An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. Damage to the fallopian tubes from infections or other causes is a major risk factor. Clinical presentation includes abdominal pain, delayed or abnormal vaginal bleeding. Diagnosis involves testing hCG levels in blood and ultrasound imaging. Treatment options are medical, using methotrexate, or surgical, typically laparoscopic surgery. Methotrexate can be used for stable patients with unruptured ectopic pregnancies.

1. ECTOPIC
PREGNANCY
PRESENTOR :
MANIKANDAN . V,
MSc. EMERGENCY MEDICINE,
AIMS, KOCHI.
MODERATOR :
Dr. DHANASEKARAN . B.S ,
PROFESSOR. EMERGENCY MEDICINE,
AIMS, KOCHI.

2. Causes &
Riskfactors
Introduction
AMPULLARY ->
ENDOMETRIUM OF
UTERUS
Pathophysiology&
Types
Clinical
manifestation
Triad
Diagnosis&
Management
surgical ,
medical
CONTENT :
Tubal
pregnancy
Anatomy & Normal
implantation
DAMAGE TO TUBAL
MUCOSA
Fallopian tube to
Peritoneal cavitry

3. INTRODUCTION
01
Tubal pregnancy

4. Introduction
Ectopic pregnancy occurs when a
conceptus implants outside of the
uterine cavity; ruptured ectopic
pregnancies ( life-threatening cause
of vaginal bleeding)are a leading
cause of maternal death in the first
trimester of pregnancy. Ectopic
pregnancies are often called tubal
pregnancies because most
are located in the fallopian tube.

5. ANATOMY &
NORMAL
IMPLANTATION
0
2
AMPULLARY -> ENDOMETRIUM OF UTERUS

6. ANATOMY :

7. NORMAL IMPLANTATION :
Fertilization of the oocyte usually
occurs in the ampullary segment of
the fallopian tube.
|
In normal pregnancy, after
fertilization, the zygote passes along
the fallopian tube and implants into
the endometrium of the uterus.

8. CAUSES &
RISK FACTORS
0
3
DAMAGE TO TUBAL MUCOSA

9. CAUSES :
INFECTION
preventing transport of
the ovum to the uterus.
Tubal sx
Elevated estradiol
or progesterone
levels
which inhibit tubal
migration.
Defects in the
ovum
resulting in premature
implantation
The vast majority of ectopic pregnancies implant in the ampullary portion of the fallopian
tube.The underlying cause is most often damage to the tubal mucosa from,

10. ● Pelvic inflammatory disease, history of sexually transmitted
infections
● History of tubal surgery or tubal sterilization
● Conception with intrauterine device in place
● Maternal age 35–44 (age-related change in tubal function)
● Assisted reproduction techniques (cause unknown, as tube is
bypassed in implantation)
● Previous ectopic pregnancy
● Cigarette smoking (may alter embryo tubal transport)
● Prior pharmacologically induced abortion
RISK FACTORS :

11. PATHOPHYSIOLOGY &
TYPES
0
4
FALLOPIAN TUBE TO PERITONEAL CAVITY

12. PATHOPHYSIOLOGY :
Tubal implantation results in the penetration of the
ovum into the muscular wall of the tube, and
maternal blood seeps into tubal tissue.
|
Intermittent distention of the fallopian tube with
blood can occur, with leakage of blood from the
fimbriated end of the fallopian tube into the
peritoneal cavity.
|
The aborting ectopic pregnancy and associated
hematoma can be completely or partially extruded
out of the end of the fallopian tube or through a
rupture site in the tubal wall

13. T
Y
P
E
S

14. TYPES :
1. Abdominal ectopic pregnancies :
(~1% of ectopic pregnancies) most commonly
derive from early rupture or abortion of a tubal
pregnancy, with subsequent reimplantation in
the peritoneal cavity.
2. Cesarean scar pregnancyis rare but can cause
massive maternal hemorrhage.

15. TYPES :
3. Cervical ectopic pregnancies ;
● occur in <1% of ectopic pregnancies.
● with predisposing factors similar to those
associated with ectopic pregnancies (previous
dilatation and curettage, previous cesarean
delivery, in vitro fertilization, adhesions or fibrosis
of the endometrium, prior instrumentation,
infertility, previous ectopic pregnancy).
● Patients develop profuse vaginal bleeding.
● Bimanual exam reveals a soft, large cervix when
compared to the uterus or an hourglass-shaped
uterus, and diagnosis is confirmed with US.

