory hCG zones:
Diagnosis of ectopic pregnancy is made if there is:Diagnosis of ectopic pregnancy is made if there is:
An empty uterine cavity by abdominal sonography with bAn empty uterine cavity by abdominal sonography with b
-hCG value above 6000 mIU/ml.-hCG value above 6000 mIU/ml.
An empty uterine cavity by vaginal sonography with bAn empty uterine cavity by vaginal sonography with b
-hCG value above 2000 mIU/ml.-hCG value above 2000 mIU/ml.

4.Culdocentesis4.Culdocentesis
in this test, a needlein this test, a needle
is inserted into the spaceis inserted into the space
at the top of the vagina,at the top of the vagina,
behind the uterus and inbehind the uterus and in
front of the rectum tofront of the rectum to
aspirate fluid andaspirate fluid and
determines if there is blood in the space behind the uterusdetermines if there is blood in the space behind the uterus
If non-clotting blood is aspirated from theIf non-clotting blood is aspirated from the Douglas pouchDouglas pouch ,,
intraperitoneal haemorrhage is diagnosed. But if not,intraperitoneal haemorrhage is diagnosed. But if not,
ectopic pregnancy cannot be excluded.ectopic pregnancy cannot be excluded.

5.laparoscopy or laparotomy5.laparoscopy or laparotomy can also be performed tocan also be performed to
visually confirm an ectopic pregnancy. Often if a tubalvisually confirm an ectopic pregnancy. Often if a tubal
abortion or tubal rupture has occurred.abortion or tubal rupture has occurred.
LaparoscopyLaparoscopy: an endoscope is inserted through a small: an endoscope is inserted through a small
incision in the woman’s abdomenincision in the woman’s abdomen
This allows you to see the fallopian tubes and other organsThis allows you to see the fallopian tubes and other organs
This takes place in an operating room with anaesthesiaThis takes place in an operating room with anaesthesia

Uncommon Sites of EctopicUncommon Sites of Ectopic
PregnancyPregnancy
1-Cornual angular pregnancy1-Cornual angular pregnancy
2-Pregnancy occurs in the blind rudimentary horn2-Pregnancy occurs in the blind rudimentary horn
of a bicornuate uterus.of a bicornuate uterus.
3-Cervical pregnancy3-Cervical pregnancy
4-Ovarian pregnancy4-Ovarian pregnancy
5-Abdominal (peritoneal)5-Abdominal (peritoneal)
pregnancypregnancy

Cornual angular pregnancyCornual angular pregnancy
It is implantation in theIt is implantation in the interstitial portion of the tubeinterstitial portion of the tube..
It is uncommon but dangerous because when ruptureIt is uncommon but dangerous because when rupture
occurs bleeding is severe and disruption is extensiveoccurs bleeding is severe and disruption is extensive
that needsthat needs hysterectomy.hysterectomy.
In some cases, the pregnancy is expelled into the uterusIn some cases, the pregnancy is expelled into the uterus
and rupture does not occur.and rupture does not occur.
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Pregnancy in a rudimentaryPregnancy in a rudimentary
hornhorn
Pregnancy occurs in the blind rudimentary horn ofPregnancy occurs in the blind rudimentary horn of aa
bicornuate uterusbicornuate uterus..
As such a horn is capable of some hypertrophy andAs such a horn is capable of some hypertrophy and
distension, rupture usually does not occur before 16-20distension, rupture usually does not occur before 16-20
weeks.weeks.

Cervical pregnancyCervical pregnancy
Implantation in the substance of the cervix below theImplantation in the substance of the cervix below the
level of uterine vessels.level of uterine vessels.
May cause severeMay cause severe
vaginal bleeding.vaginal bleeding.
Can be diagnosed byCan be diagnosed by
trans vaginal ultrasoundtrans vaginal ultrasound

Ovarian pregnancyOvarian pregnancy
Aetiology:Aetiology:
* Pelvic adhesions.* Pelvic adhesions.
* Favourable ovarian surface for implantation as in* Favourable ovarian surface for implantation as in
ovarian endometriosis.ovarian endometriosis.
Pathogenesis:Pathogenesis:
* Fertilization of the ovum inside the ovary or,* Fertilization of the ovum inside the ovary or,
* implantation of the fertilized ovum in the ovary.* implantation of the fertilized ovum in the ovary.

