An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, usually in the fallopian tubes. If not treated promptly through medication or surgery, it can cause the tube to rupture and result in life-threatening bleeding. Diagnosis is usually based on symptoms of abdominal pain and vaginal bleeding in early pregnancy, along with transvaginal ultrasound and beta-hCG blood tests. While ectopic pregnancies were once fatal, modern medical techniques have reduced the mortality rate by 90% through early detection and treatment to remove or destroy the growing pregnancy.

1. ECTOPIC PREGNANCY
Dr SHASHWAT JANI
M.S. ( OBS –
GYN )
JANI NURSING HOME.
AHMEDABAD,
GUJARAT , INDIA.

2. Definition


An ectopic
pregnancy is one
in which the
fertilized egg
implants in tissue
outside of the
uterus and the
placenta and
fetus begin to
develop there
Put very simply,
an ectopic
pregnancy means
"an out-of-place

3.  An
Ectopic Pregnancy is one of
the life–threatening condition
affecting one in 300 to one in 150
pregnancies .
 the
pregnancy grows it causes
pain and bleeding. If it is not
treated quickly enough it can
rupture and cause abdominal
bleeding, which can lead to
maternal cardiovascular collapse
and death

4. History
 Ectopic
pregnancies were initially
described in the 10th century (Albucasis
in 963 A.D.) and for a long time were
universally fatal events for the mother
 Initial treatments (in the old days) were
desperate primitive attempts designed to
destroy the growing pregnancy without
sacrificing the mother's life. These
included

5. starvation (hoping that the fetus would
starve before the mother)
bleeding (intentional exsanguination of
the mother in the hope that the fetus
would die and the mother could be
spared)
administration of strychnine (to
preferentially destroy the fetus)
administration of electricity into the
growing gestational sac

6. History (cont)
 First
serious surgery attempts
in the 19th century
→ ( Lawton Tait in 1884 ) resulted in a high maternal
mortality rate (greater than
60%)

7. AIM has changed from " saving the
mother's life " to recently
" saving the woman's fertility "

8. Ectopic Pregnancy
 Ectopics
happen in about 0.25-1% of all
pregnancies
 The
mortality rate is about 1 per 1000
ectopics (10% of all
maternal deaths)
 Ectopic
pregnancy rate increased almost
4 fold (from 4.5 per
1000 pregnancies to 16.8 per 1000
pregnancies since 1970)

9.  Fatality
rate from ectopic
pregnancies dropped almost 90%
(from 35.5 per 1000 ectopics to
3.8 per 1000 ectopics)
 Most
ectopic pregnancies occur in
women aged 25-34 years
 Over
75% of ectopics are
diagnosed before 12th week of
gestation

10. Ectopic Pregnancy
 The
decrease in maternal
morbidity is due t o
early detection of pregnancy
aseptic (sterile) technique
antibiotics
anesthetic agents
availability of blood and
transfusions
surgical techniques
(salpingectomy & salpingostomy )

11. SITES OF ECTOPIC PREGNANCY

Ampulla-
Ampulla- 55%
Isthmus- 25%
Infudibulum -18%
Interstitial – 3%

12. Risk Factors for Ectopic Pregnancy
 Previous
ectopic → about 10-20% of
women attempting pregnancy after one
ectopic will have another
 Salpingitis
Isthmica Nodosa → (3.5%
increased risk)
 Pelvic
adhesions, p elvic tumors
 Septate
 Zygote
uterus
abnormalities (chromosomal
abnormatity, neural tube defects,
abnormal spermatozoa)

13. Contd RISK FACTORS FOR ECTOPIC
PREGNANCY
 ART procedures ( risk is 5-7%)
 History of PID
 History of tubal ligation
 Contraception failure
 IUD use
 Previous induced abortion
 Age
 Endometriosis