16. CLINICAL
MANIFESTATION
0
5
TRIAD

17. CLINICAL PRESENTATION :
When the site of oocyte implantation is a fallopian tube, most cases are
diagnosed before rupture on the basis of three classic findings:
● ABDOMINAL PAIN.
● DELAYED MENSES.
● ABNORMAL VAGINAL BLEEDING.
(1) Abdominal pain:
 If the tube is unruptured - the pain begins as a dull, lower quadrant pain on
one side.
 As the tube stretches - the pain changes to a colicky pain, then a sharp,
stabbing pain
 with tube rupture - to a sudden,excruciating pain that is felt throughout
the lower abdomen. Referred shoulder pain is possible as the abdomen fills
with blood.)

18. CONT...
(2) Delayed menses : Most women report having a period that is delayed 1
to 2 weeks, a period that is lighter than usual, or an irregular period.
(3) Abnormal vaginal bleeding (spotting): that occurs about 6 to 8 weeks after
the last normal menstrual period. Up to 80% of women experience mild to
moderate dark red or brown intermittent vaginal bleeding
In ectopic pregnancy, bleeding usually occurs after the onset of pain.

19. DIAGNOSIS &
MANAGEMENT
0
6
MEDICAL & SURGICAL

20. HISTORY :
● Ask about previous pregnancies, pregnancy problems, and miscarriages.
● Discuss previous medical and surgical history, and ask about substance
abuse and smoking.
● Ask about sexual activity and contraception.
● Identify risk factors for ectopic pregnancy or spontaneous abortion,
 Determine current medications, including over-the-counter drugs.
 Pregnancy in a patient with prior tubal surgery for sterilization is assumed
to be an ectopic pregnancy until proven otherwise.
 Patients are at particularly high risk if they have undergone laparoscopic
partial salpingectomyor electrodestruction tubal ligation at a young age
(age <28 years), especially 5 to 15 years after the procedure

21. DIAGNOSIS :
The definitive diagnosis of ectopic pregnancy is made by US, by direct
visualization by laparoscopy, or at surgery. No single or combination of
laboratory tests has a sufficient negative or positive predictive value to
completely exclude ectopic pregnancy or to definitively establish the
diagnosis.
1. SERUM β -HCG :
● Differences in the dynamics of β-hCG production in normal and
pathologic pregnancy are useful in the diagnosis of ectopic pregnancy.
● Early in normal pregnancy, β-hCG levels rise rapidly until 9 to 10 weeks of
pregnancy and then plateau.

22. cont...
● Absolute levels of β-hCG tend to be lower in
pathologic pregnancies than in IUPs.
● Doubling time refers to the time needed for β-
hCG concentration in the serum to double.
● Absolute levels of β-hCG are lower and
doubling times longer in ectopic pregnancy and
other abnormal pregnancies.
● This and many other observations have led to
the widely used rule of thumb, stating that the
serum concentration of β-hCG approximately
doubles every 2 days early in a normal
pregnancy and that longer doubling times
indicate pathologic pregnancy

23. cont..
PROGESTERONE :
● Progesterone is a steroid hormone secreted by the ovaries, adrenal
glands, and placenta during pregnancy.
● During the first 8 to 10 weeks of pregnancy, ovarian production of
progesterone predominates, and serum levels remain relatively constant.
● After the 10th week of pregnancy, placental production increases and
serum levels rise. Absolute levels of progesterone are lower in pathologic
pregnancies and fall when a pregnancy fails.
● An empty uterus or nonspecific fluid collection on US associated with
progesterone ≤5.0 nanograms/mL is highly predictive of abnormal IUP or
ectopic pregnancy

24. OTHER INVESTIGATION :
● secretory endometrial protein
● Estradiol - Decreaed level compared to normal IUP
● The pregnancy-associated proteins A to D,
routine laboratory tests such as,
● Amylase - Elevated in the case of ruptured ectopic case
● creatine kinase ( non spicific) - Significantly increase in state in EP
● erythrocyte sedimentation rate - Significantly increase in state in EP

25. USG :
● Advances in sonographic imaging and the use of transvaginal US
scanning allow earlier detection of an IUP or an ectopic pregnancy.
● These advances have contributed to increasing use of real-time,
bedside US in the ED .
● ED US has the further advantage of allowing a potentially unstable
patient to remain under continuous observation in the ED.

