2. ECTOPIC PREGNANCY
In ectopic pregnancy, a fertilized ovum implants
in an area other-than the endometrial lining of
the uterus
More than 95o/o of extrauterine Pregnancies-
occuri n the fallopian tube.
4. incidence
The incidence in the United Kingdom has changed
little in the last decade with 9.6 ectopics per 1000
pregnancies in 1991–1993 and 11.0 per 1000 pregnancies
in 2000–2002
This may be due, at least in part, to a higher incidence
of salpingitis, an increase in ovularion induction
and assisted reproductive technology, and more
tubal sterilization
5. Increasing Ectopic Pregnancy
Rates
A number of reasons at least partially explain the increased
rate of ectopic pregnancies in the United States and many
European countries. Some of these include:
1. Increasing prevalence of sexually transmitted infections,
especially those caused by Chlamydia trachomatis
2. Identification through earlier diagnosis of some ectopic
pregnancies otherwise destined to resorb spontaneously
6. 3. Popularity of contraception that predisposes pregnancy
failures to be ectopic
4. Tubal sterilization techniques that with contraceptive
failure increase the likelihood of ectopic pregnancy
5. Assisted reproductive technology
6. Tubal surgery, including salpingotomy for tubal pregnancy
and tuboplasty for infertility.
7. Mortality
According to the World Health Organization (2007),
ectopic pregnancy is responsible for almost 5 percent of
maternal deaths in developed countries.
8. Risk factors for ectopic
pregnancy
History of previous ectopic pregnancy
(IUCD) or sterilization failure
Pelvic inflammatory disease
Chlamydia infection
Early age of intercourse and multiple partners
History of infertility
Previous pelvic surgery
Increased maternal age
Cigarette smoking
Strenuous physical exercise
In utero DES exposure
9. TUBAL PREGNANCY
The fertilized ovum may lodge in any portion of the
oviduct, giving rise to ampullary, isthmic, and interstitial
tubal pregnancies
In rare instances, the fertilized ovum may implant in the
fimbriated extremity. The ampulla is the most frequent
site, followed by the isthmus. Interstitial pregnancy
accounts for only about 2 percent. From these primary
types, secondary forms of tubo-abdominal, tubo-ovarian,
and broadligament pregnancies occasionally develop.
10.
11. Clinical presentation
1-subacute clinical picture of
A. abdominal pain &vaginal bleeding in early pregnancy.
Vaginal bleeding is usually dark red, indicative old blood
B- abdominal/ pelvic pain may be localized to the iliac fossa.
C- sholder tip pain indicative of free blood in the abdominal cavity
D- dizzeness (anaemia)
Bimanual examination can reveal tenderness in the fornices and there
may be cervical excitation
2- Acute clinical presentation due to rupture ectopic pregnancy with
massive intraperitoneal bleeding. They can present with signs of
hypovolaemic shock & acute abdomen
12. Investigation
The following are useful investigation for the diagnosis of
ectopic pregnancy
1- observations :Bp, pulse ,temperatuer
2- laboratory investigations:
Haemoglobin. blood group(prepare blood forr cross match) &
B-HCG
A B-HCG level of less than 5mIU/ml, is considered negative
for pregnancy& any thing above 25 mIU/ml is considered
positive for pregnancy
In 85% of pregnancy the B-HCG levels almost double every 48
hours in normally developing intrautrine pregnancy
13. In ectopic pregnancy the rise in B-HCG is suboptimal,. However
multiple readings are required for comparison purposes.
Transvaginal ultrasound scan (TVS)
An intrauterine gestational sac should be visualized at 4.5 weeks
Gestation.the corresponding B-HCG at that gestation is around
1500 mIU/ml.By the time a gestational sac with fetal heart
pulsation is detcted (at around 5 weeks gestation)B-HCGlevel
should be around 3000 mIU/ml
Thus , if there were discrepancy betwween B-HCG cocentration
and that seen on ultrasound scan(e.g.a highB-HCG with no
intruterine pregnancy on ultrasound scan), the differential
diagnosis of an ectopic pregnancy must be made.
14. Identification of an intruterine pregnancy(gestational sac, yolk
sac, and fetal pole) on TVS effectively excludes the possibility
of ectopic pregnancy in most patients except in those patients
with rare hterotopic pregnancy.
The presence of free fluid during TVSis suggestive of a
ruptured cetopic pregnancy
Lparoscopy:this can be used to diagnose and treat ectopic
pregnancy
15. Culdocentesis
This simple technique was used commonly in the past to
identify hemoperitoneum. The cervix is pulled toward the
symphysis with a tenaculum, and a long 16- or 18-gauge
needle is inserted through the posterior vaginal fornix into
the cul-de-sac. If present, fluid can be aspirated, however,
failure to do so is interpreted only as unsatisfactory entry into
the cul-de-sac and does not exclude an ectopic pregnancy,
either ruptured or unruptured. Fluid containing fragments of
old clots, or bloody fluid that does not clot, is compatible
with the diagnosis of hemoperitoneum resulting from an
ectopic pregnancy. If the blood subsequently clots, it may
have been obtained from an adjacent blood vessel rather
than from a bleeding ectopic pregnancy.
