Gynaecology

1. Ectopic
Pregnancy
Natangwe Shimhanda
MBChB V, UNAM SOM
16/08/16

2. Normal pregnancy
Pregnancy is the period during which a
woman carries a developing fetus normally
in the uterus, starting from conception
(fertilization of ova) until the baby born.
After ovulation the ovum is picked up by the
fimbria of fallopian tubes and then swept
by ciliary action towards the ampulla where
fertilization occurs.
As soon as the zygote develops it begins
dividing very rapidly, it remains in the
fallopian tube for 3 -4 days until it reaches
morula stage
(8-32 cell stage)

3. The embryo proceeds through the isthmus to the uterine cavity for up to
72 hours, by the sixth day it enters the uterus and begins to
penetrate the decidua (endometrium) this is called implantation
which takes place within the uterine cavity in normal positioned
pregnancy .
Then hCG is produced by trophoblast, which can be detected in the
serum of the mother in the first week after implantation, its level
doubles every 36-48 hours in normal healthy pregnancy starting
from 5 to 50 ,100, till reaching 1000 IU/L
Delay or obstruction of the passage of fertilized egg down the fallopian
tube to the uterus may result in implantation in the fallopian tube or
ovary or peritoneal cavity, this known as ectopic pregnancy which
eventually most fails to develop , and the hCG fails to raise
dramatically as happens in the normal intra uterine pregnancy.

5. Definition
• Implantation that occurs abnormally elsewhere outside of
the endometrial cavity

6. Common sites of an
ectopic pregnancy

7. Classification:
Tubal pregnancy
The vast majority of ectopic pregnancies 95-98 % implant
in the Fallopian tube, among these:
• 80% in the ampulla
• 10% in isthmus
• 5 % in fimbria
• 2% interstitial
• 2% in a rudimentary horn of a bicornuate uterus

8. Nontubal ectopic pregnancy
Rare sites (2-5%) are;
o The ovaries, broad ligaments,
o Abdominal cavity and peritoneum
o Cervix.
Heterotopic pregnancy
In rare cases of ectopic pregnancies (1/1000), there may
be two fertilized eggs, one outside the uterus and the
other inside. This is called a heterotopic pregnancy.
Often the intrauterine pregnancy is discovered later than
the ectopic, mainly because of the painful emergency
nature of ectopic pregnancies

9. Risk factors

10. Tubal Pregnancy Etiology
• The following risk factors have been implicated:
1.Mechanical factors(obstruction/dysfunction of tubal
transport mechanisms)
* Previous inflammatory disease
* Previous pelvic surgery
* Developmental abnormalities
* Previous ectopic pregnancy
* Intrauterine contraceptive device
2.Premature implantation (intrinsic abnormalities of the
fertilized ovum)
o Premature shedding of the zona pellucida
o Transperitoneal migration of the fertilised ovum to the contralateral tube
o Presence of ectopic endometrium in the tube.

11. Pathogenesis
• The trophoblast develops in the fertilised ovum and
invades deeply into the tubal wall.
• Following implantation, the trophoblast produces hCG
which maintains the corpus luteum.
• The corpus luteum produces oestrogen and
progesterone which change the secretory endometrium
into decidua. The uterus enlarges up to 8 weeks size
and becomes soft.

12. • The tubal pregnancy does not usually proceed beyond 8-
10weeks due to:
> lack of decidual reaction in the tube,
> the thin wall of the tube,
> the inadequacy of tubal lumen,
> bleeding in the site of implantation as
trophoblast invades.
• Separation of the gestational sac from the tubal wall
leads to its degeneration, and fall of hCG level,
regression of the corpus luteum and subsequent drop in
the oestrogen and progesterone level.
• This leads to separation of the uterine decidua with
uterine bleeding

13. Fate of tubal pregnancy
• Tubal abortion
• Tubal rupture

14. Tubal abortion
 This occurs more if ovum had been implanted in the
ampullary portion of the tube.
 Separation of the gestational sac is followed by its
expulsion into the peritoneal cavity through the tubal
ostium.
 Rarely, reimplantation of the conceptus occurs in another
abdominal structure leads to secondary abdominal
pregnancy.
 If expulsion was complete the bleeding usually ceases
but it may continue due to incomplete separation or
bleeding from the implantation site.

15. Tubal rupture
 More common if implantation occurs in the narrower
portion of the tube which is the isthmus.
 Rupture may occur in the anti-mesenteric border of the
tube. Usually profuse bleeding occurs → intraperitoneal
haemorrhage.
 If rupture occurs in the mesenteric border of the tubea
broad ligament haematoma will occur.

16. Clinical features
 Amenorrhoea
 Abdominal pain – most frequent complaint
• With rupture, the patient may experience transient relief of
pain since stretching of the serosa ceases
• Shoulder and back pain – hemoperitoneal irritation of the
diaphragm; may indicate intraabdominal hemorrhage
 Vaginal bleeding
Classical triad

17. Diagnosis
History
• Passage of decidual cast
o Occurs in 5%-10% of women
o Their passage may be accompanied by cramps similar to those occurring with a
spontaneous abortion
• The general symptoms and signs are present.
• Fainting attacks due to intraperitoneal haemorrhage.
• Nausea and vomiting due to peritoneal irritation

18. General vital signs
• Anemia of varying degree depending upon the blood
loss.
• Pulse is usually rapid.
• Temperature slightly higher (up to 38oC ) due to
absorption of blood from the peritoneal cavity.
• Blood pressure: falls in proportion to the amount of
internal hemorrhage.

