ECTOPIC PREGNANCY

Submitted by: William Leo Manongdo

Bsn – 3A

Submitted to: Sir Jay-ar Garcia

Instructor
 An ectopic pregnancy is a complication of pregnancy in which the fertilized ovum is developed in any
tissue other than the uterine wall. Most ectopic pregnancies occur in the
Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and
abdomen. The fetus produces enzymes that allow it to implant in varied types of tissues, and thus an embryo
implanted elsewhere than the uterus can cause great tissue damage in its efforts to reach a sufficient supply of
blood. An ectopic pregnancy is a medical emergency, and, if not treated properly, can lead to the death of the
woman.

Symptoms
Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2
weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more
common in communities deprived of modern diagnostic ability.

The early signs are:

• Pain in the lower abdomen, and withdrawal bleeding. This can be

inflammation (Pain may be confused with indistinguishable from an early
a strong stomach pain, it may also feel like miscarriage or the ’implantation bleed’ of
a strong cramp) a normal early pregnancy.

• Pain while urinating • Pain while having a bowel movement

• Pain and discomfort, usually mild. A
corpus luteum on the ovary in a normal
pregnancy may give very similar
symptoms.
• Vaginal bleeding, usually mild. An ectopic
pregnancy is usually a failing pregnancy
and falling levels of progesterone from the
corpus luteum on the ovary cause
Patients with a late ectopic pregnancy typically
experience pain and bleeding. This bleeding
will be both vaginal and internal and has
two discrete pathophysiologic mechanisms.
• External bleeding is due to the falling
progesterone levels.
• Internal bleeding (hematoperitoneum) is
due to hemorrhage from the affected tube.
The differential diagnosis at this point is
between miscarriage, ectopic pregnancy, and
early normal pregnancy. The presence of a
positive pregnancy test virtually rules out
pelvic infection as it is rare indeed to find
pregnancy with an active Pelvic Inflammatory
Disease (PID). The most common misdiagnosis
assigned to early ectopic pregnancy is PID.
More severe internal bleeding may cause:
• Lower back, abdominal, or pelvic pain.
• Shoulder pain. This is caused by free
blood tracking up the abdominal cavity
and irritating the diaphragm, and is an
ominous sign.

• There may be cramping or even

tenderness on one side of the pelvis.

• The pain is of recent onset, meaning it

must be differentiated from cyclical pelvic
pain, and is often getting worse.

• Ectopic pregnancy can mimic symptoms of

other diseases such as appendicitis, other
gastrointestinal disorder, problems of the
urinary system, as well as pelvic
inflammatory disease and other
gynaecologic problems.

Diagnosis
An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a
positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear
evidence of ectopic pregnancy.

An abnormal rise in blood βhCG levels may also indicate an ectopic pregnancy. The threshold of discrimination
of intrauterine pregnancy today is around 1500 IU/ml of β- human chorionic gonadotropin (βhCG). A high
resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic
pregnancy is present if the threshold of discrimination for βhCG has been reached. An empty uterus with levels
lower than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine
pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary
to wait a few days and repeat the blood work and ultrasound. If the βhCG falls on repeat examination, this
strongly suggests an abortion or rupture. Free fluid which is non-echogenic is a normal finding in the late
menstrual cycle and early normal pregnancy. This is a transudate and is not presumptive evidence of bleeding.
Echogenic free fluid suggests the presence of blood clot and is suggestive of free blood in the peritoneum.

A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal
abortion has occurred, or a tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy
in very early ectopic pregnancy rarely shows a normal looking fallopian tube.

A less commonly performed test, a culdocentesis, may be used to look for internal bleeding. In this test, a needle
is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or
fluid found there likely comes from a ruptured ectopic pregnancy. Cullen’s sign can indicate a ruptured ectopic
pregnancy.
Treatment

Nonsurgical treatment
Early treatment of an ectopic pregnancy with the antimetabolite methotrexate has proven to be a viable
alternative to surgical treatment since 1993 (though the literature dates back to at least 1989). If administered
early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of
pregnancy.

Surgical treatment
If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing
blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The
option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal
evidence of blood clot on ultrasound.

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian
and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy
(salpingectomy).

Complications
The most common complication is rupture with internal bleeding that leads to shock. Death from
rupture is rare in women who have access to modern medical facilities. Infertility occurs in 10 - 15% of women
who have had an ectopic pregnancy.

Prognosis

Fertility following ectopic pregnancy depends upon several factors, the most important of which is a
prior history of infertility. The treatment choice, whether surgical or nonsurgical, also plays a role. For example,
the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment. Rate of
fertility may be better following salpingostomy than salpingectomy.