Midwifery

1. ECTOPIC
(EXTRAUTERINE)
PREGNANCY
DR IBUA

2. • HETEROTROPIC PREGNANCY
• ECCYESIS

3. Definition:
• Implantation of the fertilised ovum in an area
other than in the uterine cavity.
• 99% occur in the fallopian tubes
• Incidence is 1 per 100 pregnancies
• Over 75% are diagnosed before the 12th week of
gestation
• May occur any time from menarche to
menopause but 40% occur in women between
20 and 29 years (peak of reproduction)

4. • Common in
– Infertile women
– Low socioeconomic group
– Previous ectopic pregnancy (10-20%) will
have 2nd ectopic pregnancy
– Prior Salpingitis
– Post tuboplasty

5. Incidence by sites
1. Tubal – Ampuillary (55%)
- Isthmic (25%)
- Finbrial (17%)
- Interstitial (2%)
- Bilateral (1%)

6. 2. Uterine (rare)- Cornual
- Angular
- In a uterine diverticulum
- In a uterine sacculation
- In a rudimentary horn
- Intramural

7. 3. Cervical (rare)
4. Intraligamentous (rare)
5. Ovarian (0.5%): - tuboovarian
- abdominovarian (secondary
abdominal pregnancy)
6. Abdominal (0.1%): primary, secondary,
abdomino-ovarian, tuboabdominal (1 per
15,000 pregnancies, 90% fetal mortality).

8. 7. Associated with hysterectomy (very rare)
- Following total or subtotal hysterectomy, in a
fallopian tube or in a prolapsed uterine tube
(fimbria), in the vesicovaginal space, in a
cervical stamp
- All very rare
8. Coexisting with intrauterine pregnancy
(compound or heterotropic)
- 1 in 17,000 – 30,000 pregnancies.

9. Aetiology:
Primary causes – conditions that either prevent or
impede passage of a fertilized ovum through
the fallopian tube viz:
1. Tubal factors:
- 50% previous salpingitis-inflammation of
fallopian tube
- Developmental abnormalities (congenital
diverticula accessory ostia or atrezia)
- Abnormal tubal anatomy due to intrauterine
exposure to DES

10. - Previous tubal or pelvic organ surgery
- Tubal ligation
- Conservative treatment of ectopic
pregnancy (surgical or medical)
- Extrincic adhesions (after peritonitis, etc)
- Pelvic tumours
- Endometriosis
- Excessive length or tortuosity

11. - Physiological factors (tubal spasms,
inadequate peristalsis.
- ? Problems associated with intrauterine
devices

12. 2. Zygote abnormalities
• Chromosomal abnormalities
• Gross malformations
• Neural tube defects
• Partners of males with abnormal sperm
counts or a high incidence of abnormal
spermatozoa.

13. 3. Ovarian factors
• Fertilization of an unextruded ovum.
• Postmidcycle ovulation and fertilization
• Ovarian enlargement due to hormonal
hyperstimulation (OHSS).

14. 4. Exogenous hormones
• POPs (4-6%)
• ECPs
• Progesterone Impregnated IUCDs (16% of
pregnancies in these women).

15. Other factors
• Tubal abortion with subsequent implantation
• Tendency of a fertilised ovum to implant in an
unusual area
• Endometriosis
• The presence of an IUCD (4-9% of rate of
ectopic pregnancies (2 in 1000 IUCD users)
• IVF and embryo transfer
• Abnormal early implantation
• Any form of intraperitoneal bleeding

16. Pathological considerations
• Lack of resistance or response of tissues
into which the developing ovum is
abnormally implanted.
• Bleeding may occur then cease
temporarily after either extracapsular or
intracapsular rupture but the embryo rarely
survives.

17. • In occasional cases, pregnancy may
continue if an adequate portion of the
placental attachment is retained or if
secondary attachment occurs elsewhere.
• There may be serious effects from
invasion of vital organs in cases of
abdominal pregnancy. The invasive
characteristics of the trophoblastic tissue
resemble those of a carcinoma.

