ECTOPIC PREGANCY

1. Medical Management of
Ectopic pregnancy
By Dr NDATABAYE Wilson Museveni
Resident OBGYN
Supervisor: Dr KAZINDU MFM
February 2024

2. Introduction
 ectopic pregnancy is a pregnancy in which blastocyst implant in sites other than endometrium of the uterine
cavity
 Estimated prevalence: 1% to 2%,
 Ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths.
 The prevalence of ectopic pregnancy with IUD in place is as high as 53%. (no difference in rates between
copper or progestin releasing IUDs)
 Note that pregnancy on IUD is less than 1%
Erin Hendriks, MD et al ( diagnosis and management of ectopic pregnancy)

5. Pathogenesis
 conditions that delay or prevent passage of the fertilized oocyte into the uterine cavity
 Factors inherent in the embryo that result in premature implantation
- Chronic salpingitis: 90%
- Salpingitis isthmica nodosa : the tubal mucosa penetrates into the myosalpinx, leading to hypertrophy of the
surrounding muscular layers; etiology is unknown, found in 10%
- Serum or extracellular factors like (eg, lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors,
cytokines, and modulator proteins) may cause premature implantation in the tube.
- Up to 50% of tubal ectopic pregnancies may abort spontaneously

8. Risk factors
• History of pelvic inflammatory disease,
• cigarette smoking,
• fallopian tube pathology/surgery
• previous ectopic pregnancy:10–15%
• infertility.
• Age > 35 years
• Pregnancy while intrauterine device is in place
A half of women with ectopic pregnancy have no identifiable risk factor

9. Risk factors
• History of ectopic pregnancy
• ART—of ectopic is 5–7% and that of heterotypic pregnancy is 1% in contrast
to 1 in 7,000 in spontaneous pregnancy
 A history of one ectopic pregnancy confers a 10% risk in subsequent
pregnancies,
 History of two or more ectopic pregnancies increases this risk to more than
25%.

11. Signs and symptoms
 A positive pregnancy test with a non-established intrauterine pregnancy and
- Vaginal bleeding and/or
- lower abdominal pain
 Bleeding is due to sloughing of decidual endometrium
 bleeding range from spotting to menstruation equivalent levels.
- The nature, location, and severity of pain in ectopic pregnancy vary
- Pain often begins as a colicky that is localized to one side as the pregnancy distends the
fallopian tube

12. Signs and symptoms:
• Location and degree of trophoblastic invasion dictates symptoms and clinical
presentation!
 Ampullary grow towards the lumen while isthmic distend a smaller space
and are more likely to rupture!
 Cornua Ectopic present late (>12 weeks) but proximity to ascending uterine
artery can make them catastrophic!
 Up to 50% of tubal ectopic pregnancies may abort spontaneously!

13. Signs and symptoms: ruptured ectopic pregnancy
• Generalized abdominal pain
• Syncope/ dizziness
• vomiting,
• diarrhea,
• shoulder pain,
• signs of hemodynamic instability
• cervical motion tenderness/ adnexa tenderness

14. Differential Diagnosis of Lower Abdominal
Pain or Vaginal Bleeding in Early Pregnancy
• Ectopic pregnancy
• Appendicitis
• Early pregnancy loss
• Ovarian torsion
• Pelvic inflammatory disease
• Subchorionic hemorrhage in viable intrauterine pregnancy
• Trauma
• Urinary calculi

15. Diagnostic tools
• visualization of gest sac, yolk sac and/or embryo in adnexa
• serial quantitative BHCG (pregnancy of unknown location)

18. Diagnosis: role of BHCG
• expected 48hours raise in BHCG of a normal pregnancy
 49% for an initial hCG level of <1500 mIU/mL,
 40%for an initial hCG level of 1500 to 3000 mIU/mL,
 33% for an initial hCG level of >3000 mIU/ml
 The rate of increase slows as pregnancy progresses and typically plateaus around 100,000
mIU per mL at 10 weeks’ gestation
 A decrease in β-hCG of at least 21% over 48 hours suggests a failed IUP, a smaller
decrease raise a concern for ectopic pregnancy
 Descriminatory zone is estimated at 3510mIU

19. ThePower of -hCG
■ the bHCG level that distinguishes patients with intrauterine
pregancies in whom a gestation sac can be seen from
those in whom it cannot be seen
■ Discriminatory zone for -hCG and sonography:
■ -hCG level that reliably identifies intrauterine
gestations
■ 1000-2000 mIU/mL for transvaginal ultrasound
■ HCG =3510 mIU/ml 99% sensitivity for IUP by TV US
■ -hCG levels above “the zone” with absence of IUP on
transvaginal ultrasound strongly suggest ectopic or early
pregnancy failure.