19. Abdominal examination
& pelvis
o Abdomen may be non-tender or tender, with or without rebound
o Uterus may be enlarged, with findings similar to a normal pregnancy
o Cervical motion tenderness may or may not be present
o Bulging of the posterior cul-de-sac
o Adnexal mass palpable in up to 50% of cases
o Cullen’s sign: a periumbilical bluish discoloration may be
present due to absorption of the blood in the peritoneal
cavity by lymphatics. A late sign

20. Tubal Rupture
General
• Rapidly developed shock, with pallor, sweating, rapid
thready pulse and hypotension.
• Shoulder tip pain and hiccoughs due to irritation of the
phrenic nerve of the diaphragm by accumulated blood
when the patient lying down.
Abdominal examination:
• The abdomen is distended, rigid with generalised
tenderness.
• Shifting dullness and periumbilical bluish discolouration
due to intraperitoneal haemorrhage.

21. Laboratory tests
Serum β-hCG
• Urine pregnancy tests are positive in only 50-60% of ectopic.
Detection of β-hCG in the serum by ELISA or
radioimmunoassay are more sensitive and can detect very
early pregnancy about 10 days after fertilisation i.e. before the
missed period.
• If the test is negative, normal and abnormal pregnancy
including ectopic are excluded.
• If the test is positive, ultrasonography is indicated.
Progesterone in ectopic pregnancy
• Serum progesterone level is lower in ectopic than normal
pregnancy and usually less than 15ng/ml.

22. Abdominal sonography
o If a gestational sac is clearly
identified within the uterine cavity,
EP rarely coexists
o With sonographic absence of a
uterine pregnancy, a positive
pregnancy test result, fluid in the
cul-de-sac, and an abnormal
pelvic mass, EP is alsmost
certain

23. • In general, a positive β-hCG test with empty uterus by
sonar indicates ectopic pregnancy.
• Discriminatory hCG zones:
> Diagnosis of ectopic pregnancy is made if there is:
1. An empty uterine cavity by abdominal sonography with
b -hCG value above 6000 mIU/ml.
2. An empty uterine cavity by vaginal sonography with b -
hCG value above 2000 mIU/ml

24. Surgical diagnosis
• Laparoscopy
o Offers a reliable diagnosis in most cases
of suspected EP and a ready transition to
definitive operative therapy
• Laparotomy
o Open abdominal surgery is preferred
when the woman is hemodynamically
unstable or when laparoscopy is not
feasible

25. Management
1
•EXPECTANT MANAGEMENT
2
•MEDICAL MANAGEMENT
3
•SURGICAL MANAGEMENT

26. Management
• Treatment
o Anti-D immunoglobulin
• D-negative women with an ectopic pregnancy who are not sensitized to D-
antigen should be given anti-D immunoglobulin
o Surgical Management
• Laparoscopy is preferred over laparotomy unless the patient is unstable
• Tubal surgery for EP is considered conservative when there is tubal salvage
(salpingostomy, salpingotomy, fimbrial expression of the EP)
• Radical surgery is defined by salpingectomy

27. Comparisons
Laparoscopy
• Less intraoperative blood loss
• Shorter operation time
• Shorter hospital stay
• Lower analgesic requirement
• Future intrauterine pregnancy rate
same
• Lower repeat ectopic pregnancy rate
Laparotomy
• Future intrauterine pregnancy rate
same
• Preferable in the haemodynamically
unstable patient

28. Salpingostomy
o Used to remove a small pregnancy that is
usually less than 2 cm in length and located
in the distal third of the fallopian tube
o A linear incision, 10-15 mm in length or
less, is made on the antimesenteric border,
immediately above the EP
o POC extruded out; small bleeding sites
controlled with needlepoint electrocautery
or laser
o Incision is left unsutured and to heal by
secondary intention
• Salpingotomy
o Essentially the same as salpingostomy except that the
incision is closed with 7-0 Vicryl or similar suture

29. Salpingectomy
o May be performed through an operative laparoscope
and may be used for both ruptured and unruptured
EP
o When removing the oviduct, it is advisable to excise
a wedge of the outer third (or less) of the interstitial
portion of the tube (cornual resection)
• To minimize the rare recurrence of pregnancy in
the tubal stump

30. Medical treatment
o Systemic MTX
• MTX acts as a folic acid antagonist and is highly effective against rapidly
proliferating trophoblasts
• Active intraabdominal bleeding is contraindicated
• May not be used if the EP is > 4 cm
• Success is greatest if the AOG is < 6 weeks, the tubal mass is not > 3.5 cm
in diameter, the fetus is dead, and the B-hCG <15,000 mIU/mL

31. Uncommon Sites of
Ectopic Pregnancy
• Cervical pregnancy
• Ovarian pregnancy
• Abdominal (peritoneal) pregnancy
• Cornual angular pregnancy
• Pregnancy occurs in the blind rudimentary horn of a
bicornuate uterus.