14. ETIOLOGY
 FACTORS
PREVENTING OR
DELAYING MIGRATION OF FERTILIZED
OVUM TO UTERINE CAVITY
 FACTORS FACILITATING NIDATION OF
THE FERTILIZED OVUM IN THE TUBAL
MUCOSA

15. FACTORS PREVENTING OR DELAYING
MIGRATION
PELVIC INFLAMMATORY DISEASE(Increases
risk by causing)
 Loss of cilia
of lining epithelium and impairment
of muscular peristalisis
 Narrowing of tubal lumen
 Formation of pockets due to adhesions between
mucosal folds
 Peritubal adhesions resulting in kinking and
angulation of the tube(Chlamydia trachomatis
infection is most common risk factor)

16. IATROGENIC

Contraceptive failure
1.
IUD – CuT 380A and levonorgestrel devices
has lowest rate while progestasert has highest.
Sterlisation operation– risk is highest following
laproscopic fulgration without tubal resection.
Use of progestin only pill increases risk by
impaired tubal motility.
Tubal surgery
Intrapelvic adhesions following pelvic surgery
2.
3.



17.  ART – risk increased following ovulation
induction and IVF-ET and GIFT procedures.
 Previous ectopic pregnancy
 Prior induced abortion
 Development defect of tube – elongation
,diverticulum,accessory ostia

18. FACTORS FACILITATING NIDATION IN THE TUBE
 Early resumption of trophoblastic activity
due to premature degeneration of zona
pellucida.
 Increased decidual reaction
 Tubal endometriosis

19. MORBID ANATOMY
CHANGES IN TUBE
 Implantation occurs in intercolumnar fashion
 Decidual changes at implantationsite is minimal
 Ovum burrows through mucous membrane and
lies deep in muscle layers called intramuscular
implantation
 Muscle undergo limited hyperplasia and
hypertrophy
 Tube on implantation site is distended and wall
is thinned out.

20. CHANGE IN UTERUS
Responds by generalised enlargement,increased
vascularity ,hypertrophy of all tissues and
decidual reaction in endometrium.
Arias-stella reaction (10-15%) –chracterised by a
mixed pattern of atypical proliferative and
secretory activity ,the epithelial cells being
enlarged and have hyperchromatic and bizzare
shaped nuclei . Cytoplasm is vacuolated and
foamy.It is under influence of progestrone

21. PREGNANCY OUTCOME
Earliest interruption occurs in isthmial implantation
(6-8wks),than in ampullary(8-12wks) and in
interstial implantation pregnancy may continue
till 3-4 months.

Tubal mole- Embryo dies due to faulty
environment and faulty implantation and is
converted in to carneous mole. Repeated small
haemorrhages occurs in chorio-capsularis space
seprating the villi from their attachments.

22. Fate of tubal mole
1. Complete absorbtion
2. Abortion with variable amount of internal
haemorrhage.The encysted blood collected in
the pouch of douglas is called pelvic
hematocele.

23. 
1.
2.
Tubal abortion –common
mode of termination if
implantation occurs in
ampulla or
infundibulum.Ovum
seprate from its
attachement leading to
haemorrhage in to the
choriocapsularis
space.Expulsion can be
Complete leading to
pelvic haematocele.
Incomplete leading to
diffuse intraperitoneal
hemmorhage.

24. 
Tubal rupture- isthmic
and interstitial
implantation.

Intraperitoneal ruptureLeads to pelvic and
peritoneal hematocele

Extraperitoneal rupture (rare) present as broad
ligament hematoma and
pelvic hematoma.

25. TUBAL PERFORATION
 Secondary abdominal pregnancy

Secondarry broad ligament pregnancy

26. 
1.
2.
3.
4.
5.
Secondary abdominal
pregnancy- prerequisites are
Perforation of tubal wall
should be a slow process
Amnion must be intact
Placental chorion should
not be injured
Herniation of amniotic
sac with living ovum and
placenta should occur
through rent
Placenta gets attached to
the neighbouring
structures and new
vascular connection
should be established.