Spiegelberg criteriaSpiegelberg criteria for diagnosis of ovarian pregnancy:for diagnosis of ovarian pregnancy:
 The gestational sac is located in the region of the ovaryThe gestational sac is located in the region of the ovary
 The ectopic pregnancy is attached to the uterus by theThe ectopic pregnancy is attached to the uterus by the
ovarian ligamentovarian ligament
 Ovarian tissue in the wallOvarian tissue in the wall
of the gestational sac is provedof the gestational sac is proved
histologicallyhistologically
 The tube on the involvedThe tube on the involved
side is intact.side is intact.

Abdominal (peritoneal)Abdominal (peritoneal)
pregnancypregnancy
Types:Types:
PrimaryPrimary: implantation occurs in the peritoneal cavity: implantation occurs in the peritoneal cavity
from the start.from the start.
Secondary:Secondary: usually after tubal rupture or abortion.usually after tubal rupture or abortion.
Intraligamentous pregnancy:Intraligamentous pregnancy: is a type of abdominal butis a type of abdominal but
extraperitoneal pregnancyextraperitoneal pregnancy. It develops between the. It develops between the
anterior and posterior leaves of the broad ligament afteranterior and posterior leaves of the broad ligament after
rupture of tubal pregnancy in the mesosalpingealrupture of tubal pregnancy in the mesosalpingeal
border or lateral rupture of intramural (in theborder or lateral rupture of intramural (in the
myometrium) pregnancy.myometrium) pregnancy.

pregnancypregnancy
Diagnosis:Diagnosis:
History:History: of amenorrhoea followed by an attack of lowerof amenorrhoea followed by an attack of lower
abdominal pain and slight vaginal bleeding which subsidedabdominal pain and slight vaginal bleeding which subsided
spontaneously.spontaneously.
Abdominal examination:Abdominal examination:
Unusual transverse or oblique lie.Unusual transverse or oblique lie.
Foetal parts are felt very superficial with no uterine muscleFoetal parts are felt very superficial with no uterine muscle
wall around.wall around.
Vaginal examinationVaginal examination::
The uterus is soft, about 8 weeks and separate from theThe uterus is soft, about 8 weeks and separate from the
foetus.foetus.
No presenting part in the pelvis.No presenting part in the pelvis.

pregnancypregnancy
Special investigations:Special investigations:
Plain X-rayPlain X-ray: shows abnormal lie. In lateral view,: shows abnormal lie. In lateral view,
the foetus overshadows the maternal spines .the foetus overshadows the maternal spines .
Ultrasound:Ultrasound: shows no uterine wall around theshows no uterine wall around the
foetusfoetus
MRI:MRI: has a particularhas a particular
importance in preoperativeimportance in preoperative
detection of placentaldetection of placental
anatomic relationships.anatomic relationships.

DIFFERENTIALDIFFERENTIAL
DIAGNOSISDIAGNOSISDDX

(1) NON GYNECOLOGICAL(1) NON GYNECOLOGICAL(1) NON GYNECOLOGICAL(1) NON GYNECOLOGICAL

(2) Gynecologic disorders(2) Gynecologic disorders

EXPECTANTEXPECTANT
MANAGEMENTMANAGEMENT
1

 Criteria for selectionCriteria for selection
 asymptomaticasymptomatic women no evidence ofwomen no evidence of
rupture or hemodynamic instabilityrupture or hemodynamic instability
 less than 100 mlless than 100 ml fluidfluid in the pouch ofin the pouch of
DouglasDouglas
 hCGhCG less than 1000 iu/l at initialless than 1000 iu/l at initial
presentationpresentation
 AdnexalAdnexal massmass less than 3cmless than 3cm
 they should objective evidence ofthey should objective evidence of
resolution, such asresolution, such as decliningdeclining bhCG levels.bhCG levels.
 They must be fullyThey must be fully compliantcompliant and must beand must be
willing to accept the potential risks of tubalwilling to accept the potential risks of tubal
rupture.rupture.