16.
17. Ultrasound
With the advent of diagnostic ultrasound and the
increasing use of conservative treatment, the diagnosis
of ectopic pregnancy is increasingly made without the
help of surgery.
Gestational sac
with a live
embryo
and a yolk sac
Uterus
18. In women with ectopic pregnancies bleeding within the
uterine cavity may resemble an early intrauterine
pregnancy (‘pseudosac’).
The presence of free fluid in the pouch of Douglas is a
frequent finding in women with normal intrauterine
pregnancies and it should not be used to diagnose an
ectopic. However, the presence of blood clots is
important and is a common finding in ruptured
ectopics
19. In women with intrauterine pregnancy on the scan a
possibility of heterotopic pregnancy should be excluded.
This is particularly the case in women who conceived
after stimulation of ovulation orIVF (in vitro
fertilization).
20. Serum Progesterone. A single progesterone measurement
can be used to establish with high reliability that there is a
normally developing pregnancy. A value exceeding 25
ng/mL excludes ectopic pregnancy with 92.5-percent
sensitivity .
Conversely, values below 5 ng/mL are found in only 0.3
percent of normal pregnancies . Thus, values 5 ng/mL
suggest either an intrauterine pregnancy with a dead fetus
or an ectopic pregnancy. Because in most ectopic
pregnancies, progesterone levels range between 10 and 25
ng/mL, the clinical utility is limited
21. Novel Serum Markers. A number of
preliminary studies have
been done to evaluate novel markers to detect ectopic
pregnancy. These include vascular endothelial growth
factor (VEGF), cancer antigen 125 (CA125), creatine
kinase, fetal fibronectin, and mass spectrometry-based
proteomics None of these are in current clinical use.
22. Differential diagnosis
The diagnosis is from any other acute abdominal
catastrophe such as rupture of a viscus or acute
peritonitis. The clinical picture is so typical that in
most cases diagnosis presents no difficulty. Other
diagnoses which may confuse are:
• inevitable miscarriage;
• bleeding with an ovarian cyst;
• pelvic appendicitis;
• acute salpingitis.
24. Expectant management
Expectant management has important advantages over
medical treatment as it follows the natural history of the
disease and is free from serious side effects of
methotrexate. Expectant management requires prolonged
follow-up and it may cause anxiety to both women and
their carers.
However, the main limiting factor in the use of expectant
management is the relatively high failure rate and
the inability to identify with accuracy the cases that are
likely to fail expectant management. To minimize the
risk of failure many authors have used very strict selection
criteria for expectant management such as the initial
hCG <250 IU
25. Surgery
Surgery has been traditionally used both for the
diagnosis and treatment of ectopic pregnancy.
With recent advances in operative laparoscopy, the
minimally invasive approach has also become accepted
as the method of choice to treat most tubal ectopic
pregnancies.
There are important advantages of laparoscopic over
open surgery which include less post-operative pain,
shorter hospital stay and faster resumption of social
activity
26. Laporatomy
In a case of severe haemorrhage in ruptured ectopic
pregnancy , the patient must be taken immediately to
the operating theatre. Little time should be wasted in
attempting resuscitation which can prove useless and
may only increase bleeding. An intravenous drip
should be set up and a blood transfusion given as soon
as possible.
27. Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic
pregnancy unless the woman is hemodynamically unstable
Tubal surgery is considered
*conservative when there is tubal salvage. Examples
include salpingostomy, salpingotomy, and fimbrial
expression of the ectopic pregnancy.
*Radical surgery is defined by salpingectomy.
28. Laparoscopy techniques exist to:
• kill the embryo with a direct injection of
methotrexate or mifepristone allowing absorption
so requiring no surgery on the tube;
• incise the swollen tube over the ectopic pregnancy,
aspirate the embryo, and achieve
haemostasis (salpingostomy).
29. Salpingostomy. This procedure is used to remove a small
pregnancy that is usually less than 2 cm in length and
located in the distal third of the fallopian tube . A 10- to
15- mm linear incision is made with unipolar needle
cautery on the antimesenteric border over the pregnancy.
The products usually will extrude from the incision and
can be carefully removed or flushed out using high-
pressure irrigation that more thoroughly
removes the trophoblastic tissue
31. Salpingotomy. Seldom performed today, salpingotomy
is essentially the same procedure as salpingostomy except
that the incision is closed with delayed-absorbable suture..
32. Salpingectomy. Tubal resection may be used for
both ruptured and unruptured ectopic pregnancies.
When removing the oviduct, it is advisable to excise a
wedge of the outer third (or less) of the interstitial portion
of the tube. This so-called cornual resection is done in an
effort to minimize the rare recurrence of pregnancy in the
tubal stump. Even with cornual resection, however, a
subsequent interstitial pregnancy is not always prevented .
