This document provides information about ectopic pregnancies, including: - Ectopic pregnancies occur when a fertilized egg implants outside of the uterus, most commonly in the fallopian tubes. - Risk factors for ectopic pregnancy include previous tubal surgery, infertility, sexually transmitted infections, IUD use, smoking, and more. - Symptoms often include abdominal pain, vaginal bleeding, and a missed period. Diagnosis involves ultrasound examination, hCG level testing, and sometimes culdocentesis. - Treatment options are medical management using methotrexate or surgical intervention like laparoscopy or laparotomy. The type of ectopic pregnancy such as tubal, cervical, or heter

1. ECTOPIC
PREGNANCY
Dr.Rafi Rozan
Obstetrician & Gynecologist

2. Ectopic Pregnancy
• Following fertilization and fallopian tube
transit, the blastocyst normally implants in
the endometrial lining of the uterine cavity
• Implantation anywhere else is an ectopic
pregnancy
• There is a 7-to 13-fold increase in the
risk for a subsequent ectopic pregnancy.
• The chance for a subsequent successful
pregnancy is reduced after an EP.

3. CLASSIFICATION

4. Risk Factor Risk
High Risk
Tubal corrective surgery
Tubal sterilization
Previous EP
In utero DES exposure
IUD
Documented tubal pathology
Moderate Risk
Infertility
Previous genital infection
Multiple partners
Slight risk
Previous pelvic or abdominal surgery
Smoking
Douching
Intercourse before 18 weeks
21.0
9.3
8.3
5.6
4.2-45
3.8-21
2.5-21
2.5-3.7
2.1
0.93-3.8
2.3-2.5
1.1-3.1
1.6
Risk Factors for Ectopic Pregnancy

5. Increasing ectopic pregnancy rates
1. Prevalence of sexually transmitted tubal infection and damage
2. Ascertainment through earlier diagnosis of some EP otherwise
destined to resorb spontaneously
3. Popularity of contraception that predisposes failures to be
ectopic
4. Use of tubal sterilization techniques that increase the likelihood
of EP
5. Use of assisted reproductive techniques
6. Use of tubal surgery, including salpingotomy for tubal pregnancy
and tuboplasty for infertility
7. Smoking

6. Evolution and Potential Outcome
1. Tubal Rupture: Tubal EP usually burst spontaneously but may
occasionally rupture following coitus or bimanual examination.
common with isthmus EP.
2. Tubal Abortion: This is common in ampullary and fimbrial EP
3. Pregnancy failure with Resolution: this is documented more
regularly with the advent of B-hCG assays.

7. There are differences between:
Acute Ectopic Pregnancy
Chronic Ectopic Pregnancy

8. CLINICAL
MANIFESTATIONS
Classic triad of symptoms
• Pain
• Amenorrhea (?)
• Vaginal bleeding or spotting

9. Presumptive Signs:
* Delayed menstruation
* Neurovegetative imbalance
* Pigmentation
* Mammary
* Jacquemier
* Chadwick
* Berstine & Montgomery
CLINICAL MANIFESTATIONS

10. Probability Signs:
•Sellheim
•Kunge
•Pschyrembel
•Hegar I
•Hegar II : not recommended
•Increase size of the uterus
•Gauss
•Noble Budin
•Holzapfel (Soft mature fruit)
•Piscacek
•Oschander
CLINICAL MANIFESTATIONS
Certainty Signs:
•US
•X-ray (Not Currently Recommended
•Fetal Movements
•Presence of fetal heart Rate.

