B Y

M U H A M M A D Z E E S H A N K H A N

A N D

S A N A J A W E D

ECTOPIC PREGNANCY (EP)

OBJECTIVE OF PRESENTATION

AT THE END OF PRESENTATION YOU SHOULD KNOW:

NORMAL SITE OF IMPLANTATION IN PREGNANCY

DEFINITION OF EP

ABNORMAL SITES OF IMPLANTATION IN EP

INCIDENCE

ETIOLOGY

CLINICAL MANIFESTATION

INVESTIGATION

MANAGEMENT

NORMAL SITES OF IMPLANTATION IN PREGNANCY

Implantation is the very early stage of pregnancy at

which the conceptus adheres to the wall of the uterus. At

this stage of prenatal development, the conceptus is

a blastocyst.

Normal site of implantation is posterior-superior wall of

the Body of uterus in most of the cases.

In addition anterior wall of body of uterus also

constitutes the normal site of implantation.

NORMAL SITE OF IMPLANTATION (shown in green)

WHAT IS ECTOPIC PREGNANCY

“IMPLANTATION OF CONCEPTUS OUTSIDE THE

NORMAL UTERINE CAVITY”.

NOTE: 1. ECTOPIC PREGNANCY VIRTUALLY NEVER LEADS TO FETAL

VIABILITY.

2. ALL SITES IN UTERINE CAVITY ARE CONSIDERED NORMAL FOR EP BUT

not IN GENERAL…

SITES OF IMPLANTATION OF ECTOPIC PREGNANCY

COMMON SITES OF IMPLANTATION ARE

1. Fallopian tubes ( 95 % of total cases of ectopic pregnancy )

a. Ampulla (74 % of 95%)

b. Isthmus ( 12 % of 95%)

c. Fimbrial end of the tube ( 12 % of 95%)

d. Interstitium ( 2% of 95%)

2. Ovaries ( 3-4 % of total)

3. Peritoneal cavity ( 1-2 % of total)

COMMON SITES OF EP

INCIDENCE

The frequency of ectopic pregnancy was 1 .3%.

Majority of patients with ectopic pregnancy were in 2 1-

30 years age group (74%)

Multiparous women were found to be more prone to have

ectopic pregnancy (6 1%).

The gestational age ranged between 4-11 weeks and the

most frequent gestational age was around 6 weeks.

ETIOLOGY/ RISK FACTORS

AMONG THE KNOWN RISK FACTORS / CAUSES OF ECTOPIC

PREGNANCIES ARE

1. Tubal Disease ; e.g. inflammatory condition due to ascending

infection i.e. PID. accounts for 40 % cases of ectopic pregnancy.

2. Previous EP

3. Previous tubal surgery.

4. Subfertility

5. Use of IUD.

PROBABLE MECHANISM OF TUBAL EP

CLINICAL MANIFESTATION OF EP

SUBACUTE PRESENTATION

1. ABDOMINAL/PELVIC PAIN(79%) , PAIN CAN BE LOCALIZED TO ILIAC FOSSA

2. VAGINAL BLEEDING(53%) , DARK RED INDICATIVE OF OLD BLOOD.

3. PAIN AT SHOULDER TIP RARE PRESENTATION , INDICATIVE OF FREE BLOOD IN ABDOMINAL CAVITY CAUSING DIPHRAGMATIC IRRITAITON.

CONT.

CLINICAL MANIFESTATION OF EP

ACUTE PRESENTATION

It occurs in cases of ruptured ectopic pregnancy and

patient presents with the symptoms of massive

intraperitoneal bleeding.

1. Hypovolemic Shock

2. Acute abdomen

INVESTIGATIONS OF EP

Useful investigations for the diagnosis of ectopic pregnancy.

OBSERVATIONS- VITALS

βHCG

TVS

LAPROSCOPY

Rarely used

Progesterone levels

βHCG

This hormone is a glycoprotein produced by placenta

Half life is 24 hours

Peaks at around 10weeks

Levels double every 48 hours in a normally developing pregnancy

Beta HCG less than 5mIU/ml is considered negative for pregnancy

Anything more than 25mIU/ml is considered positive for

pregnancy

In ectopic pregnancy:

Empty uterus on abdominal U/S with BHCG >6000mIU/ml

Empty uterus on vaginal U/S with BHCG >200mIU/ml

TRANSVAGINAL U/S SCAN(TVS)

An intrauterine GS should be visualized at 4.5weeks and corresponding

BHCG is 1500mIU/ml.

