this is a lecture to undergraduates and healthcare professionals in the Obstetrics and Gynecology field about an important topic which is ectopic pregnancy. in this lecture, I simply described ectopic pregnancy for beginners in the medical field of Obstetrics and Gynecology with a focus on tubal ectopic pregnancy as it is the most common type of ectopic pregnancy. I discussed the topic about its definition, important tips about normal pregnancy at its early stages, differential diagnosis, how to reach the correct diagnosis, different lines of management, and what is the situation of Anti D in Rh-negative women

1. By
Dr. Ahmed Mohamed Nasef
Lecturer in Obstetrics & Gynecology department
Benha University

2. What is ectopic pregnancy?
Implantation of the gestational sac outside the endometrial
lining of the normal uterine cavity
With incidence of about 1-2%

3. Important tips before we
start

4. Normal site of implantation
In the endometrium of
the upper part of the
uterus

5. On what tests do we rely on the diagnosis of
early pregnancy?
Pregnancy test (Bhcg)
Qualitative (urine or serum)
Quantitative
Ultrasound

6. Normal scan in early pregnancy
• 4-5 wks/ Bhcg >1500 mIU/ml
A gestational sac is seen
• 5-6 wks/ GMSD >10 mm
The Yolk sac is visible
• 5-6 wks/ GMSD 25 mm
1 to 2mm embryo is seen adjacent
to the yolk sac
• 6-7 wks/ CRL 7mm
Fetal cardiac activity can be detected

8. Patterns of Bhcg levels in early pregnancy
By reassessing Bhcg after 48 hours
• Rise >100%
Healthy intrauterine pregnancy
• Rise >60%
Mostly intrauterine pregnancy
• Rise <60%
Mostly ectopic pregnancy
• Drop >50%
Failing pregnancy

9. Discriminatory zone
By TVUS
• A healthy pregnancy
gestational sac should appear
intrauterine by TVUS if the
quantitative Bhcg >1500
mIU/ml
By TAUS
• A healthy pregnancy
gestational sac should appear
intrauterine by TAUS if the
quantitative Bhcg >2500-3000
mIU/ml

10. Sites of ectopic pregnancy
• Tubal (95%)
• Extra tubal (5%) (cervical- cs scar- rudimentary horn- ovarian-
abdominal)
• Heterotopic (1/30000)

12. • With problems in the tubes
PID, peri tubal adhesions, previous tubal surgery, salpingitis
isthmica nodosa & congenital fallopian tube anomalies
• Previous ectopic pregnancy (with incidence 10-20%)
• ART
Due to atypical implantation, and linked with heterotopic pregnancy
• Contraception
IUCD, POPs, tubal sterilization
• Smoking

14. Inside the tube
asking, where to
go?

15. Fate of tubal ectopic pregnancy
• Inside tube
Detected early before rupture (undisturbed ectopic pregnancy)
• Rupture
Tube can't withstand pregnancy inside it and rupture then hemorrhage
(disturbed ectopic pregnancy)
• Tubal abortion (complete or incomplete)
Complete with stoppage of symptoms
Incomplete with continuous trickling of blood inside the peritoneal cavity
• Failure and reabsorption

16. Clinical presentation
• General examination
Asymptomatic (if undisturbed)
Symptoms of early pregnancy (amenorrhea, pain, bleeding)
Anemia with pallor and hyperdynamic circulation (if disturbed with mild to
moderate bleeding)
Shock (if severe intraperitoneal bleeding)
• Abdominal examination
Pain (may be mild, moderate, or severe), Tenderness, rigidity & rebound
tenderness in the lower abdomen
• Local examination
Mild bleeding
Cervical motion tenderness

18. Differential diagnosis
• Miscarriage
Amenorrhea, bleeding (main symptom), pain, falling Q-Bhcg level
• Vesicular mole
Amenorrhea, bleeding (brown prune juice with vesicles), higher
levels of Q-Bhcg
• Other causes of acute abdominal pain
Appendicitis, diverticulitis, urinary stones, and other medical or
surgical causes

20. +ve pregnancy test +
pain or bleeding
Hemodynamic
stable
TVUS
Normal IUP miscarriage Ectopic
Molar
pregnancy
Nonconclusive
Obtain initial
Q B hcg
Hemodynamic
unstable
Surgical
abdomen
Emergency
laparotomy or
laparoscopy
Excessive
vaginal
bleeding&
findings of
abortion
Emergency
uterine
curettage

21. Patterns of Bhcg levels in early pregnancy
By reassessing Bhcg after 48 hours
• Rise >100%
Healthy intrauterine pregnancy
• Rise >60%
Mostly intrauterine pregnancy
• Rise <60%
Mostly ectopic pregnancy
• Drop >50%
Failing pregnancy

22. TVUS findings in ectopic pregnancy
• Uterus
Empty uterine cavity with no IU gestational sac
• Adnexa
The presence of an adnexal mass with or without a visible
gestational sac
• Peritoneum
The presence of hemoperitoneum or hematoma

23. What to do in early pregnancy if we can’t
reach a diagnosis:
• Repeat Bhcg level after 48 hours
• Rescan by TVUS

26. Management options
• Expectant
• Medical
• Surgical

27. Expectant management
• In women with
An ectopic pregnancy or PUL with low Bhcg levels but with the
following criteria:
- Clinically stable with no abdominal pain
- US diagnosis of ectopic pregnancy measuring less than 30mm in
diameter with no evidence of cardiac activity
Decreasing Bhcg level that was initially below 1500 mIU/L
This line should be discontinued if any of the above changed

28. Medical management
• Drug used
Methotrexate
• Criteria of methotrexate use:
An unruptured ectopic (hemodynamic stability, no pain, adnexal mass
<35mm)
Bhcg levels less than 1500 mIU/L but can be given up to5000 mIU/L
No fetal cardiac activity
No IU pregnancy
Patient consent
No contraindications to methotrexate

29. Contraindications to medical treatment
• Hemodynamic instability
• IU pregnancy
• Breast feeding
• Patient refusal
• Hypersensitivity to methotrexate
• Chronic liver disease
• Immunodeficiency
• Peptic ulcer disease

30. Methotrexate regimen
• Single dose regimen
Day Bhcg Methotrexate
1 Ideal <1500 Given
4 Level to compare with day 7 Not given
7 Decrease >15% than day 4 Repeat Bhcg weekly till become
negative
Decrease <15% than day 4 TVUS & give another dose if
criteria still not fulfilled

31. Surgical treatment
• Main line of treatment
• 2 routes:
Laparoscopy
Laparotomy
• Operation
Salpingectomy (preferred)
Salpingotomy (not preferred but if needed fertility and previous
ectopic pregnancy & contralateral tubal damage)

32. Indications of surgical management
• Hemodynamic instability
• Detected extrauterine sac with visible pulsations
• Patient preference

35. Anti-D ig for Rhesus D (RhD) negative
women with an ectopic pregnancy
Should be given with surgical removal and heavy bleeding

36. • You should be ectopic-
minded to diagnose
ectopic
• Diagnosis of ectopic
should depend on both
the ultrasound and the
Q-Bhcg