 Initial follow upInitial follow up
 twice weekly with serial hCGmeasurementstwice weekly with serial hCGmeasurements
 weekly by transvaginal examinationsweekly by transvaginal examinations
 By the first weekBy the first week
 drop in HCG leveldrop in HCG level
 Adnexal mass sizeAdnexal mass size
 Otherwise reassess the optionsOtherwise reassess the options
(Medical/Surgical)(Medical/Surgical)
 If the fall of HCG & reduction in size ofIf the fall of HCG & reduction in size of
adnexal mass satisfatoryadnexal mass satisfatory
 weekly hCG and transvaginal ultrasoundweekly hCG and transvaginal ultrasound
MONITORINGMONITORING

 45–70% of pregnancies of unknown45–70% of pregnancies of unknown
location resolve spontaneously withlocation resolve spontaneously with
expectant managementexpectant management
 Ectopic pregnancy was subsequentlyEctopic pregnancy was subsequently
diagnosed in 14–28% of cases ofdiagnosed in 14–28% of cases of
pregnancy of unknown locationpregnancy of unknown location
 Intervention has been shown to beIntervention has been shown to be
required in 23–29% of cases.required in 23–29% of cases.

 Selection criteriaSelection criteria
 Minimal symptoms & The patient must beMinimal symptoms & The patient must be
hemodynamicallyhemodynamically stablestable
 no signs or symptoms of activeno signs or symptoms of active bleedinbleeding org or
haemoperitoneum.haemoperitoneum.
 Absence of foetal heartAbsence of foetal heart beatbeat
 Normal FBC,U&E(urea & electrolytes),LFT(liverNormal FBC,U&E(urea & electrolytes),LFT(liver
function tests)function tests)
 Exclusion criteriaExclusion criteria
 AnyAny hepatichepatic dysfunction, thrombocytopeniadysfunction, thrombocytopenia
(platelet count <100,000), blood dyscrasia(WCC(platelet count <100,000), blood dyscrasia(WCC
<2000 cells cm3).<2000 cells cm3).
 Difficulty or unwillingness of patient for prolongedDifficulty or unwillingness of patient for prolonged
CRITERIA forCRITERIA for MEDICAL MANAGEMENTCRITERIA forCRITERIA for MEDICAL MANAGEMENT

 Methotrexate – a drug that destroys actively growing tissues such as theMethotrexate – a drug that destroys actively growing tissues such as the
placental tissues ,is used as an injection in selected cases to avoid surgery (in nonplacental tissues ,is used as an injection in selected cases to avoid surgery (in non
ruptured ectopic)ruptured ectopic)
 Side effects include abdominal pain for 3 – 7 days in 50% of cases and mildSide effects include abdominal pain for 3 – 7 days in 50% of cases and mild
symptoms of nausea, mouth dryness and soreness and diarrhoea,symptoms of nausea, mouth dryness and soreness and diarrhoea,
 Methotrexate-Intramuscular(buttock or lateral thigh)Methotrexate-Intramuscular(buttock or lateral thigh)
 Dose calculated from body surface areaDose calculated from body surface area
 Usual dose ranges between 75-95 mgUsual dose ranges between 75-95 mg
 HCG checked on day 4 & day 7HCG checked on day 4 & day 7
 If fall is less than 15 % consider second dose of methotrexateIf fall is less than 15 % consider second dose of methotrexate
 Anti-D should also be given if requiredAnti-D should also be given if required
 Rest up to one hour after the injection.Rest up to one hour after the injection.
 Check for any local reaction.Check for any local reaction.
METHOTREXATEMETHOTREXATEMETHOTREXATEMETHOTREXATE

 90% successful treatment with single dose regime.90% successful treatment with single dose regime.
 Recurrent ectopic pregnancy rate 10 – 20%.Recurrent ectopic pregnancy rate 10 – 20%.
 Tubal patency approximately 80%.Tubal patency approximately 80%.
 14 % of medical management second dose of14 % of medical management second dose of
methotrexatemethotrexate
 75% would experience abdominal pain-separation75% would experience abdominal pain-separation
pain. This usually occurs between day 3-7pain. This usually occurs between day 3-7
 10% would finally require surgical management10% would finally require surgical management
OUTCOME

