ECTOPIC PREGNANCY

ECTOPIC PREGNANCY
TUBAL PREGNANCY
CLINICAL MANIFESTATIONS
MULTIMODALITY DIAGNOSIS
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
INTERSTITIAL PREGNANCY
ABDOMINAL PREGNANCY
OVARIAN PREGNANCY
CERVICAL PREGNANCY
CESAREAN SCAR PREGNANCY
ECTOPIC PREGNANCY
The blastocyst normally implants in the endometrial lining of the
uterine cavity
1 to 2 % of all first-trimester pregnancies
6 % of all pregnancy-related deaths
TUBAL PREGNANCY
Risks
Surgeries - prior tubal pregnancy, for fertility restoration, or for
sterilization confer the highest risk
Prior STD/tubal infection
Peritubal adhesions (salpingitis, appendicitis, endometriosis)
Salpingitis isthmica nodosa, -epithelium-lined diverticula extend
into a hypertrophied muscularis layer
TUBAL PREGNANCY
Risks
Congenital fallopian tube anomalies DES exposure
Infertility, as well as the use of ART atypical implantationscornual,
abdominal, cervical, ovarian, and heterotopic pregnancyare more common
following ART
TUBAL PREGNANCY
smoking
contraceptive method failures- tubal sterilization, copper and progestin-
releasing intrauterine devices (IUDs), and progestin-only contraceptives
Evolution and Potential Outcomes
Fallopian tube lacks a submucosal layer, the fertilized ovum
burrows through the epithelium zygote comes to lie near or
within the muscularis (invaded in most cases by rapidly proliferating
trophoblast) the embryo or fetus is often absent or stunted
Evolution and Potential Outcomes
1.tubal rupture
2. tubal abortion
3. pregnancy failure with resolution
Evolution and Potential Outcomes
1.RUPTURE- the invading expanding products of conception and
associated hemorrhage may tear rents in the fallopian tube at any of
several sites
Interstitial portion-- rupture usually occurs later

As a rule, if the tube ruptures in the first few weeks,

the pregnancy is most likely located in the isthmic
portion
 Evolution and Potential Outcomes
2.ABORTION - pregnancy may abort out the distal FT, and the frequency of this
depends in part on the initial implantation site
common in fimbrial and ampullary

Hemorrhage disrupts the connection between the placenta and membranes and the tubal wall

1. If placental separation is complete, the entire conceptus fimbriated end into peritoneal
cavity

2. If the fimbriated extremity is occluded, the fallopian tube may gradually become distended by
blood forming a hematosalpinx
Evolution and Potential Outcomes
3. ABSORBED- an unknown number of ectopic pregnancies spontaneously fail
and are reabsorbed
-hCG assays
acute ectopic pregnancy and chronic
ectopic pregnancy
acute ectopic pregnancy
high serum -hCG level
rapid growth
higher risk of tubal rupture

chronic ectopic pregnancy

abnormal trophoblast die early
negative or lower static serum -hCG levels
typically rupture late
commonly form a complex pelvic mass diagnostic surgery
Clinical Manifestations
delayed menstruation
pain
vaginal bleeding or spotting
Clinical Manifestations
TUBAL RUPTURE
severe lower abdominal and pelvic pain -sharp, stabbing, or
tearing
tenderness during abdominal palpation

Bimanual pelvic examination, - exquisite pain

posterior vaginal fornix may bulge from blood in the rectouterine cul-de-sac
tender boggy mass may be felt to one side of the uterus
the uterus may be pushed to one side by an ectopic mass
Hemoperitoneum- diaphragmatic irritation, pain in the neck or shoulder
 Clinical Manifestations
Some degree of vaginal spotting or bleeding in 60 to 80 % of women
profuse vaginal bleeding
intraabdominal hemorrhage

Responses to moderate bleeding

- include no change in VS
-slight rise in BP or a vasovagal response with bradycardia and hypotension
BP will fall and pulse will rise only if bleeding continues and hypovolemia becomes significant
Vasomotor - vertigo / syncope
Clinical Manifestations
After an acute hemorrhage, a decline in hemoglobin or hematocrit level over
several hours is a more valuable index of blood loss than is the initial level
leukocytosis up to 30,000/L
 Clinical Manifestations
Decidua is endometrium that is hormonally prepared for pregnancy, women with ectopic tubal
pregnancy may pass a decidual cast, which is the entire sloughed endometrium that takes the form of
the endometrial cavity

