DIWAN SHRESTHA (D1) presentation on ECTOPIC PREGNANCY

1. TEXT PRESENTATION ON
ECTOPIC PREGNANCY
Diwan (D1) Shrestha
Intern

2. Ectopic Pregnancy
Definition
Any pregnancy where the fertilised ovum
gets implanted & develops in a site other than the
normal endometrial cavity.

3. Incidence
 Accounts for 1-2 % of total pregnancy
 Rising due to PID, use of IUCD, tubal surgeries, ART &
STIs
 Recurrence rate – 15% after 1st, 25% after 2 ectopics

4. Sites for ectopic pregnancy

6. Risk Factors of Ectopic Pregnancy
Up to half of women with ectopic pregnancy will
have no identifiable risk factors.
• History of prior tubal
surgery including
tubal ligation
• Prior ectopic
pregnancy
• In utero
diethylstilbestrol
(DES) exposure
• History of PID
• IUD use
• Perimenopausal
women
• Infertility
• Smoking
• Multiple sexual
partners
• Endometriosis

8. Clinical Features
Wide spectrum of clinical presentation from asymptomatic pt
to others with acute abdomen & hemodynamic shock.
The classic symptom triad of it is pain, amenorrhea
& vaginal bleeding.
- Pain
May be unilateral / bilateral & may occur in upper or lower
abdomen
dull, sharp or crampy
continuous or intermittent
 With rupture transient relief of pain may occur.
Feeling of nausea, vomiting, fainting attack, syncope attack
due to reflex vasomotor disturbance may be present

9. Clinical Features Contd..
- Physical examination
Should include vital signs & examination of abdomen &
pelvis
The abdomen may be non tender or mildly tender with or
without rebound
Uterus may be slightly enlarged
Cervical motion tenderness may or may not be present
An adnexal mass may be palpable in up to 50% cases
but the mass varies markedly in size, consistency &
tenderness

10. Clinical Features Contd..
-With rupture & intra abdominal hemorrhage,
 patient develops tachycardia followed by
hypotension
Bowel sounds are decreased or absent
Abdomen is distended with marked
tenderness & rebound tenderness
Cervical motion tenderness is present.

11. Investigation
Accuracy of initial clinical evaluation is less
than 50%. Additional tests are frequently
required to differentiate early viable
intrauterine pregnancy or suspected ectopic
or abnormal intrauterine pregnancy
General investigation such as Hb,
blood grouping & cross matching, TC, DC,
BT, CT

12. Investigation contd.
Bed side test :
1.Urine pregnancy test : positive in 95% cases
2.Culdocentesis:
It can be done with
18-20G spinal needle
through posterior fornix
into POD. If non clotting
blood is obtained, results
are positive.If serous fluid
is present,results are
negative
A lac of fluid return or clotted
blood is non- diagnostic

13. Investigation Contd:Other invest as
1) Ultrasonography:
Transvaginal USG is superior to
transabdominal USG
Evidence of an empty uterus,
detection of adnexal masses , free
peritoneal fluid & signs of ectopic
pregnancy are more reliably
established with transvaginal procedure
Identification of double decidual sac
sign is the best method to differentiate true
sacs from pseudosacs
Presence of free cul-de-sac fluid is
frequently associated with ectopic pregnancy
TVS can detect gestational sac at 4 weeks & by
TAS at 6 wks

14. # USG PICTURE
 Bagel sign – Hyperechoic ring around
gestational sac in adnexal region
 Hyperechoic Hyperechoic ring around
gestational gestational in adnexal region
Investigation Contd

15. Investigation Contd:
2)Color Doppler Sonography :
It improve the accuracy & identify the placental
shape (ring of fire pattern) & blood flow outside
the uterine cavity

16. Investigation contd
3)Quantitative B-hCG :
• -Diagnostic cornerstone for ectopic pregnancy
• -The hCG enzyme immunoassay is positive in
virtually all documented ectopic
pregnancies
• -When hCG level < 2000IU/Ldoubling time
helps to predict viable Vs non viable pregnancy
• -Rise of B-hCG < 66% in 48 hrs indictate
ectopics or nonviable intrauterine pregnancy