21. Ultrasound in the Diagnosis
of Ectopic Pregnancy
■ The first step in the ultrasound diagnosis of an ectopic pregnancy is
to evaluate the uterus for an IUP
■ The second step in diagnosis is to evaluate the adnexa for the
presence of a pregnancy or mass suspicious for an ectopic
gestation
■ The final step in diagnosis is to evaluate the pelvis for signs of tubal
rupture

22. Free Fluid
■ Small amounts may be physiologic.
■ Possible etiologies include:
■ Leaking corpus luteum
■ Tubal abortion without active bleeding
■ Active bleeding indicative of ruptured ectopic pregnancy
■ Manipulation of gain settings allows the evaluation of the
echogenicity and the swirling motion of the pelvic fluid,
which would suggest hemoperitoneum.

24. Heterotopic pregnancy
■ Simultaneous intrauterine and ectopic pregnancies
■ 1 per 30,000 pregnancies.
■ Increased incidence secondary to ovulation induction and ART
■ Dizygotic twin pregnancy and one gets stick in the tube
■ However, because of assisted reproductive technologies (ART),
■ Estimated 1 per 30,000 pregnancies
■ May need progesterone supplementation if corpis luteum is damaged wth
surgery

25. Diagnosis
■ Culdocentesis
■ Non-clotted blood
■ Hematocrit >15%
■ Laparoscopy +/- curettage
■ Laparatomy for late diagnosis and
hemoperitoneum

31. Management
• expectant
• surgical
• medical
Note: Rhogam if GA is less than 12 weeks
Natural history
If left untreated tubal pregnancy progress to:
 tubal rupture: surgical emergency
 tubal abortion to ovarian, intraabdominal pregnancy or tissue resorption
 spontaneous resolution

32. Expectant: must meet all criteria
 Asymptomatic.
 Understand the clinical implications and risks of an ectopic pregnancy;
reliable for follow up
 Ready access to a medical facility if emergency surgical treatment is needed.
 BHCG below descriminatory zone and plateauing or decreasing
 if initial BHCG ≤200 miu/mL) there is 88% complete resolution of
pregnancy

34. Medical management : methotrexate
folic acid antagonist : inhibits DNA synthesis and cell reproduction, primarily in
actively proliferating cells such as malignant cells, trophoblasts, and fetal cells
The optimal candidates:
Hemodynamically stable.
 BHCG < 5000
 No fetal cardiac activity detected on transvaginal ultrasound.
 Ectopic mass size less than 4 cm
- 2 doses protocol is indicated if BHCG is ≥ 5000mIU
- Folic acid supplements and NSAIDs can decrease the effectiveness of
methotrexate

35. Contraindications to MTX
• Renal insufficiency;
• Moderate to severe anemia,
• Leukopenia,
• Thrombocytopenia;
• Liver disease or alcoholism;
• Active peptic ulcer disease
• Breastfeeding.

39. Equations used
BSA = SquareRoot[(Height *
Weight / 3600)]

40. Leucovorin
• MTX reduces folates (called folinic acid, N5-formyl-
tetrahydrofolate, citrovorum factor)
• Leucovorin is given in combination with MTX
• To bypass the metabolic block induced by MTX and
• To rescue normal cells from toxicity.

43. Aggravating factors to avoid until treatment
of MTX is completed (ACOG,2019)
(1) Folic acid-containing supplements, which can competitively reduce MTX binding to
dihydrofolate reductase;
(2) Nonsteroidal antiinflammatory drugs, which reduce renal blood flow and delay drug
excretion;
(3) Alcohol, which can predispose to concurrent hepatic enzyme elevation;
(4) Sunlight, which can provoke MTXrelated dermatitis; and
(5) Sexual activity, which can rupture the ectopic pregnancy

44. Take home message
• Ectopic pregnancy is an obstetric emergency
• early recognition and appropriate management saves life
• ruptured ectopic pregnancy is a surgical emergency
• BHCG follow up is a cornerstone in medical management

45. References
• Dutta DC obstetrics 8th edition
• Williams obstetrics 24th edition
• Erin Hendriks et al; management and diagnosis of ectopic pregnancy 2020
• Up to date
• DeCherney AH, Jones EE. Ectopic pregnancy. Clin Obstet Gynecol. 1985 Jun;28(2):365-74.
doi
• Cohen A, Almog B, Cohen Y, Bibi G, Rimon E, Levin I. The role of HCG increment in the
48h prior to methotrexate treatment as a predictor for treatment success. Eur J Obstet
Gynecol Reprod Biol. 2017 Apr;211:103-107. doi: 10.1016/j.ejogrb.2017.02.007. Epub 2017
Feb 9. PMID: 28214759.