26. CONT..
● An empty uterus with embryonic cardiac activity visualized outside the
uterus is diagnostic of ectopic pregnancy.
● When performed by trained individuals, point-of-care ED US in the first
trimester of pregnancy is accurate and can decrease ED length of stay, as
long as a conclusive IUP is identified.
● It has previously been assumed that if an IUP exists, the diagnosisof ectopic
pregnancy has been excluded. This assumption is based on the historical
incidence of heterotopic pregnancy (combined IUP and ectopic pregnancy),
reported to occur in 1 in 3,000 pregnancies

28. IMAGING :
● MRIhas high sensitivity and specificity for the diagnosis of ectopic
pregnancy, but cost, availability, and the time to perform the study
make the use of MRI of only theoretical interest at the present time.
● Laparoscopymay be both diagnostic and therapeutic. Laparoscopy
is primarily useful in patients with suspected ectopic pregnancy and a
nondiagnostic US. It may provide an earlier diagnosis and a possible
route for definitive treatment when compared with serial β-hCG
measurements and US.

29. MEDICAL :
SURGICAL :
For unruptured ectopic
pregnancy, the most frequently
used surgical approach is
laparoscopic salpingostomy
MANAGEMENT :
Administration of systemic
methotrexate, comparable
success rates to surgical
therapies with unruptured
ectopic pregnancies

30. MEDICAL MANAGEMENT :
is the only drug currently
recommended as a medical alternative to
surgical treatment of ectopic pregnancy and is
ideally used in patients with,
 Hemodynamic stability
 Minimal abdominal pain
 The ability to follow up reliably, and normal
baseline liver and renal function tests.

31. ABSOLUTE :
• Intrauterine pregnancy
• Evidence of immunodeficiency
• Moderate to severe anemia,
leukopenia, or thrombocytopenia
• Sensitivity to methotrexate
• Active pulmonary disease
• Active peptic ulcer disease
• Clinically important hepatic or renal
dysfunction
• Breastfeeding
• Hemodynamic instability
RELATIVE :
• Embryonic cardiac activity detected
by transvaginal US
• Human chorionic gonadotropin
concentrations >5000 mIU/mL
• Ectopic pregnancy >4 cm in size as
imaged by transvaginal US
• Refusal to accept blood transfusion
• Inability to reliably return for follow-
up

32. ● MOA :
Methotrexate is an antimetabolite chemotherapeutic agent
|
That binds to the enzyme dihydrofolate reductase, which is involved in the
synthesis of purine nucleotides.
|
This interferes with deoxyribonucleic acid (DNA) synthesis and disrupts cell
multiplication.
DOSE : 50 mg/m2 IM in a single injection or as a divided dose injected into
each buttock.
Advise patients not to take vitamins with folic acid until complete resolution
of the ectopic pregnancy. They should also refrain from alcohol consumption
and intercourse for the same period.

33. PROTOCOL :
Day 0 :
Obtain β-HCG level, ultrasonography, and +/- dilatation and curettage.
Day 1 :
Obtain,
 β-HCG
 Liver function
 Blood urea nitrogen (BUN)
 Creatinine
Evidence of hepatic or renal compromise is a contraindication to
methotrexate therapy. Blood type, Rh status, and antibody screening are
also performed, and all Rh-negative patients are given Rh immunoglobulin.

34. Day 4 :
The patient returns for measurement of her β-HCG level. The level may be higher than
the pretreatment level. The day-4 hCG level is the baseline level against which
subsequent levels are measured.
Day 7 :
Draw β-HCG and AST levels and ,CBC. If the β-HCG level has dropped 15% or more
since day 4, obtain weekly β-HCG levels until they have reached the negative level.
WHEN - SECOND DOSE ?
● If the weekly levels plateau or increase
● If the β-HCG level has not dropped at least 15% from the day-4 level
If no drop has occurred by day 14, surgical therapy is indicated.
If the patient develops increasing abdominal pain after methotrexate therapy, repeat a
transvaginal ultrasonographic scan to evaluate for possible rupture.

35. ● Abdominal pain after treatment followed by flatulence and then stomatitis.
● Lower abdominal pain lasting up to 12 hours is common 3 to 7 days after
methotrexate treatment and is thought to be secondary to methotrexate-
induced tubal abortion or tubal distention due to hematoma formation
(“separation pain”).
● The pain is usually self-limited and may respond to NSAIDs.
● SURGICAL INTERVENTION INDICATION :
 Hemodynamic instability and/or falling hematocrit
 patients with moderate to severe pain, free fluid in the cul-de-sac
 Rebound tenterness.

36. REFERENCES :
BOOK :
1. NANCY CAROLINE’S “ EMERGENCY CARE IN THE STREET “
EDITION : EIGTH
PG.NO : 1246 - 1248
2. TINTINALLIS EMERGENCY MEDICINE .
EDITION : NINTH
PG.NO : 615 - 620
WEB:
MEDSCAPE

37. SHALOM