27.  Fate of secondary abdominal pregnancy
Death of ovum with complete absorbtion
Massive intraperitoneal hemorrhage
3. Fetus dies and becomes calcified to form
lithopaedion
4. Rarely continue to term associated with fetal
malformation.
1.
2.

28.  Secondary broad ligament pregnancy- growth of
pregnancy is limited in between two layers of
peritoneum.Occasionaly sac may rupture
secondarily and fetus is extruded in to peritoneal
cavity forming a secondary abdominal
pregnancy.
 Rarely continuation of pregnancy may occur

29. CLINICAL FEATURES

1.
2.
Acute ectopic( Cases of tubal rupture or tubal
abortion with massive intraperitoneal
haemorrhage).
The classical triad of symptoms are
amenorrhoea followed by abdominal pain and
vaginal bleeding.
A history short period of amenorrhoea(6-8wks)
or delayed period or slight spotting .
Acute Abdominal pain(dull,crampy or colicky
pain)

30. 3. Vaginal bleeding-slight, sanguinous or dark
coloured and continuous.
4. Feeling of nausea, vomiting , fainting attacks
5. Combination of pain and syncope is
characterstic symptom of ectopic.

31. ON EXAMINATION
 Pallor –severe and out of proportion to visible
bleeding.
 Evidence of hemodynamic unstabilityhypotension, rapid and feeble pulse and cold
and clammy extremity.
 Abdominal examination- abdomen is tense,
tumid and tender.

32.  Bimanual examination( if done should be very
gentle)- a) vaginal mucosa – blanched white
b) Uterus normal or slightly bulky in size c)
extreme tenderness on fornix palpation or
movement of cervix
d) Mass may or may not be felt through fornix.

33. Chronic ectopic
 History of short period of amenorrhoea of
6-
8wks
 Lower abdominal pain starts as acute and
gradually becomes dull and colicky in nature
 Vaginal bleeding – scanty sanguinous or dark
coloured
 Slight intermittent pyrexia – effect of absorbtion
of products of degenerated blood.

34.  One-sided
pain in abdomen - can be
persistent and severe, but may not be on the
same side as an ectopic pregnancy
 Shoulder-tip pain -due to internal bleeding
irritating the diaphragm when woman breathe in
and out
 Bladder or bowel problems – dysuria,
frequency or retention of urine.Rectal tenesmus
may appear following infected hematocele.

35.  Pallor
ON EXAMINATION
 Features of shock are absent
 Persistent high pulse rate
 Abdominal examination a) tenderness and muscle guard on lower
abdomen specially on affected site
 b) irregular and tender mass may be felt in lower
abdomen
 c) Cullens sign- haemoperitoneum of 2 or 3 wks
can cause brusing around umblicus.

36.  Bimanual examination- an irregular,boggy and
tender mass felt through posterolateral fornix

37. DIAGNOSIS
 Mostly diagnosis is based on classical clinical
triad of pelvic pain , vaginal spotting and
amenorrhoea( 5-9 wks).
 Tests and Aids to diagnosis
 Blood examination –
a) Haemoglobin
 b) ABO and Rh grouping
 c) TLC and DLC
 d) ESR - There may be lecuocytosis and raised
ESR.


38.  UPT –
 Positive in 50% cases . Negative test may be
seen in old ectopic ( dead chorionic tissue)
Beta HCG levels –
 a) value is less compared to normal pregnancy
b) subnormal rise in levels < 66% in 48 hrs
suggests ectopic pregnancy.