33. Persistent Trophoblast. Incomplete removal of
trophoblast
may result in persistent ectopic pregnancy. Because of this,
administered a “prophylactic” 1 mg/m2 dose of
methotrexate postoperatively. Persistent trophoblast
complicates 5 to 20 percent of salpingostomies and can be
identified by persistent or rising hCG levels. Usually -
hCG levels fall quickly and are at about 10 percent of
preoperative values by day 12 . Also, if the postoperative
day 1 serum - hCG value is less than 50 percent of the
preoperative value, then persistent trophoblast rarely is a
problem
34. Medical Management with Methotrexate
This folic acid antagonist is highly effective against rapidly
proliferating trophoblast, and it has been used for more
than 40 years to treat gestational trophoblastic disease
35. Selection criteria for conservative management of ectopic
pregnancy
1. Minimal clinical symptoms
2. Certain ultrasound diagnosis of ectopic
3. No evidence of embryonic cardiac activity
4. Size <5 cm
5. No evidence of haematoperitoneum on ultrasound scan
6. Low serum hCG (methotrexate <3000 IU/l; expectant
7. <1500 IU/l)
36. The followin are resonable indications for
methotrexate use
1-cornual pregnancy
2-Prsistant trophoblastic disorders
3- patient with one fallopian tubeand fertility desired .
4-patient who refuse surgery or whome surgery is risky
5-treatment of ectopic pregnancy where trophoblast is
adherent to bowel or blood vessel
37. Contrindications of medical
treatment
1- chronic liver, renal or haematological disordes
2- active infection
3-immunodeficency
4- breast feeding
Side effect of methotrexate
nausea.vomiting ,stomatitis, cojuctivitis, GI upset,
photosensitive skin reaction Abdominal pain
Advise the women to take contraception for three months
after methotreate. It is also important to avoid alcohol &
exposure to sunlight during treatment
38. Non-tubal ectopics
Interstitial ectopics
The implantation of the conceptus in the proximal portion
of the Fallopian tube, which is within the muscularwall
of the uterus, is called an interstitial pregnancy. The
incidence of interstitial ectopic is 1 in 2500–5000 live
births and it accounts for2–6% of all ectopic pregnancies
39. Ruptured interstitial pregnancy usually presents
dramatically with severe intra-abdominal bleeding, which
requires urgent surgery. Haemostasis can usually be
achieved by removing the pregnancy tissue and suturing
the rupture site. However, in cases of extreme bleeding a
cornual resection or in rare cases a hysterectomy may be
necessary to arrest the bleeding.
40. The sac is completely surrounded by a myometrial
mantle, which is typical of
interstitial pregnancy.
41. Pregnancies located below the internal os –cervical
and Caesarean scar ectopics
Cervical pregnancy is defined as the implantation of the
conceptus within the cervix, below the level of the
internal os. Caesarean scar pregnancy is a novel entity,
which refers to a pregnancy implanted into a deficient
uterine scar following previous lower segment
Caesarean section
42. An attempt to remove cervical or Caesarean section
pregnancy is likely to cause severe vaginal bleeding and
hysterectomy rates of 40% have been described when
a D&C was attempted without pre-operative diagnosis
of cervical pregnancy
43. Ovarian pregnancy
Ovarian pregnancy is defined as the implantation of the
conceptus on the surface of the ovary or inside the ovary,
away from the fallopian tubes
. The diagnosis of ovarian pregnancy is rarely achieved
pre-operatively; hence most women are treated
surgically as the diagnosis is reached only at operation
44. Abdominal pregnancy
Abdominal pregnancy is a rarity that only a few
gynaecologists will encounter during their professional
career. Most abdominal pregnancies are the result of
reimplantation of ruptured undiagnosed tubal ectopic
pregnancies.
With the increasing accuracy of first-trimester
transvaginal scanning it is likely the prevalence of
advanced abdominal pregnancy will decrease even further
in the future.
45. The clinical and ultrasound features
of an early abdominal pregnancy are very similar to
tubal ectopic pregnancies. However, viable abdominal
pregnancies, which progress beyond the first trimester,
are typically missed on routine transabdominal scanning.
Abdominal pregnancy should be suspected in women
with persistent abdominal pain later in pregnancy and
in those who complain of painful fetal movements.
46. Treatment of abdominal pregnancy is surgical. In
advanced abdominal pregnancies
accompanied by normal fetal development diagnosed
in the late second trimester termination of pregnancy
may be delayed for a few weeks until the fetus reaches
viability.
At surgery the gestational sac should be opened carefully
avoiding disruption of the placenta. The fetus should be
removed, the cord cut short and the placenta should be
left in situ .
47. Any attempt to remove the placenta may result
in massive uncontrollable haemorrhage. Adjuvant
treatment with methotrexate is not necessary and the
residual placental tissue will absorb slowly over a
period of many months, sometimes a few years. The
placental tissue left in situ may become infected
leading to the formation of a pelvic abscess, which may
require drainage.