(-)gestational sac
(-) villi

EP

This decidual cast was passed by a patient with a tubal ectopic pregnancy. The cast mirrors the shape of the endometrial cavity, and each arrow marks the portion of decidua that lined the
cornua.
 Multimodality Diagnosis
Differential diagnosis

(A) uterine conditions -miscarriage, infection, degenerating or enlarging leiomyomas, molar

pregnancy, or round-ligament pain
(B) adnexal disease may include ectopic pregnancy; hemorrhagic,
ruptured, or torsed ovarian masses; salpingitis; or tuboovarian abscess
(C) non-gynecological sources -appendicitis, cystitis, renal stone, or gastroenteritis
Multimodality Diagnosis
1. physical findings
2. transvaginal sonography (TVS)
3. serum -hCG level measurement
initial and the subsequent pattern of rise or decline

4. diagnostic surgery- uterine curettage, laparoscopy, laparotomy

aExpectant management, D&C, or medical regimens are suitable options. bSerial serum -hCG levels may be appropriate if a normal uterine pregnancy or if completed abortion is
suspectedclinically. -hCG = beta human chorionic gonadotropin; D&C = dilatation and curettage; IUP =intrauterine pregnancy; TVS = transvaginal sonography.
Multimodality Diagnosis
Beta Human Chorionic Gonadotropin
sensitive to levels of 10 to 20 mIU/mL and are positive in > 99 % of ectopic pregnancies

1. Levels above the Discriminatory Zone- -hCG concentration 1500 mIU/, mL 2000
mIU/Ml Diagnosis: failed uterine pregnancy, completed abortion, or an EP; early multifetal
gestation

2. Levels below the Discriminatory Zone- With these PULs, serial - hCG level assays are
done to identify patterns that indicate either a growing or failing uterine pregnancy
 Multimodality Diagnosis
Beta Human Chorionic Gonadotropin
3. Levels that rise or fall -increase the concern for EP
-hCG level is below the discriminatory threshold, are seen 2 days later for further evaluation.

no single pattern characterizes EP and that ~ of ectopic pregnancies will show decreasing -hCG
levels, the other will have increasing levels

with a failing IUP, patterned rates of -hCG level decline can also be anticipated.
rates of decline ranging between 21 and 35 % are commonly used
 In pregnancies without these expected rises or falls in -hCG levels, distinction between a
nonliving intrauterine and an ectopic pregnancy may be aided by repeat -hCG level
evaluation.
Expected Minimum Percentage Decline of Initial Serum -hCG Levels to Subsequently Drawn Values for Nonliving Pregnancies
Multimodality Diagnosis
Serum Progesterone
A value exceeding 25 ng/mL excludes ectopic pregnancy with
- values below 5 ng/mL are found in only 0.3 percent of normal pregnancies

< 5 ng/mL suggest either a nonliving uterine pregnancy or an ectopic

pregnancy
Multimodality Diagnosis
Transvaginal Sonography
Endometrial Findings
intrauterine gestational sac is usually visible between 4 and 5 weeks
yolk sac -between 5 and 6 weeks
fetal pole with cardiac activity -5 to 6 weeks
In contrast, with ectopic pregnancy, a trilaminar endometrial pattern can be
diagnostic
 Anechoic fluid collections, which might
normally suggest an early IU gestational sac,
may also be seen with EP
1. pseudogestational sac
2. decidual cyst

pseudosac is a fluid collection between the

endometrial layers and conforms to the
cavity shape.

decidual cyst is identified as an anechoic

area lying within the endometrium but
remote from the canal and often at the
endometrial-myometrial border.

