ECTOPIC PREGNANCY
Dr.Najwa.B.Eljabu
Arab & Libyan Board
Msc reproductive and Maternal sciences
Glasgow University
DEFINITION
Ectopic pregnancy is implantation occurring outside the
uterine cavity.
Either implanted outside the uterus (fallopian tube, ovary
and abdominal cavity) or in abnormal position within the
uterus (cornua, cervix).
Combined tubal and uterine (Heterotopic) pregnancies are
uncommon)
It is a major cause of maternal mortality in the first
trimester.
OVERVIEW
Incidence Increasing (16/1000 Pregnancies in UK)
 95-98% tubal
 50% ampulla
 20% isthmus
 12% fimbrial
 10% interstitial
 Mortality Decreasing With Better Detection
 Surgical and Medical Treatment Available
 Recurrence Rate ~ 10-15%
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RISK FACTORS
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Maternal age
Number of sexual partners
Cigarette smoking
Previous Ectopic Pregnancy
PID (Gonorrhea, Chlamydia)
Tubal Surgery or pelvic surgery
Infertility and infertility treatment
ICUD
IVF
SITES
Ampulla (50%)
 Isthmus (20%)
 Cornua (< 2%)
 Ovary (< 2%)
 Abdomen (< 2%)
 Cervix (< 2%)
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Simultaneous intrauterine and ectopic pregnancies
(heterotopics) occur in 1/3000 to 1/30000 pregnancies
SYMPTOMS
Amenorrhea (typically 6-8 weeks)
 Abdominal Pain
 Vaginal Bleeding (small amount)
 Syncope
 Pelvic Mass
 Shoulder tip pain
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15% of the cases present acutely with abdominal pain,
amenorrhea and haemodynamic compromise
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In most cases the history will be more chronic
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Arias-stella reaction
EVALUATION AND DIAGNOSIS
History and Physical Exam
 Blood investigations (CBC, blood group)
 Serial Quantitative HCG
 Ultrasound
 Laparoscopy
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EVALUATION AND DIAGNOSIS
 Clinical:
O/E: look for signs of intra-peritoneal hemorrhage
 Abdominal tenderness(95%)
 Peritonism
 Abdominal distension
 Pain on movement of the cervix (cervical excitation
(50%)
 Adnexal mass (63%)
 Cervix ----closed
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SERIAL B-HCG
HCG Levels Double Every 48 Hrs
 66% Rise / 48 Hrs Consistent With Ectopic
 Single Determination Not Helpful
 Best If Done Within Same Laboratory
 At HCG of 1000 IU/L gestational sac of an
intrauterine pregnancy should be detected by US
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ULTRASOUND
May or May Not Be Helpful
 Discriminatory Zone:
TV: 1500-2000 mIU/ml
TA: 6500 mIU/ml
 +IUP: Generally Excludes Ectopic
 Free fluids in POD
 Adnexal mass
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TREATMENT
Observation
 Laparoscopy
 Laparotomy
 Medical
 MTX
 Hyperosmolar Glucose
 PG
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OBSERVATION
Many Tubal Pregnancies Abort
 Needs simple follow up
 Criteria for selection of patients
 Serial HCG levels and US
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MANAGEMENT OF ACUTE
HEMORRHAGE
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Urgent hospital assessment
Resuscitation
Intravenous access and two large cannula
Start IVF (colloid)
Send for blood group, CBC and cross match
Serum BHCG
Transfer to theater
Anti D should be given to all RH negative
women
LAPAROSCOPY
 Allows
Diagnosis and Treatment
 Lower post op morbidity and quicker recovery
 Salpingotomy
 Salpingectomy (Total / Partial)
 Cornual Resection
 Minimally Invasive, Unlike Laparotomy
 Few Contraindications: Unstable Patient
(Possibly)
MINI-LAPAROTOMY
Salpingectomy
 Salpingotomy
 Needed in acute intra-peritoneal
haemorrhage-------for immediate ligation of
the bleeding point
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MEDICAL TREATMENT
Suitable patients are:
 Haemodynamically stable
 serum BHCG less than 10000IU/L
 no extrauterine fetal heart by US
 compliant patient
METHOTREXATE
Toxic to Trophoblast Cells
 Minimal Side Effects
 May Preserve Fertility in Cases of Cervical
Pregnancy
 Requires Compliant Patient, Time
 Pain Not Uncommon
 BHCG May Rise Initially
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PERSISTENT TROPHOBLAST
Most Often after Salpingostomy
 Laparoscopic
 Minilap
 Most Easily Treated With MTX
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OUTCOMES
15% Repeat Ectopic Rate
 60-70% intra-uterine pregnancy after single
ectopic
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SUMMARY
Ectopic Pregnancy is a Common, Treatable
Problem
 Sensitive Assays Allow Early Detection
 Surgical and Medical Options Exist
 Ruptured Ectopics should be Unusual with
Compliant Patients and Appropriate Medical
Care
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THANKS