17. Investigation Contd:
4)Laparoscopy:
Gold standard for the diagnosis of ectopic pregnancy
Diagnosis & removal of ectopic mass can be done at the
same time

18. Investigation Contd:
5)Dilatation & Curettage:
It is performed when the pregnancy
is confirmed to be nonviable & location
of pregnancy cannot be confirmed
by USG
Identification of decidua
without chorionic villi is suggestive
of extra uterine pregnancy

19. Investigation Contd:
6) Other tests
a)Estradiol: Levels are significantly lower in ectopic
pregnancies when compared with viable pregnancies
b)Relaxin: is a protein hormone produced solely by corpus
luteum of pregnancy & its levels are significantly lower in ectopic
pregnancies.
c)Maternal AFP: levels are elevated in ectopic pregnancies
d)Serum progesterone: With ectopicpregnancies is lower than
25 ng/mL
.

20. Management Of Ectopic Pregnancy
Management may be medical or surgical or expectant
 Management approach depends on clinical
circumstances, site of ectopic pregnancy & the available
resources
1.Surgical treatment :
•It can be accomplished by laparoscopy or laparotomy
•The hemodynamic stability of patient, size & location of
ectopic mass & surgeons expertise all contribute to
determining the appropriate surgical approach

21. Surgical management: Contd
 Laparotomy: Indicated when the patient
becomes hemodynamically unstable & an
expedited abdominal entry is required
 Advantages of laparoscopy: decreased cost,
operative time ,blood loss & hospital stay
 An alternative to laparoscopy is the use of
minilaparotomy incision.

22. Surgical management: contd
There is debate about which surgical procedure
(Salpingectomy or Salpingostomy) is best.
The decision to choose one technique over the other
depends on the condition of the affected & contralateral
fallopian tubes, history of previous ectopic in the affected tube
& patients desire for future fertility
Linear salpingostomy:
Can be considered when the
patient has an unruptured ectopic
pregnancy, wishes to retain her
potential for future fertility & the
affected fallopian tube appears
otherwise normal
If the contralateral tube appears damaged ,
a salpingostomy should be considered

23. Surgical management: Contd
In salpingostomy the products of conception are
removed through an incision made into the tube on
its antimesenteric border
Contraindications Of salpingostomy:
Ruptured fallopian tube
use of extensive cautery to obtain hemostasis
severely damaged tube
recurrent ectopic pregnancy in the same tube.

24. Mx Of Ectopic Pregnancy: Contd
2. Medical Treatment:
The drug most frequently used for medical
management of ectopic pregnancy is
methotrexate
Other agents such as KCL, hyperosmolar
glucose, prostaglandins are not recommended
because their safety & accuracy are not well
documented
These agents may be given systemically ( IV,
IM or orally ) or locally (laparoscopic direct
injection or retrograde salpingography ).

25. Medical Treatment Contd:
Methotrexate:
It is a folic acid analogue that inhibits dehydrofolate
reductase & thereby prevents synthesis of DNA
Candidates for Methotrexate – patients with confirmed or
high suspicion for ectopic pregnancy who are
hemodynamically stable with no evidence of rupture
Contraindications:
hemodynamically unstable
ruptured ectopic pregnancy
unable to comply with medical management follow up
Breastfeeding
Immunodeficiency
preexisting blood dyscrasias
active pulmonary disease

26. Medical Treatment Contd:
Methotrexate treatment regimens –
1.Multidose regimen –
MTX 1mg/kg IM on 1,3,5,7 days
Leucovorin 0.1mg/kg on 2,4,6,8 days
Measure B-hCG levels on days 1,3,5,7 until
15% decrease between 2 measurement
Once B-hCG level drops 15%, stop MTX &
monitor B-hCG weekly until non pregnant level