These two findings contrast with the

intradecidual sign seen with IUP.
-an early gestational sac and is eccentrically
located within one of the endometrial stripe
layers

Transvaginal sonography of a pseudogestational sac within the endometrial cavity. Its cavity-conforming shape and central location are characteristic of these anechoic fluid collections.Distal to
this fluid, the endometrial stripe has a trilaminar pattern, which is a common finding with ectopic pregnancy.
Various transvaginal sonographic findings with ectopic tubal pregnancies. For sonographic diagnosis, an ectopic mass should
be seen in the adnexa separate from the ovary and maybe seen as:

(A) a yolk sac (shown here) and/or fetal pole with or without cardiac activity within an extrauterine sac
(B) an empty extrauterine sac with a hyperechoic ring
(C) an inhomogeneous adnexal mass. In this last image, color Doppler shows a classic ring of fire, which reflects increased
vascularity typical of ectopic pregnancies. LT OV = left ovary; SAG LT AD = sagittal left adnexal; UT = uterus.
 Multimodality Diagnosis
Transvaginal Sonography
Hemoperitoneum
1. Sonography- anechoic or hyperechoic fluid
2. Culdocentesis- blood fills the retrouterine cul-de-sac, then additionally surrounds the uterus as
it fills the pelvis.

Fluid containing
fragments of old clots
or bloody fluid that
does not clot.

Techniques to identify hemoperitoneum. A. Transvaginal sonography of an anechoic fluid collection (arrow) in the retrouterine cul-de-sac. B. Culdocentesis: with a 16- to 18-gauge spinal needle
attached to a syringe, the cul-de-sac is entered through the posterior vaginal fornix as upward traction is applied to the cervix with a tenaculum
Multimodality Diagnosis
Laparoscopy
- direct visualization ;offers a reliable diagnosis in most cases of suspected ectopic pregnancy
- also a ready transition to definitive operative therapy
Treatment Options
Medical therapy antimetabolite methotrexate
Surgical -salpingostomy or salpingectomy
 Treatment Options
Medical Management
Regimen Options
Methotrexate is a folic acid antagonist-- binds to dihydrofolate reductase, blocking the reduction of dihydrofolate
to tetrahydrofolate- de novo purine and pyrimidine synthesis is halted, which leads to arrested DNA, RNA, and
protein synthesis: highly effective against rapidly proliferating tissue such as trophoblast.

overall ectopic tubal pregnancy resolution rates approximate 90 % with its use
 methotrexate embryopathy- notable for craniofacial and skeletal abnormalities and fetal-growth restriction
excreted into breast milk and may accumulate in neonatal tissues and interfere with neonatal cellular metabolism
Treatment Options
Medical Management
Treatment Side Effects
liver involvement12 %
stomatitis6 %
gastroenteritis1 %
bone marrow depression

65 -75 % of women initially given methotrexate will have increasing pain beginning several days
after therapy.
20 % of women given single-dose methotrexate will have significant pain, and 20 % of these will
require laparoscopy.
5 to 14 % of women treated initially with MTX ultimately required surgery,
4 to 20 %of those undergoing laparoscopic resection eventually received MTX for persistent trophoblast

Rupture of persistent ectopic pregnancy is the worst form of primary therapy failure -5 to 10%
 Treatment Options
Medical Management
Monitoring Therapy Efficacy
Serum -hCG levels are used to monitor response to both medical and surgical therapy
After linear salpingostomy, serum -hCG levels decline rapidly over days and then more gradually, with a mean
resolution time of ~20 days
After single-dose methotrexate, mean serum - hCG levels increase for the first 4 days, and then gradually decline,
with a mean resolution time of 27 days

Lipscomb and colleagues (1998) used single-dose methotrexate to successfully treat 287
women and reported that the average time to resolutiondefined as a serum -hCG level < 15
mIU/mL, was 34 days
Treatment Options
Medical Management
Patient Selection
asymptomatic, motivated, and compliant
some classic predictors of success
low initial serum -hCG level
small ectopic pregnancy size
absent fetal cardiac activity

initial serum -hCG level is the single best prognostic indicator of successful treatment with single-
doseMTX
Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is
hemodynamically unstable

-conservative salpingostomy
-radical surgery -salpingectomy
Surgical Management
Salpingostomy

