ECTOPIC PREGNANCY
Danforth’s Obstetrics and
Gynecology
Tenth edition
Ectopic pregnancy, the implantation of a fertilized ovum outside of the endometrial
cavity
a leading cause of life-threatening first-trimester morbidity
Incidence
Pathogenesis
•Sites of implantation
Etiology and Risk Factors
•Tubal Damage and Infection
•Salpingitis Isthmica Nodosa
•Diethylstilbestrol
•Cigarette Smoking
•Contraception:
IUD
Tubal ligation
OCP
Barrier contraception
Risk Factor
High risk
Tubal surgery
Tubal ligation
Previous ectopic pregnancy
In utero exposure to DES
Use of IUD
Tubal pathology
Assisted reproduction
Moderate risk
infertility
Previous genital infections
I
Odds Ratioa
21.0
9.3
8.3
5.6
4.2–45.0
3.8–21.0
4.0
2.5–21.0
2.5–3.7
Multiple sexual partners
2.1
Salpingitis isthmica nodosa
1.5
Low risk
Previous pelvic infection
0.9–3.8
Cigarette smoking
Vaginal douching
First intercourse <18 y
2.3–2.5
1.1–3.1
1.6
Clinical Manifestations
•Symptoms:
abdominal or pelvic pain
vaginal bleeding or spotting
a positive pregnancy test(mensturation delay)
•Signs:
Abdominal tenderness
rebound tenderness
cervical motion tenderness
tender adnexal mass
Diagnosis:
Ectopic pregnancy can be diagnosed as early as 4.5 weeks gestation
•serial measurements of B-hCG
•ultrasonography
•uterine sampling via manual vacuum extraction or
curettage
•serum progesterone levels
•Human Chorionic Gonadotropin ( B -hCG)
The B-hCG, produced by trophoblastic cells in normal pregnancy, has long been
accepted to rise at least 66% and up to twofold every 2 days
Eight-five percent of abnormal pregnancies, whether intrauterine or ectopic,
have impaired B-hCG production with an abnormal rate of B-hCG rise
•Sonography
transvaginal ultrasonography reliably detects intrauterine gestations when the BhCG levels are between 1,500 and 2,500 mIU/mL
Diagnosis of an ectopic pregnancy can be made with 100% sensitivity but with low
specificity (15% to 20%) if an extrauterine gestational sac containing a yolk sac or
embryo is identified
Some sonographic images, such as the pseudogestational sac, may mislead even an
experienced examiner to falsely diagnose a gestational sac
Ultrasonography should be used to document the presence or absence of an
intrauterine pregnancy when the B-hCG levels have risen above the designated
discriminatory cutoff zone
•Progesterone
Although progesterone levels are higher in intrauterine pregnancies than in
ectopic pregnancies, there is no established cutoff to use to discriminate
between these two entities
a low progesterone level of less than 5 ng/mL can rule out a normal pregnancy
with almost 100% accuracy but does not differentiate whether that pregnancy
is an abnormal one in the uterus or at an ectopic site
•Uterine Evacuation
necessary when a transvaginal ultrasonogram and a rising or plateauing B-hCG
level below the cutoff value are not sufficient for diagnosis
Treatment for Ectopic Pregnancy
•Medical Management:
Methotrexate therapy
The folic acid antagonist, methotrexate, inhibits de novo synthesis of purines
and pyrimidines, interfering with DNA synthesis and cell multiplication
methotrexate directly impairs trophoblastic production of hCG with a
secondary decrement of corpus luteum progestin secretion
1-unruptured ectopic pregnancy measuring less than or equal to 4 cm by
ultrasonography
2-Hemodynamically stable
3-B-HCG<10,000
4-Exist of FHR
Methotrexate treatment regimens include:
the multiple dose, single dose,two-dose protocol
Methotrexate by Direct Injection
Side Effects
bone marrow suppression, hepatotoxicity, stomatitis, pulmonary fibrosis,
alopecia, and photosensitivity
Fortunately, the side effects reported with methotrexate used to treat
ectopic pregnancy have mostly been minor
Direct Injection of Cytotoxic Agents
Prostaglandins, hyperosmolar glucose, potassium chloride, and saline by
direct injection have been tried as therapeutic alternatives to
methotrexate
•Surgical Treatment
Ruptured Ectopic Pregnancy
laparotomy or laparoscopy with salpingectomy is the first choice for
rupture
Stable Ectopic Pregnancy
If methotrexate is contraindicated, laparoscopic salpingostomy is the
first surgical choice
Persistent Ectopic Pregnancy Following
Salpingostomy:
drop of <50% from the preoperative level of B-HCG on
postoperative day 1
prophylactic methotrexate administration is recommended
Other methods
segmental excision followed by intraoperative or delayed
microsurgical anastomosis
Manual fimbrial expression
oEctopic Pregnancy and Assisted
Reproductive Technology
•Incidence
•Location
•Tubal Pathology
•Ovulation Induction
Rare Types of Ectopic Pregnancy
•Abdominal Pregnancy
Incidence
Clinical manifestations
Diagnosis
treatment
•Ovarian Pregnancy
•Cornual Pregnancy
•Cervical Pregnancy
•Heterotopic Pregnancy
Summary Points
In most circumstances, ectopic pregnancy can be diagnosed before symptoms develop
and treated definitively with few complications.
Quantitative B-hCG testing, ultrasonography, and curettage allow early diagnosis of
ectopic pregnancy and use of medical therapy as the initial therapy option.
Conservative surgical therapy and medical therapy for ectopic pregnancy are comparable
in terms of success rates and subsequent fertility. Medical therapy is the preferred
choice because of the freedom from surgical complications and lower cost.
Surgery is the treatment of choice for hemorrhage, medical failures, neglected cases, and
when medical therapy is contraindicated.
Multiple-dose methotrexate is preferable to single-dose methotrexate, direct injection,
or tubal cannulation and is the first choice for unruptured, uncomplicated ectopic
pregnancy.
Laparoscopic salpingostomy or salpingectomy is favored for cases of intra-abdominal
hemorrhage, medical failure, neglected cases, and complex cases when medical therapy
is contraindicated