27. Medical Treatment Contd:
2.Single dose regimen:
MTX 50mg/m2 on day 0
Measure B-hCG level on days 4 & 7
If level drops by 15%, monitor B-hCG weekly until non
pregnant level. If levels do not drop by 15%, repeat dose of
MTX & measure B-hCG on days 4 & 7
3.Two dose regimen:
MTX 50mg/m2
on days 0 & 4
Measure B-hCG levels on days 4 & 7
 If levels drop by 15%, monitor B-hCG weekly until non
pregnant level
If level do not drop by 15%, repeat dose of MTX on days 7 &
11 & measure B-hCG on days 7 & 11. If levels drop 15%,
monitor B-hCG level weekly until non pregnant level

28. Medical Treatment Contd:
Effectiveness of Methotrexate
The overall effectiveness of MTX therapy ranges from 78
to 96%.
Side effects:
Dose & frequency dependent
 nausea, vomiting
 Stomatitis
 abdominal pain
 bone marrow suppression
 Alopecia
 dermatitis & pneumonitis..
• The risk of subsequent ectopic pregnancy is about 10%
following either methotrexate or salpingostomy. Comparision
of laparoscopically treated & methotrexate treated patients
shows 2 methods have similar reproductive outcomes

29. Mx of ectopic pregnancy: Contd
3.Expectant management:
# Identification criteria :
1.Tubal ectopic pregnancies only
2.Haemodynamically stable
3.Haemoperitoneum < 50 ml
4.Adnexal mass of < 3.5cm without heart beat
5.Initial B-hCG < 1000 IU/L & falling in titre
* Success rate – up to 60 %

30. Expectant Mx: Contd
# Protocol
 Hospitalisation with strict monitoring of clinical
symptom
 Daily Hb estimation
 Serum B-hCG monitoring 3-4 days until it is <10
IU/L
 TVS to be done twice a week
#Spontaneous resolution occurs in 72%,
while 28% will need laparoscopic
salpingostomy

31. Management of ruptured ectopic
PRINCIPLE: Resuscitation &
Laparotomy
ANTI SHOCK TREATMENT:
- IV line opened, crystalloid
started
- Folleys catheterization done
- colloids for volume
replacement
LAPAROTOMY:
- Rapid exploration of
abdominal cavity done
- Salpingectomy is the
definitive surgery
- Blood transfusion done

32. Cervical Ectopic
• Clinical criteria for diagnosing cervical ectopic:
 Uterus smaller than the surrounding distended cervix
 External os may be open
 Visible cervical lesion often blue or purple in colour
 Profuse bleeding on manipulation of cervix
Management
 Medical treatment with methotrexate & surgical
dilation & curettage
 Ideal regimen for medical Mx is unknown & success
is reported with both single & multidose regimens as
previously described

33. Ovarian ectopic
A pregnancy confined to ovary accounts for up to 3% of
all ectopic pregnancies.
• Criteria for ovarian pregnancy diagnosis:
1.The fallopian tube on the affected side must be intact
2.The fetal sac must occupy the position of the ovary
3.The ovary must be connected to the uterus by the
ovarian ligament
4.Ovarian tissue must be located in the sac wall
Treatment:
 Ovarian cystectomy &/or wedge resection
 Successful treatment with Methotrexate is reported

34. Abdominal ectopic pregnancy
• It can be classified
1. Primary
2. Secondary
#Studdifords criteria for diagnosis of primary abdominal
pregnancy are -
 Presence of normal tubes & ovaries with no evidence of recent
or past pregnancy
 No evidence of uteroplacental fistula
 The presence of a pregnancy related exclusively to the
peritoneal surface & early enough to eliminate the possibility
of secondary implantation after primary tubal nidation
# Secondary – conceptus escapes out through a rent from
primary site – Intraperitoneal or Extraperitoneal broad ligament
 Surgical intervention is recommended when an abdominal
pregnancy is diagnosed
 It can be treated with Methotrexate in patients not
considered to be optimal surgical candidates.

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