11. ECTOPIC PREGNANCY
CLINICAL MANIFESTATIONS
• Martin *Alder (Abd Hypersensitivity)
• Rounge Simon * Blumberg (Decp RLW)
• Laffont * Guencav Mussy (Decp Abd)
• Kustallov * Granville Chapman (Incorporate Dif)
• Oddy * Wynter (Absence Resp Mv)
• Banki * Moylan & Mosadeg (Tenesmos)
• Frankel * Solowy (Pos Fornix Resistance)
• Douglast *Hergfeld (Need to urinate rup EP)
• Proust * Monadegh (proctodynia rup EP)
• Hofstaetter Cullen Hellendal * Cattomas (Rapid relief rup EP)
• Santomanso & Salmon: Anisocoria

12. Passage of Decidual Cast
• Occurs in 5%-10% of women
• Their passage may be accompanied by
cramps similar to those occurring with
a spontaneous abortion
• Comes out in the shape of the uterine
cavity. Decidual Casts have a well-
known association with ectopic
pregnancies

13. Arias-Stella Reaction Phenomenon
It is a benign change in the endometrium due to progesterone primarily,
associated with the presence of chorionic tissue. Cytologically, it looks
like a malignancy and, historically, it was diagnosed as endometrial
cancer.

14. Algorithm for evaluation of EP

15. Culdocentesis
• A simple technique to identify
hemoperitoneum
• The cervix is pulled toward the
symphysis pubis with a tenaculum
• A long 16- or 18-gauge needle is
inserted through the posterior
fornix into the
culdesac
• Non-clotting blood aspirated:
compatible
with the diagnosis of
hemoperitoneum resulting
from an rupture EP.

16. • In gestations longer than 5.5 weeks, a transvaginal ultrasonographic
examination should identify an intrauterine pregnancy with almost
100% accuracy.
• Approximately 25 to 50% of women with an ectopic pregnancy initially
present with a pregnancy of unknown location, and approximately 7 to
20% of women with a pregnancy of unknown location ultimately receive
a diagnosis of an ectopic pregnancy.
Ultrasonographic Examination

17. Ectopic (tubal)
pregnancy
Ultrasonographic
Findings
Comments
Viable extrauterine
pregnancy
Extrauterine gestational
sac with fetal pole and
cardiac activity
Presence of a yolk sac or
fetal pole has positive
predictive value of almost
100% for identifying ectopic
pregnancy
Nonviable extrauterine
gestation
Extrauterine gestational
sac with a fetal pole,
without cardiac activity
Fetal pole with or without
cardiac activity seen in 13%
of ectopic pregnancies
diagnosed by
ultrasonography
Ring sign Adnexal mass with a
hyperechoic ring around
a gestational sac
Seen in 20% of ectopic
pregnancies diagnosed by
ultrasonography
Nonhomogeneous
mass
Adnexal mass separate
from the ovary
Seen in 60% of ectopic
pregnancies diagnosed by
ultrasonography; positive
predictive value ranges from
80 to 90%

18. Early gestational sac in the uterus without a yolk sac or fetal pole in anEarly gestational sac in the uterus without a yolk sac or fetal pole in an
intrauterine pregnancy. The gestational sac has a diameter of 0.65 cm andintrauterine pregnancy. The gestational sac has a diameter of 0.65 cm and
is consistent with a gestational age of 5 weeks 2 days.is consistent with a gestational age of 5 weeks 2 days.
A

19. Pseudo-gestational sac that resembles the gestational sac, but it is centrallyPseudo-gestational sac that resembles the gestational sac, but it is centrally
located, it is not symmetric, and it is associated with septation.located, it is not symmetric, and it is associated with septation.
B

20. C
A gestational sac and a yolk sac with evidence of associated free fluid.A gestational sac and a yolk sac with evidence of associated free fluid.

21. Ring sign — a hyperechoic ringRing sign — a hyperechoic ring around an extrauterine gestational sac.
D

22. E
Ectopic pregnancy characterized by an extrauterine adnexal mass,Ectopic pregnancy characterized by an extrauterine adnexal mass,
separate from the ovary, without any evidence of a gestationalseparate from the ovary, without any evidence of a gestational sac.
The mass is 2.2 by 2.2 cm.