At 5th week GS with fetal heartbeat is detected with BHCG level around

3000mIU/ml

High BHCG level and no IU pregnancy seen on TVS is suggestive of

ectopic pregnancy

Presence of free fluid during TVS is suggestive of ruptured ectopic

pregnancy

FALSE NEGATIVE occurs in case of heterotopic pregnancy. i.e.

simultaneous pregnancy within and outside the uterus.

DIAGRAM SHOWING TVS

LAPROSCOPY

This is the gold standard test

Endoscope is inserted into the abdomen to allow a

surgeon to see fallopian tubes and other organs and

do surgery at the same time

DIAGRAM SHOWING LAPROSCOPY

PROGESTERONE LEVELS

Progesterone is a hormone formed by corpus luteum

>25ng/ml is related with normal intrauterine

pregnancy

<5ng/ml is related with ectopic or non viable

pregnancy

MANAGEMENT OF EP

Depending on clinical presentation and patients

choice:

EXPECTANT (Do nothing)

MEDICAL (Do something)

SURGICAL (Do everything)

EXPECTANT

Based on assumption that all tubal pregnancies

will resolve through regression or miscarriage

without any treatment.

Suitable for patients who are hemodynamically

stable and asymptomatic

Requires serial βHCG measurements and

ultrasonography

MEDICAL MANAGEMENT BY METHOTREXATE

METHOTREXATE

Folic acid antagonist that inhibits DNA synthesis in the

trophoblastic cells

Standard dose is 50mg/m2

Can be administered as a single I/M injection or multiple

fixed dose regimen.

INDICAITONS

Cornual pregnancy

Persistent trophoblastic disease

Patient with one fallopian tube and fertility desired

Patient who refuses surgery

Ectopic pregnancy where trophoblast is adherent to

bowel or blood vessel

GS is <4cm

CONTRAINDICATIONS

Chronic liver, renal or hematological disorder

Active infection

Immunodeficiency

Breastfeeding

SIDE EFFECTS

Nausea, vomiting

Stomatitis, conjunctivitis

GI upset

Photosensitive skin reactions

Non specific abdominal pain

SPECIAL ADVICE PRIOR TO USE

Avoid sexual intercourse during treatment

Take contraception for 3months after treatment

Avoid alcohol and sunlight exposure during

treatment

SURGICAL MANAGEMENT

INDICATIONS FOR SURGEICAL MANAGEMENT

Patient is not suitable for medical therapy

Medical therapy has failed

Patient has heterotropic pregnancy with viable

uterine pregnancy

Heamodynamically unstable and needs immediate

treatment

GS is >4cm

METHODS OF SURGERY

1. LAPROSCOPY- surgery through small incision,

having many advantages, like. less blood loss, shorter

hospital stay, less analgesia requirement, shorter

convalescence than laprotomy.

2. LAPROTOMY- surgery through large incision

especially reserved for severely compromised patient or

due lack of endoscopic facilities.

PROCEDURE OF SURGERY

1. SALPINGECTOMY

During surgery the fallopian tubes are removed

Done in patients:

• Who have tubal rupture

• Who no longer desire fertility

• Who have history of ectopic pregnancy in the same tube before

• Who have severely damaged tubes

PROCEDURE OF SURGERY

2. SALPINGOTOMY

During surgery, a small opening can be made at the site of ectopic

pregnancy and the trophoblastic tissue is extracted out via that

opening

Done when the tube has not ruptured or patient desires to

conserve her fertility

Monitoring needed for BHCG levels to identify persistent

trophoblast

High risk of subsequent ectopic pregnancy

PROGNOSIS AFTER MANAGEMENT

Rate of IU pregnancy may be higher following

treatment with methoteraxate as compared to

surgery

Rate of fertility may be better following

salpingotomy as compared to salpingectomy