Ectopic Pregnancy5

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ECTOPICPREGNANCY

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Ectopic Pregnancy

Ectopic Pregnancy

The blastocyst normally implants in

the endometrial lining of the uterine

cavity

Implantation anywhere else is an

ectopic pregnancy

There is a 7-to 13-fold increase in

the risk for a subsequent ectopic

pregnancy

Intrauterine pregnancy: !" to #!"

Tubal pregnancy: $!" to %"



Ectopic Pregnancy

Ris !actor Ris

High Risk

Tubal corrective surgery

Tubal sterili&ation

Previous EP

In utero 'E( e)posure

I*'

'ocumented tubal pathology

Moderate Risk

Infertility

Previous genital infection

+ultiple partners

Slight risk

Previous pelvic or abdominal surgery (moking

'ouching

Intercourse before $# weeks

%$.!

,.-

#.-

.

.%0

-.#0%$

%.0%$

%.0-.1

%.$

!.,-0-.#%.-0%.

$.$0-.$

$.

Table $. 2isk 3actors for Ectopic Pregnancy



Ectopic Pregnancy

Increasing ectopic pregnancy

rates

$. Prevalence of se)ually transmitted tubal

infection and damage

%. 4scertainment through earlier diagnosis ofsome EP otherwise destined to resorb

spontaneously

-. Popularity of contraception that predisposesfailures to be ectopic



Ectopic Pregnancy

Increasing ectopic pregnancy

rates

. *se of tubal sterili&ation techniques that

increase the likelihood of EP

. *se of assisted reproductive techniques. *se of tubal surgery5 including salpingotomy

for tubal pregnancy and tuboplasty for

infertility



Ectopic Pregnancy

"istory

6lassic triad of symptoms

Pain# a$enorr%ea# &aginal 'leeding

(een in only about !" of patients +ost typical in patients in whom EP has ruptured

4bdominal pain 7 most frequent complaint

8ith rupture5 the patient may e)perience transient relief of

pain since stretching of the serosa ceases

Shoulder and back pain 7 hemoperitoneal irritation of the

diaphragm9 may indicate intraabdominal hemorrhage



Ectopic Pregnancy

"istory

Passage of decidual

cast

ccurs in "0$!" ofwomen

Their passage may be

accompanied by cramps

similar to those occurringwith a spontaneous

abortion

'ecidual cast



Ectopic Pregnancy

P%ysical E(a$ination +easurement of

vital signs

8ith rupture and

intraabdominalhemorrhage5 the

patient develops

tachycardia

followed by

hypotension



Ectopic Pregnancy

P%ysical E(a$ination

E)amination of the abdomen and pelvis

4bdomen may be nontender or tender5 with orwithout rebound

*terus may be enlarged5 with findings similar toa normal pregnancy

6ervical motion tenderness may or may not be

present ;ulging of the posterior cul0de0sac

4dne)al mass palpable in up to !" of cases



Ectopic Pregnancy

C)ldocentesis 4 simple technique to identify hemoperitoneum

The cervi) is pulled toward the symphysis pubis with atenaculum

4 long $0 or $#0gauge needle is inserted through the posteriorforni) into the culdesac

Non-clotting blood aspirated :compatible with the diagnosis ofhemoperitoneum resulting from an

EP



Ectopic Pregnancy

*a'oratory tests

<emogram

Even after substantive hemorrhage5 hemoglobin

and hematocrit readings may at first show only a

slight reduction

<ence after an acute hemorrhage5 a decrease in

hemoglobin or hematocrit level over several hours is a

more valuable inde) of blood loss than the initial

reading



Ectopic Pregnancy

*a'oratory tests

h6= assays

EP cannot be diagnosed by a positive pregnancy

test alone

h6= assays positive in over ,," of EPs

(ensitive to levels of chorionic gonadotropin of $!0

%! mI*/ml

The h6= pattern that is most predictive of EP is

one that has reached a plateau >doubling time of

more than 1 days?