Indications for surgical treatmentIndications for surgical treatmentIndications for surgical treatmentIndications for surgical treatment
 The patient is not a suitable candidate forThe patient is not a suitable candidate for
medical therapy.medical therapy.
 Medical therapy has failed.Medical therapy has failed.
 The patient has a heterotopic pregnancy with aThe patient has a heterotopic pregnancy with a
viable intrauterine pregnancy.viable intrauterine pregnancy.
 The patient is hemodynamically unstable andThe patient is hemodynamically unstable and
needs immediate treatment.needs immediate treatment.

ECTOPICECTOPIC
PREGNANCYPREGNANCY
RUPTUREDRUPTURED

 GetGet helphelp- call senior /Consultant on call- call senior /Consultant on call
 ABCABC of resuscitationof resuscitation
 give facial oxygengive facial oxygen
 Site two IV lines , commence IV fluids (crystalloid)Site two IV lines , commence IV fluids (crystalloid)
 Send blood for FBC, Clotting screen and cross-match at least 4 units of blood.Send blood for FBC, Clotting screen and cross-match at least 4 units of blood.
 insert indwellinginsert indwelling cathetercatheter
 arrange theatre forarrange theatre for laparotomylaparotomy
 whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensivewhilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive
monitoring of haemodynamic statemonitoring of haemodynamic state
 do not wait for BP and pulse to normalise prior to transfer-resuscitation and surgerydo not wait for BP and pulse to normalise prior to transfer-resuscitation and surgery
need to go hand in hand.need to go hand in hand.
 PfannensteilPfannensteil incision,incision,
 salpingectomysalpingectomy and wash out of abdomenand wash out of abdomen
 assess bloods /consider CVPassess bloods /consider CVP
 record operativerecord operative findingsfindings including the state of the remaining tube/pelvisincluding the state of the remaining tube/pelvis
 Anti – DAnti – D immunoglobulin (250 IU)to be given to Rhesus negative womenimmunoglobulin (250 IU)to be given to Rhesus negative women

LaparascopyLaparascopy OROR laparatomy??laparatomy??LaparascopyLaparascopy OROR laparatomy??laparatomy??
 Laparoscopy has become the recommended approach inLaparoscopy has become the recommended approach in
most cases.most cases.
 Laparotomy is usually reserved for patients:Laparotomy is usually reserved for patients:
 who are hemodynamically unstablewho are hemodynamically unstable
 patients with cornual ectopic pregnancies.patients with cornual ectopic pregnancies.
 for surgeons inexperienced in laparoscopy and in patientsfor surgeons inexperienced in laparoscopy and in patients
where laparoscopic approach is difficultwhere laparoscopic approach is difficult

SalpingectomySalpingectomy OROR SalpingotomySalpingotomySalpingectomySalpingectomy OROR SalpingotomySalpingotomy
 SalpingectomySalpingectomy
 Salpingectomy (tubal removal) is the principle treatmentSalpingectomy (tubal removal) is the principle treatment
especially where there is tubal ruptureespecially where there is tubal rupture
 SalpingotomySalpingotomy
 Conservative surgical management may be employed when theConservative surgical management may be employed when the
ectopic has not ruptured and where the tube appears normalectopic has not ruptured and where the tube appears normal
 Total salpingectomy is the procedure of choice:Total salpingectomy is the procedure of choice:
 In a patient who has completed childbearing and noIn a patient who has completed childbearing and no
longer desires fertilitylonger desires fertility
 in a patient with a history of an ectopic pregnancy in thein a patient with a history of an ectopic pregnancy in the
same tube.same tube.
 in a patient with severely damaged tubes,in a patient with severely damaged tubes,

H
eterotropic
C
ervical
C
ervical
Abdom
inal
Abdom
inal
O
varian
O
varian
Other TypesOther TypesMx

