This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It provides details on the classification, risk factors, symptoms, diagnosis, and treatment of ectopic pregnancy. Ectopic pregnancies are typically diagnosed through transvaginal ultrasound or serum hCG levels. Treatment options include medical management with methotrexate or surgical intervention like laparoscopy or laparotomy depending on the stability of the patient and size of the ectopic mass. The goal is to resolve the ectopic pregnancy while preserving the patient's future fertility if possible.

1. ECTOPIC PREGNANCY
Dr Manal Behery
Professor OB&GYNE
Zagazig university 2014

2. Ectopic
:
(Ektopos) out of place
Definition
Ectopic pregnancy: fertilized embryo
implanted outside the uterine cavity

4. Classification of ectopic pregnancy
>95%

8. Mechanical factors






Congenital: long narrow tube, diverticulae and
accessory ostia.
Traumatic: operation on the tube as salpingoplasty
and tubal reversal following ligation.
Inflammatory: Chronic salpingitis
Neoplastic: Narrowing of the tube by a fibroid or a
broad ligament tumor.
Functional: As tubal spasm or antiperistaltic
contractions.
endometriosis in the tube. encourages embedding
of the fertilized ovum.

9. RISK FACTORS

Hz of tubal surgery
Hx of STD’s (such as chlamydia)
 Hx of ART
 Hx of ectopic (esp if conservatively
managed without surgery)
 Smoking
 IUD in place at time of conception


10. Prior history of PID (pelvic
inflammatory disease)

11. TUBAL SURGERY

12. Animation of intrauterine implantation

13. P
athology of E
ctopic
P
regnancy

14. Outcomes
1.
Tubal abortion

15. 2. Rupture of tubal pregnancy

16. Ruptured ectopic pregnancy

17. •Extraperitoneal rupture (rupture through floor of the tube)
•may lead to broad ligament hematoma with death of the
ovum, or intraligamentary pregnancy.
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18. 3. Secondary abdominal pregnancy

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

21. 
Clinical Finding: Undistrubed ectopic

 Amenorrhoea
A dull aching pain is usually present in
one iliac fossa. It is due to distension of the
tube and stretching of its peritoneal coat.
 Classic signs –
 adnexal or cervical motion
tenderness.


22. Signs:




Abdominal examination: Tenderness in one
iliac fossa.
Vaginal examination:
(cervical motion tenderness or jumping sign)
The cervix is soft and severe pain occurs
when it is moved from side to side
A mass may be felt to one side of the uterus.
It is very tender, soft and may be pulsating.

23. Subacute type:Symptoms:

Short period of amenorrhea in (25%) no history
of amenorrhea due to occurrence of post
conceptional bleeding that mistaken as a true
menstrual period

Pain: It is felt in one iliac fossa. It may be dull
aching or sharp stabbing or colicky
Fainting attacks or even shock
Vaginal bleeding occurs after pain



24. With ruptured ectopic pregnancy




abdominal guarding and rigidity,
shoulder pain
fainting attacks
and shock.

25. When a woman presents with an
early pregnancy…

Ask yourself two questions…
Where is this pregnancy?
Is it viable?

26. Where is this pregnancy?
In a woman with an early pregnancy you
must determine if the pregnancy is
intrauterine or an ectopic, because her
life could depend on it!

27. How to you determine location of
the pregnancy?




First determine dating by LMP
Then perform ultrasound
If you can see location of the pregnancy, you
are done!
If you cannot…it becomes more
complicated…

28. β-hCG discriminatory value (or zone)

It is the lower limit of hCG at which an
examiner can reliably visualize pregnancy
on ultrasound. It is 1000-2000 IU/L with
vaginal ultrasound and 5000-6000 IU/L
with abdominal ultrasound.

29. If β-hCG levels above the
discriminatory value

The absence of uterine pregnancy
signifies an abnormal pregnancy; ectopic,
incomplete abortion

If β-hCG levels are still below the
discriminatory value, serial β-hCG and
ultrasound should be done.

30. Doubling sign:

In normal pregnancy a 66% or greater increase
in serum β-hCG levels should be observed
every 48 hours (nearly doubles).

Inappropriately rising serum β-hCG levels
suggest (but do not diagnose) an abnormal
pregnancy including ectopic, however, they do
not identify its location.

31. Tran abdominal US

32. Transvaginal ultrasound ( TVS):

33. Early pregnancy with unknown
location



Check a serum BHCG
If it is above the discriminatory zone (DZ)an
intrauterine pregnancy should be seen
Then do an ultrasound to see if you see the
pregnancy

34. LAPROSCOPY

35. Treatment of tubal pregnancy





If the patient is shocked: antishock measures.
If the patient is Rh negative and not sensitized
anti-D serum is given.
Medical therapy:
methotrexate (a folic acid antagonist).
IM methotrexate given as a single dose.

36. 
The best candidate is the woman who is
asymptomatic, compliant with follow-up, with
an initial serum value <5000 IU/L.
 Contraindications:
Breastfeeding
 Immunodeficiency / active infection
 Chronic liver disease
 Active pulmonary disease
 Active peptic ulcer or colitis
 Blood disorder
 Hepatic, Renal or Haematological
dysfunction


37. Signs and Treatment failure and tubal
rupture:

Significantly worsening abdominal pain,

Haemodynamic instability

Level of HCG do not decline by at least 15%
between Day 4 & 7 post treatment

 or plateauing HCG level after first week of
treatment

38. 
Follow-Up:

If the β-hCG level does not decline (plateau or
increase), the patient may require either a
second dose of methotrexate or surgery.
Surgical management:

Laparoscopy approach – salpingostomy

Laprotomy – salpingostomy
salpingectomy

39.  Salpingostomy / Salpingotomy is only indicated
when:
1. The patient desires to conserve her fertility
2. Patient is haemodinmically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 4Cm. In size
5. Contralateral tube is absent
or damaged

41. •Segmental resection: removal of
a portion of the affected tube.

42. laparatomy (if the mass is greater than 3.5 cm in
diametar, internal bleeding, cardiovascular colapse)

43. Treatment:
-metotrexate (if the mass is less then 3.5 cm in diametar)
-laparascopy,or Laprotomy
SALPINGOSTOMY
SALPINGECTOMY
intrapertoneal blood then peritoneal toilet.
Removal of any pelvic hematomas or

44. Algorithm for the diagnosis of unruptured ectopic pregnancy
without laparoscopy.

45. Management of ectopic pregnancy
11- Positive pregnancy test
Lowe abdominal pain +
Minimal Vaginal bleeding
Asymptomatic with factors
for ectopic pregnancy
2. History + clinical examination

46. If sure of date of LMP and /or
Regular cycle, i.e.
>6 wks. gestation,
Arrange TV ultrasound
If unsure of date of LMP
and /or irregular cycle,
Measure serum hCG
If hCG <1000
(?early Intrauterine/
? Ectopic pregnancy
If Hcg >1000, use
protocol for
suspected
Ectopic pregnancy
3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000
Meet criteria for
Methorexate treatment
Use methotrexate
protocol
Does not meet criteria
for methotrexate treatment
Laproscopic /salpingotomy/
Salpingectomy ?Proceed to
laparotomy OR Laparotomy if
haemodynamically unstable

47. Thank you
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