Ectopic Pregnancy

*a'oratory tests

(erum progesterone levels

4 single progesterone measurement can be used

to establish that there is a normally developing

pregnancy with high reliability

4 value e)ceeding % ng/m@ e)cludes EP with

,1." sensitivity

Aalues below ng/m@ occur only in !.-" ofnormal pregnancies 7 suggests a dead fetus or

EP



Ectopic Pregnancy

+ltraso)nd i$aging

4bdominal sonography If a gestational sac is clearly

identified within the uterine

cavity5 EP rarely coe)ists

8ith sonographic absence

of a uterine pregnancy5 a

positive pregnancy test

result5 fluid in the cul0de0sac5and an abnormal pelvic

mass5 EP is alsmost certain



Ectopic Pregnancy

+ltraso)nd i$aging

Aaginal sonography

The imaging of choice in early pregnancy

4 tubal pregnancy may be missed when the massis small or obscured by bowel

2eported sensitivity for diagnosing EP varies

widely from %!" to #!"



Ectopic Pregnancy

,)rgical diagnosis

@aparoscopy ffers a reliable diagnosis in

most cases of suspected EP and

a ready transition to definitive

operative therapy

@aparotomy

pen abdominal surgery is

preferred when the woman is

hemodynamically unstable orwhen laparoscopy is not feasible



Ectopic Pregnancy

"istologic c%aracteristics

Evidence of chronic salpingitis and salpingitis

isthmica nodosa >(IB?

4rias0(tella reaction



Ectopic Pregnancy

Type of EP 'efinition

Tubal pregnancy 4 pregnancy occurring in the fallopian tube 7 most often theseare located in the ampullary portion of the fallopian tube

Interstitial pregnancy 4 pregnancy that implants within the interstitial portion of thefallopian tube

4bdominalpregnancy

Primary 7 the $st and only implantation occurs on a peritoneal

surface

(econdary 7 implantation originally in the tubal ostia5

subsequently aborted and then reimplanted into the

peritoneal surface

6ervical pregnancy Implantation of the developing conceptus in the cervical canal

@igamentouspregnancy

4 secondary form of EP in which a primary tubal pregnancyerodes into the mesosalpin) and is located between the leaves

of the broad ligament

<eterotopicpregnancy

4 condition in which ectopic and intrauterine pregnancies coe)ist

varian pregnancy 4 condition in which an EP implants within the ovarian corte)

Table %. 'efinitions of Types of Ectopic Pregnancies



Ectopic Pregnancy

T)'al Pregnancy

The fertili&ed ovum may

lodge in any portion of the

oviduct5 giving rise to

ampullary5 isthmic5 andinterstitial tubal pregnancies

4mpulla is the most frequent site5 followed by

the isthmus

Interstitial pregnancy accounts for only -" ofall tubal gestations



Ectopic Pregnancy

T)'al Pregnancy

Treatment 4nti0' immunoglobulin '0negative women with an ectopic pregnancy who

are not sensiti&ed to '0antigen should be given anti0' immunoglobulin



Ectopic Pregnancy

T)'al Pregnancy

Treatment (urgical +anagement @aparoscopy is preferred over laparotomy unless the

patient is unstable Tubal surgery for EP is considered conservative

when there is tubal salvage >salpingostomy5

salpingotomy5 fimbrial e)pression of the EP?

2adical surgery is defined by salpingectomy



Ectopic Pregnancy

T)'al Pregnancy

(alpingostomy *sed to remove a small pregnancy

that is usually less than % cm in length

and located in the distal third of the

fallopian tube

4 linear incision5 $!0$ mm in lengthor less5 is made on the antimesenteric

border5 immediately above the EP

P6 e)truded out9 small bleeding

sites controlled with needlepoint

electrocautery or laser Incision is left unsutured and to heal

by secondary intention



Ectopic Pregnancy

T)'al Pregnancy

(alpingotomy Essentially the same as salpingostomy e)cept

that the incision is closed with 10! Aicryl or

similar suture



Ectopic Pregnancy

T)'al Pregnancy

(alpingectomy +ay be performed through an operative

laparoscope and may be used for both ruptured

and unruptured EP 8hen removing the oviduct5 it is advisable to

e)cise a wedge of the outer third >or less? of the

interstitial portion of the tube >cornual resection? To minimi&e the rare recurrence of pregnancy in the

tubal stump



Ectopic Pregnancy

T)'al Pregnancy

(egmental resection and anastomosis 2esection of the ectopic mass and tubal

reanastomosis is sometimes used for an

unruptured isthmic pregnancy becausesalpingostomy may cause scarring and

subsequent narrowing of the small isthmic lumen



Ectopic Pregnancy

T)'al Pregnancy

+edical +anagement (ystemic +TC +TC acts as a folic acid antagonist and is highly

effective against rapidly proliferating trophoblasts 4ctive intraabdominal bleeding is contraindicated

+ay not be used if the EP is D cm

(uccess is greatest if the 4= is weeks5 the tubal

mass is not D -. cm in diameter5 the fetus is dead5and the ;0h6= $5!!! mI*/m@



Ectopic Pregnancy

Cer&ical Pregnancy

$ in %5!! to $ in !5!!! pregnancies >*(?