Linear salpingostomy for ectopic pregnancy

Surgical Management
Salpingectomy
Tubal resection may be used for both ruptured and unruptured ectopic pregnancies.
To minimize the rare recurrence of pregnancy in the tubal stump, complete excision of the
fallopian tube is advised
Surgical Management
Persistent Trophoblast
This complicates 5 -20 % of salpingostomies and can be identified by stable or rising -hCG
levels.
-hCG levels fall quickly and are at approximately 10 % of preoperative values by day 12
if the postoperative day 1 serum -hCG value is less than 50 %of the preoperative value, then persistent
trophoblast rarely is a problem
Persistent Trophoblast

pregnancies less than 2 cm

early pregnancy less than 42 menstrual days
serum -hCG level > 3000 mIU/mL
implantation medial to the salpingostomy site

standard therapy for this is single-dose methotrexate, 50 mg/m2 body surface area (BSA).
MEDICAL VS SURGICAL
Women who are hemodynamically stable and in whom there is a small tubal diameter, no fetal
cardiac activity, and serum -hCG concentrations < 5000 mIU/mL have similar outcomes with
medical or surgical management
Expectant Management
Stovall and Ling (1992a) restrict expectant management to women with

tubal ectopic pregnancies only

decreasing serial -hCG levels
diameter of the ectopic mass 3.5cm
no evidence of intraabdominal bleeding or rupture by TVS

American College of Obstetricians and Gynecologists (2012); 88 percent of ectopic pregnancies

will resolve if the -Hcg is < 200 mIU/mL
INTERSTITIAL PREGNANCY
These pregnancies implant within the proximal tubal segment that lies within the muscular
uterine wall

previous ipsilateral salpingectomy is a specific risk factor for interstitial pregnancy

INTERSTITIAL PREGNANCY
Undiagnosed interstitial pregnancies usually rupture following 8 to 16 weeks of
amenorrhea
Because of the proximity of these pregnancies to the uterine and ovarian arteries,
there is a risk of severe hemorrhage, which is associated with mortality rates as high
as 2.5 %
INTERSTITIAL PREGNANCY
Timor-Tritsch

Criteria that may aid differentiation include:

an empty uterus
a gestational sac seen separate from the endometrium and > 1 cm away from the most lateral
edge of the uterine cavity
thin, < 5-mm myometrial mantle surrounding the sac
INTERSTITIAL PREGNANCY
an echogenic line, known as the interstitial line sign, extending from the
gestational sac to the endometrial cavity most likely represents the interstitial
portion of the fallopian tube and is highly sensitive and specific

MANAGEMENT:
Surgical management with either cornual resection or cornuostomy may be
performed via laparotomy or laparoscopy,
 INTERSTITIAL PREGNANCY

During cornual resection, the pregnancy, surrounding myometrium, and ipsilateral fallopian tube are excised en bloc.
ABDOMINAL PREGNANCY
an implantation in the peritoneal cavity exclusive of tubal, ovarian, or intraligamentous
implantations
incidence of 1 in 10,000 to 25,000 live births
most are thought to follow early tubal rupture or abortion with reimplantation
ABDOMINAL PREGNANCY
Studdiford Criteria
the tubes and ovaries must be normal, with no evidence of recent or past injury
there must be no evidence of uteroplacental fistula
the pregnancy must be related only to the peritoneal surface and early enough in gestation to
eliminate the possibility of secondary implantation after primary tubal nidation
 ABDOMINAL PREGNANCY
Management
Termination generally is indicated when the diagnosis is made. Certainly, before 24 weeks, conservative
treatment rarely is justified
Preoperative options
angiographic embolization
catheters placed in the uterine arteries
insertion of ureteral catheters
Bowel preparation

In many ways, surgical management is similar to that for placenta percreta

 ABDOMINAL PREGNANCY
Management

The principal surgical objectives involve delivery of the fetus and careful assessment of placental
implantation without provoking hemorrhage.

Wide bladder flap before making the hysterotomy incision

Round ligaments are divided, lateral edges of peritoneal reflection are dissected downward
Classical hysterotomy incision is made
Unless there is spontaneous separation with bleeding that mandates emergency hysterectomy the OR begins after
full assessment is made
Leaving placenta in situ- --wise in whom abnormal placentation was not suspected before CS and in whom uterine closure stops bleeding
INTRALIGAMENTOUS PREGNANCY
In zygotes implanted toward the mesosalpinx,-rupture may occur at the portion of the tube
not immediately covered by peritoneum-gestational contents may then be extruded into a
space formed between the broad ligament