Cervical pregnancyCervical pregnancy

 Laparotomy and inoculation of theLaparotomy and inoculation of the
ectopic pregnancy andectopic pregnancy and
reconstruction of the ovary ifreconstruction of the ovary if
possible. Otherwise, removal of thepossible. Otherwise, removal of the
affected ovary is indicated.affected ovary is indicated.
 Ovarian cystectomy is the preferredOvarian cystectomy is the preferred
treatmenttreatment
 Treatment with MTX andTreatment with MTX and
prostaglandin injection has also beenprostaglandin injection has also been
reportedreported

pregnancypregnancy
 The condition should be terminated surgicallyThe condition should be terminated surgically
through Laparotomy once diagnosedthrough Laparotomy once diagnosed
 MTX treatment appears to be contraindicatedMTX treatment appears to be contraindicated
because of the high rate of complications due tobecause of the high rate of complications due to
rapid tissue necrosisrapid tissue necrosis

Heterotropic pregnancyHeterotropic pregnancy
 Depends uponDepends upon
the state of thethe state of the
womanwoman
and the skill ofand the skill of
the doctor.the doctor.
 .Surgical.Surgical

 LaparoscopyLaparoscopy is the ideal surgical method tois the ideal surgical method to
remove an ectopic pregnancy before it rupturesremove an ectopic pregnancy before it ruptures
without interrupting the viable pregnancy.without interrupting the viable pregnancy.
Although the intrauterine pregnancy can stillAlthough the intrauterine pregnancy can still
survive if the ectopic pregnancy ruptures, theresurvive if the ectopic pregnancy ruptures, there
is an increasedis an increased danger of miscarriage.danger of miscarriage. TheThe
surgery must be done with great skill and it issurgery must be done with great skill and it is
important that bleeding be addressed quickly.important that bleeding be addressed quickly.
Medical therapies include injecting the ectopicMedical therapies include injecting the ectopic
pregnancy in order to terminate the gestation.pregnancy in order to terminate the gestation.

Anti DAnti DAnti DAnti D
 Non sensitized women who are rhesusNon sensitized women who are rhesus
negative with a confirmed or suspectednegative with a confirmed or suspected
ectopic pregnancy should receive anti-Dectopic pregnancy should receive anti-D
immunoglobulin.immunoglobulin.
 In accordance with RCOG Guideline it isIn accordance with RCOG Guideline it is
recommended that anti-D immunoglobulin at arecommended that anti-D immunoglobulin at a
dose of 250 IU (50 micrograms) be given to alldose of 250 IU (50 micrograms) be given to all
non sensitized women who are rhesus negativenon sensitized women who are rhesus negative
and who have an ectopic pregnancy.and who have an ectopic pregnancy.

ADVICEADVICE
 Not using IUCDNot using IUCD
 Not using progesterone only pillsNot using progesterone only pills
 Treatment for any PIDTreatment for any PID
 Follow up by HCG that should disappear after 1Follow up by HCG that should disappear after 1
monthmonth
 Do HSG after 40 day to see patency of the tubeDo HSG after 40 day to see patency of the tube
 Use barrier method of contraceptionUse barrier method of contraception
 Timing of pregnancy, visit specialist in any missedTiming of pregnancy, visit specialist in any missed
periodperiod

 Recurrence of ectopicRecurrence of ectopic
 InfertilityInfertility
 Shock & deathShock & death
 Tubal rupture & organ damageTubal rupture & organ damage
 PsychologicalPsychological
 Surgical RxSurgical Rx
 Medical RxMedical Rx
COMPLICATIONCOMPLICATIONCOMPLICATIONCOMPLICATION

PrognosisPrognosis
Fertility following ectopic pregnancyFertility following ectopic pregnancy
depends upon several factors, the mostdepends upon several factors, the most
important of which is a prior ofimportant of which is a prior of
infertilityinfertility. The treatment choice. The treatment choice
history , whether surgical orhistory , whether surgical or
nonsurgical, also plays a role. Fornonsurgical, also plays a role. For
example, the rate of intrauterineexample, the rate of intrauterine
pregnancy may be higher followingpregnancy may be higher following
methotrexate compared to surgicalmethotrexate compared to surgical
treatment. Rate of fertility may betreatment. Rate of fertility may be
better following salpingostomy thanbetter following salpingostomy than
salpingectomy.salpingectomy.

Ectopic pregnancy

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