6onditions that predispose:

Previous therapeutic abortion 4shermanFs syndrome

Previous 6(

'E( e)posure

@eiomyomas

IA3



Ectopic Pregnancy

Cer&ical Pregnancy

'iagnostic 6riteria

$. The uterus is smaller than the surrounding

distended cervi)

%. The internal os is not dilated

-. 6urettage of the endometrial cavity is non0

productive of placental tissue

. The e)ternal os opens earlier than in

spontaneous abortion



Ectopic Pregnancy

Cer&ical Pregnancy

Preoperative preparation should include

blood typing and cross0matching5 IA access5

and detailed informed consent which

include the possibility of hysterectomy in theevent of hemorrhage

Bon0surgical management: intraamniotic

and systemic +TC administration



Ectopic Pregnancy

O&arian Pregnancy

6riteria for diagnosis >(piegelbergFs 6riteria?

$. The fallopian tube on the affected side must be

intact

%. The fetal sac must occupy the position of the

ovary

-. The ovary must be connected to the uterus by the

ovarian ligament

. varian tissue must be located in the sac wall



Ectopic Pregnancy

O&arian Pregnancy

!." to $" of all ectopic pregnancies

+ost common type of non0tubal pregnancy

+isdiagnosis common because it is confused with a

ruptured corpus luteum in up to 1" of cases

varian cystectomy is the preferred treatment

Treatment with +TC and prostaglandin inGection has

also been reported



Ectopic Pregnancy

A'do$inal pregnancy

6lassified as primary and secondary

(econdary abdominal pregnancies are by farthe most common and result from tubal

abortion or rupture or5 less often5 fromsubsequent implantation within the abdomenafter uterine rupture

$ in -1% to $ in ,51$ live births Incidence of congenital anomalies: %!"0

!"



Ectopic Pregnancy

A'do$inal pregnancy

6linical presentation

In the $st and early second trimester5 thesymptoms may be the same as a tubal EP

In advanced pregnancy: Painful fetal movement

3etal movements high in the abdomen or suddencessation of movements

Persistent abnormal fetal lies5 abdominal tenderness5displaced cervi)5 fetal superficiality

Bo uterine contractions after o)ytocin infusion



Ectopic Pregnancy

A'do$inal pregnancy

6riteria for diagnosis 7 (tuddifordFs 6riteria

$. Presence of normal tubes and ovaries with no

evidence of recent or past pregnancy

%. Bo evidence of uteroplacental fistula

-. The presence of a pregnancy related e)clusively

to the peritoneal surface and early enough to

eliminate the possibility of secondary implantationafter primary tubal abortion



Ectopic Pregnancy

A'do$inal pregnancy

(urgical intervention

Placenta can be removed if its vascular

supply can be identified and ligated9

otherwise it is left behind5 packing is done

which is removed after % to # hours

+TC treatment appears to be

contraindicated because of the high rate of

complications due to rapid tissue necrosis



Ectopic Pregnancy

Interstitial pregnancy

2epresent about $" of EPs

Patients tend to present later in gestation

than those with tubal pregnancies

ften associated with uterine rupture 7

represent a large proportion of fatalities from

EP

Treatment: cornual resection by laparotomy



Ectopic Pregnancy

Interliga$ento)s pregnancy

2are form of EP9 $ in -!! EPs

*sually results from trophoblastic penetrationof a tubal pregnancy through the serosa and

into the mesosalpin)5 with secondaryimplantation between the leaves of the broadligament

6an also occur if a uterine fistula developsbetween the endometrial cavity andretroperitoneal space



Ectopic Pregnancy

"eterotopic pregnancy

ccurs when there are coe)isting

intrauterine and ectopic pregnancies

$ in $!! to $ in -!5!!! pregnancies

<igher in patients who undergo ovulation

induction

Treatment is operative



E t i P

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Ectopic Pregnancy5

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