18. • The corpus luteum of pregnancy continues
only as long as there is viable
trophoblastic tissue.
• The uterus enlarges slightly and is
softened because of the added circulation
and the decidual reaction in the
endometrium.

19. • There may be endometrial separation and
uterine bleeding when the ectopic
pregnancy terminates and separates.
• In tubal ectopic pregnancy– bleeding may
be of uterine origin – endometrial
involution and slough of the superficial
tissues – largely decidua.

20. • Atypical change in the endometrium
occasionally suggestive but not diagnostic
of ectopic pregnancy.
• NB The Arias-Stella reaction – probably
due to hormonal overstimulation.
Occasionally endometrial tissue may be
passed as so called decidual cast
Superficial secretory endometrium usually
is present, but no trophoblastic cells.

21. • Times of rupture of various sites in the
tube.
Isthmic 6-8 weeks
Ampullary 8-12 weeks
Interstitial 4 months – depending on
such factors as size of the uterus and
whether or not trauma occurs.

22. Essential of diagnosis
• Abdominal pain
• Amenorrhoea followed by irregular vaginal
bleeding
• Abdominal tenderness
• Adnexal tenderness or mass
• Ultrasonic evidence of adnexal mass and
no intrauterine gestation.
• Positive (beta – h Cg) – 82.5%

23. NB: No specific symptoms or signs are
pathoguomonic of ectopic pregnancy – but
a combination of findings may be
suggestive.
- Over 16% will present as surgical
emergencies
- A negative PDT does not rule out ectopic
gestation.

24. Investigations
1. Abdominal paracentesis/yields non clotting
blood.
2. Culdocentsis
3. Ultrasound, (clearly defined POCs or a cystic
or complex mass)
4. Laparascopy: (Replaced EUA)
5. D & C – Arias-Stella reaction (abnormally
shaped nuclei of endometrial cells)
6. Exploratory laparotomy – the final diagnostic
procedure

25. Differential Diagnosis
• Upto 50
• Most common include; appendicitis,
Salpingitis, ruptured corpus luteum cyst or
ovarian follicle, uterine abortion, twisted
ovarian cyst and urinary tract disease.
• Less common are degenerating
leiomyomas,normal intrauterine pregnancy
etc

26. Complications
• 1 in 1000 result in maternal death due to
haemmorhage.
• Chronic salpingitis following neglected
ruptured tubal ectopic pregnancy.
• Infertility
• Intestinal obstruction and fistulas after
haemoperitoneum and peritonitis

27. Prevention
• Early and rigorous treatment of salpingitis.
• Prompt uterine evacuation for incomplete
abortion to avoid adhesions.
• Early diagnosis of unruptured tubal
pregnancy to avoid later extensive
surgery.
• Most forms of ectopic pregnancy other
than tubal are not preventable.

28. Treatment
A. Emergency treatment
- Immediate surgery
- Transfusion with whole blood or appropriate
blood components therapy if in shock including
intravenous pumping with a large bore needle.
- Other antishock measures as indicated ie
keep patient warm, oxygen, moderate snug
torniquets around the upper legs.

29. B. Surgery
• Ensure rapid entry into the abdomen to control
haemmorhage (a life saving feat).
• For advanced pregnancies, do not disturb the
placenta instead leave it in situ.
• Avoid drains
• May autotransfuse with patient’s own citrated
and filtered blood.

30. • Chemotherapy – Methotexate for very early
unruptured ectopics with serial scans to
ascertain elimination of the trophoblast.
Supportive treatment
- Treat for infection with broad spectum antibiotics
- High protein diet with vitamins and mineral
supplements.

31. Prognosis
• Recurent ectopic in 10-20% of cases
treated.
• Infertility (20% of those who have
undergone surgery for ectopic)
• Normal pregnancy achieved in half of
those with one ectopic.
• MMR (USA = 1-2%)
• Perinatal MR almost 100%

32. • THE END