Ectopic Pregnancy

Kavya Liyanage

What is an Ectopic pregnancy?Implantation of the conceptus outside the normal uterine cavity.

What is the normal site of implantation?

Uterine endometrium

Common sites of implantation within the abdominal cavity

Fallopian tubes (95%) Ampulla (74%) Isthmus (12%) Fimbriae ends  (12%) Interstitium  (2%)

Ovaries (3%)Peritoneal cavity (1%)

Heterotopic Pregnancy

Simultaneous development of a pregnancy within and outside the uterine cavity

Risk of incidence is rising with in vitro fertilization (IVF) treatment

Risk factors for ectopic pregnancy

Tubal disease Eg- Chlamydia infection that cause pelvic infection accounts for 40% of ectopic pregnancies

Previous ectopic pregnanciesPrevious tubal surgerySubfertilityUse of intrauterine device

What is the clinical presentation?• Subacute abdominal pain• Vaginal bleeding in early pregnancy

Abdominal pain

The pain maybe localized to the iliac fossa

Sometimes the pain presents as a tip of the shoulder pain, due to the free blood in abdominal cavity causing diaphragmatic irritation and symptoms of dizziness

Per vaginal bleeding

Usually dark red Indicative of old blood

When the ectopic pregnancy ruptures

Massive intraperitoneal bleeding causing Hypovolemic shock Acute abdomen

Investigations • Observations• Laboratory investigations• HCG• Transvaginal ultrasound scan 

Observations 

Blood pressurePulseTemperature 

Laboratory investigations

Haemoglobin Blood group β-hCG

HCG level In 85% pregnancies, hCG level almost double in every 48 hours.

In ectopic pregnancies, the level is suboptimal.

Transvaginal ultrasound scan(TVS)

An intrauterine pregnancy is detected by TVS at 4.5 weeks of gestation

At that time hCG level is about 1500 mIU/mL. At 5th week of gestation, fetal heart beat is detected

in TVS. There, the hCG level is about 3000 mIU/mL.

A discrepancy between hCG level and TVS may suggest ectopic pregnancy.

Free fluid detected in TVS suggests of a ruptured ectopic pregnancy.

Management basis• Clinical presentation• β-hCG• Ultrasound findings• Patient's choice

Management methods

Expectant approach Medical approach Surgical approach 

Expectant approach

Suitable for haemodynamically stable and asymptomatic patients

Assuming that significant proportion of all tubal pregnancies will resolve with regression or tubal abortion without treatment

Medical approach

Intramuscular methotrexate Which is a folic acid analog that inhibit DNA synthesis in trophoblastic cells

Methotrexate treatment

Indications  Cornual pregnancy Persistent trophoblastic disease

Patient with one fallopian tube and fertility desired

When trophoblastic cells adherent to bowel or blood vessel

Contraindications 

Chronic liver, renal or haematological disorder

Active infection Immunodeficincy Breast feeding

Surgical approach 

LaparoscopyLaparotomy 

Laparoscopy 

Less blood loss Shorter operating time Less anaelgesia Shorter hospital stay Shorter convalescence Mainstay of management 

Laparotomy 

For severely compromised patients When endoscopic facilities are lack

During surgery

SalpingectomyRemoval of fallopian tubeTreatment of choice when one normal tube is remaining

Salpingotomy Fallopian tube opened at the site of ectopic pregnancy and trophoblastic cells extracted

Associated with higher rate of subsequent ectopic pregnancy

Thank You!