39. Serum progestrone level –
Level less than 5ng/ml suggests ectopic
pregnancy or early pregnancy failure.
 Other Endocrinologic markers –
a) Level of estrodiol – less compared to viable
pregnanacy
b) Serum creatine kinase – increases
c) Pregnancy specific beta (1)- glycoprptein(sp1)decreases


40. d)Human placental lactogen – decreases
e)Pregnancy associated plasma proteins(PAPP-A)
–decrease
f)Serum IL-8,IL-6 and TNF alpha – increases
g) maternal serum alpha feto protein – increases
h) C- reactive protein – level is low , help in
differentiating b/w ectopic pregnancy with an
acute infectious process

41. Trans vaginal ultrasound –
Level of serum beta HCG at
which gestational sac can
be seen by using TVS is
1500 IU/L and 6000IU/L for
TAS .
Uterine findings –
1.
Empty uterus
2.
Thickened endometrium
3.
Pseudogestational sac

Uterus outlined in red

Uterine lining in green

Ectopic pregnancy
yellow

Fluid in uterus at blue
circle is called a
"pseudogestational sac"

42. Extra uterine findings

No findings

Live tubal pregnancy

Complex adnexal mass

Free fluid in pouch of
douglas



Tubal pregnancy circled
in red
4.5 mm fetal pole
(between cursors) in
green
Pregnancy yolk sac in
blue

43.  Dilatation and curettage -
Identification of decidua without villi is suggestive
of ectopic pregnancy
 Culdocentesis –
Rarely done now days .Aspiration of non clotting
blood through pouch of douglas is suggestive of
intraperitoneal blood.

44. Laproscopy –
Gold standard for diagnosis .
It shold be done when
patient is hemodynamically
stable.
A right tubal ectopic
pregnancy seen at
laparoscopy
 The swollen right tube
containing the ectopic
pregnancy is on the
right at E
 The stump of the left
tube is seen at L - this
woman had a previous
tubal ligation


45. Ectopics Manifestatio n
 Emergency
presentation - Suddenly,
without warning a woman is very unwell,
collapses and is taken to hospital in fase
of haematoperitoneum and hemorrhage
shoc k
 Subacute presentation - The most
common presentation is with a missed
period, positive pregnancy test, some
abdominal pain, and irregular vaginal
bleeding
 Rrisk pregnancy group - After previous
ectopic, tubal surgery or assisted
conception ( IVF) → detection rate is high
→ women are primary observed

46. Differential Diagnosis

1.
2.
3.
4.
Obstetrical causes –
Abortion of an early intra
uterine pregnancy
Early pregnancy with pelvic
tumors
Abortion followed by
salpingitis
Septic abortion

47.  Gynaecological
diseases
1. Degenerating fibroid
2. Dysfunctional uterine bleeding
3. Endometriosis
4. Torsion of adnexal mass
5. Acute or subacute salpingitis

48. 
Non- gynaecological conditions-
1.
Appendicitis
Gastroenteritis
Perforated peptic ulcer
Intra peritoneal haemorrhage
2.
3.
4.

49. MANAGEMENT
 It will depend on –
Condition of the patient
Acute ruptured ectopic
Chronic ectopic
Unruptured ectopic
Ectopic in places other than fallopian tube
Treatment Hospitalisation
 Management of Shock immediately
Immediate laparotomy and clamping of bleeding
vessel may be the only means of saving life of
moribund patient

50. Salpingectomy- removal of part or whole of the
tube
Done usually in
1. Ruptured ectopic
2. Complete family
3. Tube is grossly damage
4. Recurrence of ectopic pregnancy in a tube
already treated
Oophorectomy is done if ovary is damaged
beyond salvage or pathological.


51. Salpingostomy –
Incision is made over
distended segment of
tube using needle tipcautery, laser, scalpel,
or scissors and
products of gestation
are removed.Tube is
irrigated to remove
trophoblastic tissue and
ensure haemostasis.
DONE IN –
1.
Unruptured ectopic
2.
Family not completed


52. Milking the tube- done when
pregnancy is at fimbrial
end .Not done commonly
Risk of ectopic in subsequent
pregnancy is high.
 Segmental resection with
microsurgical
reanastomosis – isthmic
pregnancy
Pregnancy rates are similar to
other procedures
Difficult procedure


53. Expectant managementDone in1. Initial HCG level<1000 mIU/ml
2. Falling HCG titre
3. Ectopic mass <2cm
4. No evidence of bleeding or rupture
5. Symtomless
Requires regular monitoring of HCG levels and USG.
2/3rd of patient resolve spontaneously and others
may require surgical intervention.