32. Cervical Pregnancy
• Conditions that predispose:
o Previous therapeutic abortion
o Asherman’s syndrome
o Previous CS
o DES exposure
o Leiomyomas
o IVF
• Diagnostic Criteria
1. The uterus is smaller than the surrounding distended cervix
2. The internal os is not dilated
3. Curettage of the endometrial cavity is non-productive of placental tissue
4. The external os opens earlier than in spontaneous abortion

33. Treatment:
• Preoperative preparation should include blood typing
and cross-matching, IV access, and detailed informed
consent which include the possibility of hysterectomy in
the event of hemorrhage
• Non-surgical management: systemic MTX administration
• Evacuation and cervical packing with haemostatic
agentas fibrin glue and gauze.
• If bleeding continues or extensive rupture occurs
hysterectomy is needed

34. Ovarian pregnancy
Etiology:
• Pelvic adhesions.
• Favourable ovarian surface for
implantation as in ovarian endometriosis.
Pathogenesis:
• Fertilisation of the ovum inside the ovary
or,
• implantation of the fertilised ovum in the
ovary.

35. • Criteria for diagnosis (Spiegelberg’s Criteria)
1. The fallopian tube on the affected side must be intact
2. The fetal sac must occupy the position of the ovary
3. The ovary must be connected to the uterus by the ovarian ligament
4. Ovarian tissue must be located in the sac wall
• 0.5% to 1% of all ectopic pregnancies
• Most common type of non-tubal pregnancy
• Misdiagnosis common because it is confused with a ruptured
corpus luteum in up to 75% of cases
• Ovarian cystectomy is the preferred treatment
• Laparotomy and inoculation of the ectopic pregnancy and
reconstruction of the ovary if possible. Otherwise, removal of the
affected ovary is indicated
• Treatment with MTX and prostaglandin injection has also been
reported

36. Abdominal pregnancy
Types:
• Primary: implantation occurs in the peritoneal cavity from the start.
• Secondary: usually after tubal rupture or abortion. Secondary
abdominal pregnancies are by far the most common and result from
tubal abortion or rupture or, less often, from subsequent implantation
within the abdomen after uterine rupture

37. • Clinical presentation
o In the 1st and early second trimester, the symptoms may be the same as a tubal
EP
o In advanced pregnancy:
• Painful fetal movement
• Fetal movements high in the abdomen or sudden cessation of movements
• Persistent abnormal fetal lies, abdominal tenderness, displaced cervix, fetal
superficiality
• No uterine contractions after oxytocin infusion
• Criteria for diagnosis – Studdiford’s Criteria
1. Presence of normal tubes and ovaries with no evidence of recent or past
pregnancy
2. No evidence of uteroplacental fistula
3. The presence of a pregnancy related exclusively to the peritoneal surface and
early enough to eliminate the possibility of secondary implantation after primary
tubal abortion

38. Management
• Surgical laparotomy and termination
• Placenta can be removed if its vascular supply can be
identified and ligated; otherwise it is left behind,
packing is done which is removed after 24 to 48 hours
• MTX treatment appears to be contraindicated because
of the high rate of complications due to rapid tissue
necrosis

39. Interstitial pregnancy
• It is implantation in the interstitial portion of the tube.
• It is uncommon but dangerous because when rupture
occurs bleeding is severe and disruption is extensive
that it needs hysterectomy.
• In some cases, the pregnancy is expelled into the uterus
and rupture does not occur.
• Treatment: cornual resection by laparotomy

40. Pregnancy in a
rudimentary horn• Pregnancy occurs in the blind rudimentary horn
of a bicornuate uterus.
• As such a horn is capable of some hypertrophy
and distension, rupture usually does not occur
before 16-20 weeks.
Treatment:
• Excision of the horn. During the operation,
pregnancy in a rudimentary horn can be
differentiated from interstitial cornual tubal
pregnancy by finding the attachment of the round
ligament lateral to the first and medial to the later.

41. Interligamentous
pregnancy
• Rare form of EP; 1 in 300 EPs
• Usually results from trophoblastic penetration of a tubal
pregnancy through the serosa and into the
mesosalpinx, with secondary implantation between the
leaves of the broad ligament
• Can also occur if a uterine fistula develops between
the endometrial cavity and retroperitoneal space

42. Heterotopic pregnancy
• Occurs when there are coexisting intrauterine and
ectopic pregnancies
• 1 in 30,000 pregnancies
• Higher in patients who undergo ovulation induction
• Treatment is operative

43. References
• Decherney., A.H., & Nathan.,L. (2007). Current diagnosis
& treatment. USA: The McGraw hill, Cenveo publisher.
• Hoffman., B.L., Schorge.J.O & Schaffer., J.I. (2012).
William Gynecology. USA, Texas:The McGraw hill
• Gynecology & obstetrci by Ten teachers 19th edition
• RCOG guidelines (Royal college of obstetric &
gynecology)