Ectopic Pregnancy has certain risks associated with it. Dr Manavita Mahajan explains the risks, diagnosis and management of Ectopic Pregnancy. She is a renowned Gynaecologist and is known all over the world for her professionalism and experience.

1. Dr Manavita Mahajan
MD (PGI Chandigarh) , FRCOG (London)
Sr Consultant Obstetrician & Gynecologist

2. What is Ectopic
Pregnancy
Pregnancy
1. Inside uterus –
NORMAL Pregnancy
Location
2. Outside Uterus –
ECTOPIC PREGNANCY
Incidence – approx. 2%
Commonest Site – Fallopian
tube
Other sites – Ovary , Cervix ,
Abdomen

3. Why Worry
About Ectopic
Pregnancy
DANGEROUS
Intra-abdominal
Haemorrhage &
Death
Loss of TUBE -
Fertility
Compromised

4. Risk Factors / Etiology
 ETIOLOGY of Ectopic Pregnancies is unknown
 RISK FACTORS
1. Current or previous Pelvic Inflammatory Disease
2. Previous Ectopic pregnancy
3. Previous Tubal surgery (including reversal of tubal sterilisation
operation)
4. Pregnancy with Intra Uterine Contraceptive Device still in place
5. Pregnancies resulting from Fertility Treatments (including IVF)
6. Failed Emergency Contraceptive Pill (progestin only)
7. Prior Abdominal Surgeries ( esp. Ruptured appendix)
8. Congenital Uterine Malformations

5. SYMPTOMS
Women with Ectopic Pregnancy may present in
many different ways and a high index of clinical
suspicion is needed to diagnose this condition.
 Missed Period
 Abdominal Pain
 Vaginal Bleeding
 Dizziness/ Fainting/Shoulder tip pain
 ASYMPTOMATIC

6. SIGNS
 Tachycardia
 Hypotension
 Pallor
 Distended Abdomen / free fluid / tenderness
 Vaginal Assessment – Tender Pelvis

7. Differential Diagnosis
 Abortion (Intrauterine Pregnancy)
 Ovarian Cyst – Torsion / Haemorrhage
 Corpus Luteal Haematoma
 Acute Appendicitis
 UTI
 Ureteric Colic
 Acute Abdomen

8. FINAL VERDICT
 WHO IS AT RISK - ALL PREGNANT WOMEN
 HIGH INDEX OF SUSPICION
All women of the childbearing age presenting with
acute abdomen or cramping and abnormal
vaginal bleeding should have a pregnancy test
performed to confirm or exclude the possibility of
pregnancy (Intrauterine or Ectopic).

9. HOW TO DIAGNOSE ECTOPIC
PREGNANCY EARLY?
STEP 1 Correct Diagnosis of Pregnancy
 History of Missed Period – UNRELIABLE
 Urine Pregnancy Test – Usually Positive
 Beta hCG ( Blood Pregnancy Test) – positive in all
pregnant women. Level less than 5 rules out
pregnancy
 Ultrasound
1. TRANSABDOMINAL - Unreliable
2. TRANSVAGINAL –very early pregnancy not
diagnosed

10. DIAGNOSIS OF PREGNANCY
 Urine Pregnancy Test
 Blood Pregnancy Test

11. DIAGNOSIS OF ECTOPIC
PREGNANCY
 Clinical Scenario 1 – Woman presents to Emergency
with acute abdomen & is in Haemorrhagic Shock &
pregnancy test is positive
 Clinical Scenario 2 – Asymptomatic patient with +ve
pregnancy test +/- risk factors for ectopic pregnancy
 Clinical Scenario 3 – Patient with pain abdomen
and/or bleeding per vaginum in early pregnancy

12. DIAGNOSIS IN STABLE PATIENT
 Perform Trans Vaginal Sonography(TVS)
1. Intrauterine pregnancy confirmed ( I.U. Gestational
Sac with yolk sac +/- embryo)
2. Ectopic Pregnancy confirmed ( Empty Uterus ,
Adnexal Mass with Gestational Sac , Free fluid in pelvis/
abdomen)
3. Empty uterus , no adnexal mass (NO EVIDENCE of
PREGNANCY)

13. DIAGNOSTIC DILEMMNA –
POSITIVE PREGNANCY TEST ,EMPTY
UTERUS ON TVS
Beta hCG test should be performed
 Beta hCG < 1500 . The test should be repeated at 48 hours
and if doubling of the previous titre is seen then it is likely
to be intrauterine pregnancy. Transvaginal Ultrasound should
then be repeated by an experienced sonographer when the level
is >1500 and intrauterine pregnancy should be identified
.
 Beta hCG > 1500-2000 with an empty uterus on Transvaginal
sonography by an experienced sonographer generally
implies an ectopic pregnancy (exception being a multiple
gestation) and the woman should be counselled accordingly.

14. Let’s Remember
 Diagnose pregnancy by pregnancy test (urine or
beta hCG)
 Perform pregnancy test in all cases of acute
abdomen in women of childbearing age
 Trans Vaginal Sonography should detect
pregnancy in all cases when beta hCG > 1500.
Failure to detect ( empty Uterus)implies possible
Ectopic Pregnancy

15. Management of Ectopic Pregnancy
 Case 1 – Patient presents with Haemorrhagic
Shock
IMMEDIATE RESUSCITATION WITH LAPAROTOMY
 Case 2 – Stable Patient with Ectopic Pregnancy
1. Laparoscopy & Surgical Management
2. Medical Management with Methotrexate

16. ROLE of LAPAROSCOPY
 Tubal Ectopic pregnancies are readily diagnosed and
treated by laparoscopic approach.
 Surgical procedures that are performed are
1. removal of the involved tube (Salpingectomy)
2. removal of the pregnancy tissue with conservation
of tube (salpingostomy).

17. Salpingectomy video

18. What is Medical Management of
Ectopic Pregnancy?
 Methotrexate (folate antagonist) has good activity against pregnancy tissue
(trophoblastic tissue) and has been used to destroy the ectopic gestation in
carefully selected women.
 The prerequisites for methotrexate administration are
1. Haemodynamically stable patient with no intraabdominal bleed.
2. Beta hCG </=3000
3. No cardiac activity demonstrated in the fetus on Ultrasound(TVS)
4. Ectopic size<3.5 cm
5. No Medical problems in the women (exclude anaemia, kidney or liver or
haematological disorders)
6. Good patient compliance with follow up visits as tubal ruptures have been
known to occur in some women in the resolution phase of the disease.


19. Post Ectopic pregnancy -Some
Counselling Points
 Risk of Ectopic Pregnancy in next pregnancy is
around 7-10% and hence she must report early in next
pregnancy.
 Contraception – Barrier methods or OC Pills are
advocated. Should avoid Intra Uterine Contraceptive
Device and progestin only emergency pills
 Anti D should be administered to Rhesus negative
non sensitised women.


20. SUMMARY
 To summarise , early diagnosis of Ectopic pregnancies
requires constant vigilance on the part of the
clinician and we have been greatly helped in this
endeavour by the modern improved pregnancy
diagnosis(serum Beta hCG)methods and
Transvaginal Scanning.This ,along with operative
laparoscopic techniques , has improved the
outcomes for great majority of women with Ectopic
Pregnancies.

21. Thank you