23. Laboratory tests
• hCG assays
• EP cannot be diagnosed by a positive pregnancy test alone
• hCG assays positive in over 99% of EPs
• Sensitive to levels of chorionic gonadotropin of 10-20 mIU/ml
• The hCG pattern that is most predictive of EP is one that has reached a
plateau (doubling time of more than 7 days)

24. The “discriminatory hCG value” has been reported to be 1500, 2000
and 3510 mIU/ml, which can be used to determine the level of hCG
at which the sensitivity of ultrasonography for the detection of
intrauterine pregnancy approaches 100% and at which the absence
of an intrauterine pregnancy suggests abnormal or ectopic gestation.
Correlation of Ultrasonographic
Findings with hCG Values

26. Change in the hCG
Level in Intrauterine
Pregnancy, Ectopic
Pregnancy, and
Spontaneous Abortion.
An increase or decrease in the
serial hCG level in a woman
with an ectopic pregnancy is
outside the range expected for
that of a woman with a
growing intrauterine
pregnancy or a spontaneous
abortion 71% of the time.
However, the increase in the
hCG level in a woman with an
ectopic pregnancy can mimic
that of a growing intrauterine
pregnancy 21% of the time,
and the decrease in the hCG
level can mimic that of a
spontaneous abortion 8% of
the time.

27. Management
- Medical
Use of Methotrexate, a folic antagonist which tightely binds to
dihydrofolate reductase blocking the reduction of dihydrofolate
to tetrahydrofolate which is the active form of the folic acid.
As a result the new purine and pyrimidine synthesis is halted which
leads to arrested DNA, RNA and protein synthesis.
- Surgical

29. Surgical diagnosis
• Laparoscopy
• Offers a reliable diagnosis in most
cases of suspected EP and a ready
transition to definitive operative
therapy
• Laparotomy
• Open abdominal surgery is preferred
when the woman is
hemodynamically unstable or when
laparoscopy is not feasible
Ectopic Pregnancy

30. Type of EP Definition
Tubal pregnancy A pregnancy occurring in the fallopian tube – most often these
are located in the ampullary portion of the fallopian tube
Interstitial pregnancy A pregnancy that implants within the interstitial portion of the
fallopian tube
Abdominal
pregnancy
Primary – the 1st
and only implantation occurs on a peritoneal
surface
Secondary – implantation originally in the tubal ostia,
subsequently aborted and then reimplanted into the
peritoneal surface
Cervical pregnancy Implantation of the developing conceptus in the cervical canal
Ligamentous
pregnancy
A secondary form of EP in which a primary tubal pregnancy
erodes into the mesosalpinx and is located between the leaves
of the broad ligament
Heterotopic
pregnancy
A condition in which ectopic and intrauterine pregnancies coexist
Ovarian pregnancy A condition in which an EP implants within the ovarian cortex
Table 2. Definitions of Types of Ectopic Pregnancies

31. Tubal Pregnancy
• The fertilized ovum may
lodge in any portion of the
oviduct, giving rise to ampullary,
isthmic, and interstitial tubal
pregnancies
• Ampulla is the most frequent site, followed by
the isthmus
• Interstitial pregnancy accounts for only 3% of all
tubal gestations

32. Tubal Pregnancy
• Treatment
• Anti-D immunoglobulin
• D-negative women with an ectopic pregnancy who are not sensitized to D-antigen
should be given anti-D immunoglobulin

33. Tubal Pregnancy
• Treatment
• Surgical Management
• Laparoscopy is preferred over laparotomy unless the patient is unstable
• Tubal surgery for EP is considered conservative when there is tubal salvage
(salpingostomy, salpingotomy, fimbrial expression of the EP)
• Radical surgery is defined by salpingectomy

34. Tubal Pregnancy
• Salpingostomy
• Used to remove a small pregnancy that is
usually less than 2 cm in length and
located in the distal third of the fallopian
tube
• A linear incision, 10-15 mm in length or
less, is made on the antimesenteric
border, immediately above the EP
• POC extruded out; small bleeding sites
controlled with needlepoint
electrocautery or laser
• Incision is left unsutured and to heal by
secondary intention

35. Tubal Pregnancy
• Salpingotomy
• Essentially the same as salpingostomy except that the incision is closed
with 7-0 Vicryl or similar suture

36. Tubal Pregnancy
• Salpingectomy
• May be performed through an operative laparoscope and may be used
for both ruptured and unruptured EP
• When removing the oviduct, it is advisable to excise a wedge of the outer
third (or less) of the interstitial portion of the tube (cornual resection)
• To minimize the rare recurrence of pregnancy in the tubal stump