54. Medical managementDrugs commonly used are methotrexate (most
commonly used), KCL 20% , prostaglandin,
RU486 , hyperosmolar glucose or actinomycin.
Indications1. Haemodynamically stable
2. Tubal diameter < 4cm without any cardiac
activity
3. HCG levels<2000IU/ml
4. HCG is positive after salpingotomy


55. Single dose of MTX 50mg/m2 can be given. HCG
levels should be measured on day 4 and 7 . If
decline is > 15% patient shold be followed till
level< 10mIU/ml. If decline is < than 15% than
second dose of MTX 50mg/m2 is given on day
7.
Approx 5% do not respond and require surgery.

56. Complications of Methotrexate
 Bone
marrow suppression
 Acute and chronic hepatotoxicity transient
elevations in serum liver transaminases
 Progressive pulmonary toxicity
(pneumonitis and pulmonary fibrosis)
 Dermatologic effects (rashes, itch,
folliculitis, photosensitivity, pigment
changes, rarely alopecia)
 Renal impairment
 GI side effects (stomatitis, gastritis,
diarrhoea)

57.  Salpingocentesis – Agents like KCL , MTX (most
commonly used) , RU486 , hyperosmolar
glucose instilled directly in to gestational sac
transvaginally or laproscopy.2ml of solution
containing 50 mg of drug is injected in to sac.
Useful in interstial or cornual ectopic pregnancy.

58.  Laproscopic sugery-
Done when patient is haemodynamically stable
Confirmation of diagnosis and management can
be done at same time.

59. INTERSTITIAL PREGNANCY
Rarest type of tubal pregnancy.
Pregnancy may continue up to 12-14 wks before
termination occurs which is tubal rupture
associated with massive intraperitoneal
haemorrhage
Diagnosis is difficult , may be confused with
pregnancy in a bicornuate uterus or myoma
wih pregnant uterus.

60. Made by HCG , high resolution sonography and
laproscopy.
Generally cornual resection is done
Hysterectomy may have to be done .

61. OVARIAN PREGNANCY
Very rare type
Here ovum is fertilized while it
is in the abdominal cavity,
in graafian follicle or in
process of leaving the
follicle and pregnancy
developed with in a
capsule of ovarian tissue.
Criteria for diagnosis
(Spiegelberg)
Tube and ovary are
normal and seprate from
pregnancy sac.
Ovary is the white structure in the middle
Pregnancy is implanted on the far right side o
the ovary at the "X„
Around the ovary are seen bleeding and
clotted blood

62. 

Sac is in position of ovary and attached to uterus by
ovarian ligament
Histologically recognisable ovarian tissue around the
wall of pregnancy
Pregnancy will not continue for more than 2-3wks, and
capsule bursts and is a source of intra abdominal
haemorrhage.
Management requires urgent laprotomy and removal of
affected ovary.

63. CORNUAL PREGNANCY
Implantation occurs in cavity of rudimentary horn
of uterus. Pregnancy may continue up to 12 –
20th wk and if rupture is associated with massive
bleeding.
Diagnosis is difficult may be confused with fibroid
or ovarian tumor with pregnancy. In laparotomy
may be confused with interstitial pregnancy. A
distinguishing feature is insertion of round
ligament which is lateral to cornual pregnancy.