Clinical findings and management mirror those for abdominal pregnancy

laparotomy
laparoscopic excision
OVARIAN PREGNANCY
SPEILBERG CRITERIA
(1) the ipsilateral tube is intact and distinct from the ovary;
(2) the ectopic pregnancy occupies the ovary;
(3) the ectopic pregnancy is connected by the uteroovarian ligament to the uterus;
(4) ovarian tissue can be demonstrated histologically amid the placental tissue
Ovarian pregnancy. A. Transvaginal sonogram shows a gestational sac containing fetal parts of a 16-week gestation
OVARIAN PREGNANCY
classically, management has been surgical

small lesions -ovarian wedge resection or cystectomy

larger lesions -oophorectomy
systemic or locally injected methotrexate has been used successfully to treat small
unruptured ovarian pregnancies
 CERVICAL PREGNANCY
Defined by cervical glands noted histologically opposite the placental attachment site
and by part or all of the placenta found below the entrance of the uterine vessels or
below the peritoneal reflection on the anterior uterus

incidence : 1 in 8600 and 1 in 12,400 pregnancies

In a typical case, the endocervix is eroded by trophoblast, and the pregnancy develops
in the fibrous cervical wall
more cephalad -greater is its capacity to grow and hemorrhage
CERVICAL PREGNANCY
painless vaginal bleeding -90 %
distended, thin walled cervix with a partially dilated external os may be evident
above the cervical mass, a slightly enlarged uterine fundus can be felt

Identification: Speculum examination, palpation, and TVS MR imaging and 3-D

sonography
 CERVICAL PREGNANCY

Cervical pregnancy. Transvaginal sonographic findings may include: (1) an hourglass uterine shape and ballooned
cervical canal; (2) gestational tissue at the level of the cervixblack arrow); (3) absent intrauterine gestational tissue
(white arrows); and (4) a portion of the endocervical canal seen interposed between the gestation and the
endometrial canal.
CERVICAL PREGNANCY

RUBIN CRITERIA
1. Cervical glands must be present opposite to the placental attachment
2. Attachment of placenta to the cervix must be intimate
3. The placenta must be below the entrance of the uterine vessels or below
the reflection of the anteroposterior surface of the uterus
CERVICAL PREGNANCY
Management
methotrexate has become the first-line therapy in stable women also can be injected directly into
the gestational sac, alone or with systemic doses

With a single-dose IM methotrexate protocol - 50 and 75 mg/m2 BSA is typical

For women in whom fetal cardiac activity is detectable, a sonographically guided fetal intracardiac
injection of 2 mL (2 mEq/mL) potassium chloride solution can be given

If -hCG levels do not decline more than 15 percent after 1 week, a second dose of methotrexate
can be given
CERVICAL PREGNANCY
Hung and colleagues (1996) noted higher risks of systemic methotrexate treatment failure
WITH:
o gestational age > 9 weeks
o -hCG levels > 10,000 mIU/mL,
o crown-rump length > 10 mm
o fetal cardiac activity
many induce fetal death with intracardiac or intrathoracic injection of potassium chloride

*Suction curettage may be especially favored in rare cases of a heterotopic pregnancy

hysterectomy
 CESAREAN SCAR PREGNANCY
implantation within the myometrium of a prior cesarean delivery scar
1 in 2000 normal pregnancies
pathogenesis of CSP has been likened to that for placenta accreta and carries similar risk for
serious hemorrhage
usually present early, pain and bleeding are common
40 %of women are asymptomatic, and the diagnosis is made during routine sonographic
examination
 CESAREAN SCAR PREGNANCY
Management

Hysterectomy
Fertility preserving options- locally/systemic MTX injection
Suction curettage/ transvaginal aspiration
Hysteroscopic removal
 CESAREAN SCAR PREGNANCY
Godin
An empty uterine cavity is
identified by a bright
hyperechoic endometrial
stripe (long, white arrow).
An empty cervical canal is
similarly identified (short,
white arrow)
Last, an intrauterine mass is
seen in the anterior part of
the uterine isthmus (red
arrows).
B. Hysterectomy specimen containing a cesarean scar pregnancy. C. This same hysterectomy specimen is transversely
sectioned at the level of the uterine isthmus and through the gestational sac.