37. Tubal Pregnancy
• Segmental resection and anastomosis
• Resection of the ectopic mass and tubal reanastomosis is sometimes
used for an unruptured isthmic pregnancy because salpingostomy may
cause scarring and subsequent narrowing of the small isthmic lumen

38. Tubal Pregnancy
• Medical Management
• Systemic MTX
• MTX acts as a folic acid antagonist and is highly effective against rapidly proliferating
trophoblasts
• Active intraabdominal bleeding is contraindicated
• May not be used if the EP is > 4 cm
• Success is greatest if the AOG is < 6 weeks, the tubal mass is not > 3.5 cm in
diameter, the fetus is dead, and the B-hCG <15,000 mIU/mL

39. Cervical Pregnancy
• 1 in 2,400 to 1 in 50,000 pregnancies (US)
• Conditions that predispose:
• Previous therapeutic abortion
• Asherman’s syndrome
• Previous CS
• DES exposure
• Leiomyomas
• IVF

40. Cervical Pregnancy
• Diagnostic Criteria
1. The uterus is smaller than the surrounding distended cervix
2. The internal os is not dilated
3. Curettage of the endometrial cavity is non-productive of placental tissue
4. The external os opens earlier than in spontaneous abortion

41. Cervical Pregnancy
• Preoperative preparation should include blood typing and cross-
matching, IV access, and detailed informed consent which include
the possibility of hysterectomy in the event of hemorrhage
• Non-surgical management: intraamniotic and systemic MTX
administration

42. Ovarian Pregnancy
Criteria for diagnosis (Spiegelberg’s Criteria)
1. The fallopian tube on the affected side must be
intact
2. The fetal sac must occupy the position of the ovary
3. The ovary must be connected to the uterus by the
ovarian ligament
4. Ovarian tissue must be located in the sac wall

43. Ovarian Pregnancy
• 0.5% to 1% of all ectopic pregnancies
• Most common type of non-tubal pregnancy
• Misdiagnosis common because it is confused with a
ruptured corpus luteum in up to 75% of cases
• Ovarian cystectomy is the preferred treatment
• Treatment with MTX and prostaglandin injection has
also been reported

44. Abdominal pregnancy
• Classified as primary and secondary
• Secondary abdominal pregnancies are by far the most common and
result from tubal abortion or rupture or, less often, from subsequent
implantation within the abdomen after uterine rupture
• 1 in 372 to 1 in 9,714 live births
• Incidence of congenital anomalies: 20%-40%

45. Abdominal pregnancy
• Clinical presentation
• In the 1st
and early second trimester, the symptoms may be the same as a tubal
EP
• In advanced pregnancy:
• Painful fetal movement
• Fetal movements high in the abdomen or sudden cessation of movements
• Persistent abnormal fetal lies, abdominal tenderness, displaced cervix, fetal superficiality
• No uterine contractions after oxytocin infusion

46. Abdominal pregnancy
Criteria for diagnosis – Studdiford’s Criteria
1. Presence of normal tubes and ovaries with
no evidence of recent or past pregnancy
2. No evidence of uteroplacental fistula
3. The presence of a pregnancy related
exclusively to the peritoneal surface and
early enough to eliminate the possibility of
secondary implantation after primary tubal
abortion

47. Abdominal pregnancy
• Surgical intervention
• Placenta can be removed if its vascular supply can be identified and
ligated; otherwise it is left behind, packing is done which is removed
after 24 to 48 hours
• MTX treatment appears to be contraindicated because of the high
rate of complications due to rapid tissue necrosis

48. Interstitial pregnancy
• Represent about 1% of EPs
• Patients tend to present later in gestation than those with tubal
pregnancies
• Often associated with uterine rupture – represent a large proportion
of fatalities from EP
• Treatment: cornual resection by laparotomy

49. Heterotopic pregnancy
• Occurs when there are coexisting intrauterine and ectopic
pregnancies
• 1 in 100 to 1 in 30,000 pregnancies
• Higher in patients who undergo ovulation induction
• Treatment is operative