64.  Treatment requires requires removal
of affected horn along with pregnancy

65. ABDOMINAL PREGNANCY



1.
2.
3.
Implantation of fertilized ovum occurs on
abdominal organ
Primary origin is very rare mostly secondary in
origin
Clinical features
History suggestive of disturbed tubal
pregnancy is present
Minor ailments of normal pregnancy
exaggerated
Uterine contour not well defined

66. 4. Fetal parts are easily palpable with increased
fetal movements
5. Abnormal attitude and position of fetus on
repeated examination
6. On examination – uterus may not felt separate
from abdominal mass , cervix is not soft and
displaced depending upon the position of sac

67.  Diagnosis
Difficult to made because of its rarity lead to
confusion in diagnosis .
Imaging studies –
Sonography
Magnetic resonance imaging
X – ray examination

68.  Management
Hospitalisation
Immediate laparotomy –
Ideal surgery is to remove entire sac-fetus
,placenta and membranes.
If placenta is attached to vital organs or where
vessels can not be ligated easily better to
remove fetus and leaving behind placenta with
sac. In such cases HCG and pregestrone level
should be monitored.

69. CERVICAL PREGNANCY


1.
2.
3.
4.
Rare type implantation occurs in cervical canal
at or below the internal os
Clinical features –
Uterine bleeding following amenorrhoea
without cramping pain.
Uterus above the distended cervix is smaller
Internal os is closed and partially opened
external os
No placental tissue obtained on endometrial
curettage

70. Sonography findings –
 Empty uterine cavity or false gestation sac
 Hour- glass uterine shape
 Ballooned cervical canal containing gestation
sac and placental tissue
 Closed internal os
Abortion takes place associated with severe
bleeding often requires hysterectomy

71. COMPLICATIONS
 Hemorrhage
and hypovolemic shock
Infection
Loss of reproductive organs following
surgery
Infertility, sterility
Urinary and/or intestinal fistulas
following complicated surgery
Disseminated intravascular coagulation
Persistent ectopic (complication of
conservative surgical
treatment, incomplete removal of
trofoblastic tissue)

72. Emotions Changes
 Ectopic
pregnancy can be a devastating
experience
(loss of baby, loss of part of fertility,
recovery from surgery)
 Postsurgery
 S udden
disarray
 D istress
depression
end to pregnancy → hormonal
and disruption of family life

73. Prognosis
 The
prognosis with an ectopic
pregnancy is good for patients with an
early diagnosis
 Good
when fertility is preserved (as
much as possible)
 Patients
with a previous ectopic
pregnancy should be educated
regarding the potential increased risk
for another ectopic pregnancy

74. The Future Pregnancy

If one of the tubes was removed, woman ovulate
as before, but chances of conceiving will be
reduced to about 50%

Woman can still become pregnant and have a
successful pregnancy with one intact tube

Overall chances of a repeat ectopic are between
7–10% and depends on the type of surgery

If infertility occurs, fertility treatment techniques
can still help a woman achieve pregnancy (IVF)

75. Keep in Mind
Why is ectopic pregnancy
so dangerous?




If the ectopic does´nt die, the thin wall of the
tube will stretch and cause pain, discomfort in
the lower abdomen
There may be some vaginal bleeding at this time
As the pregnancy grows, the tube may rupture,
causing severe abdominal bleeding, pain,
collapse and if not recognized ► death
Even if woman has ectopic, first urine pregnancy
test-may be negative !

76. CASE REPORT
 I here by like to remind you a recent and very
rare case of ectopic pregnancy
A 22 yr old young female came with history of 1
and half month amenorrhoea and history of PV
bleeding and pain in abdomen
Clinically Pt was stable
Routine investigations doneBeta hcg level- 9585mIU/ml
USG –showing Rt sided ectopic pregnancy

77.  Decision taken for laproscopic evaluation-
Intra-op:
Pregnancy on Rt side tube seen and tubal
hematoma on left tube.
B/L salpingostomy with cauterisation of right side
tube done.
Histopathological Report shows – B/L ectopic
pregnancy.

78. Thanks for your
attention !