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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 pregnancy„ PZ

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A n 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


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 PZ

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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

History (cont):

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

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

Ectopic Pregnancy:

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) PZ

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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

Ectopic Pregnancy:

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 ) PZ


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

Risk Factors for Ectopic Pregnancy:

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 uterus Zygote abnormalities (chromosomal abnormatity, neural tube defects, abnormal spermatozoa) PZ


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




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)


IATROGENIC Contraceptive failure 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

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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


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


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.


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


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.

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

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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.

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

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TUBAL PERFORATION Secondary abdominal pregnancy Secondarry broad ligament pregnancy

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Secondary abdominal pregnancy- pre-requisites 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.

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


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


CLINICAL FEATURES 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)

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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.


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

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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.

Chronic ectopic :

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.

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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.


ON EXAMINATION Pallor 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.

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


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.

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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.

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

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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


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 – Empty uterus Thickened endometrium Pseudogestational sac Uterus outlined in red Uterine lining in green Ectopic pregnancy yellow Fluid in uterus at blue circle is called a "pseudogestational sac"

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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

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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.

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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

Ectopics Manifestation:

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

Differential Diagnosis:

Differential Diagnosis Obstetrical causes – Abortion of an early intra uterine pregnancy Early pregnancy with pelvic tumors Abortion followed by salpingitis Septic abortion PZ

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Gynaecological diseases Degenerating fibroid Dysfunctional uterine bleeding Endometriosis Torsion of adnexal mass Acute or subacute salpingitis

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Non- gynaecological conditions- Appendicitis Gastroenteritis Perforated peptic ulcer Intra peritoneal haemorrhage


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

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

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

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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

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Expectant management- Done in- Initial HCG level<1000 mIU/ml Falling HCG titre Ectopic mass <2cm No evidence of bleeding or rupture Symtomless Requires regular monitoring of HCG levels and USG. 2/3rd of patient resolve spontaneously and others may require surgical intervention.

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

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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.

Complications of Methotrexate :

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) PZ

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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.

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


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.

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


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 of the ovary at the "X„ Around the ovary are seen bleeding and clotted blood

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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.


CORNUAL PREGNANCY Implantation occurs in cavity of rudimentary horn of uterus. Pregnancy may continue up to 12 – 20 th 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.


Treatment requires requires removal of affected horn along with pregnancy


ABDOMINAL PREGNANCY 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

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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

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

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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.


CERVICAL PREGNANCY 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

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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


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) Rh disease

Emotions Changes:

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


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 PZ

The Future Pregnancy :

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) PZ

Keep in Mind:

Keep in Mind 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 ! PZ Why is ectopic pregnancy so dangerous?


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 done- Beta hcg level- 9585mIU/ml USG –showing Rt sided ectopic pregnancy

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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.

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Thanks for your attention ! PZ

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