Ectopic PregnancyEctopic Pregnancy

An ectopic pregnancy is a gestation tAn ectopic pregnancy is a gestation that implants outside of the endomitriahat implants outside of the endomitrial cavity. It represents a serious hazard l cavity. It represents a serious hazard to a woman’s health and reproductive to a woman’s health and reproductive potential, requiring prompt recognitiopotential, requiring prompt recognition and early aggressive intervention.n and early aggressive intervention.

More than 95% of ectopic pregnancies imMore than 95% of ectopic pregnancies implant in various anatomic segments of the plant in various anatomic segments of the fallopian tube, including the interstitial (1fallopian tube, including the interstitial (1%), isthmic (5%), ampullary (85%), and i%), isthmic (5%), ampullary (85%), and infundibular portions (9%). Other less confundibular portions (9%). Other less common sites of ectopic implantation are thmmon sites of ectopic implantation are the uterine cervix, ovary, and the peritoneal e uterine cervix, ovary, and the peritoneal cavity (Fig. 1).cavity (Fig. 1).

Fig. 1. Possible locations of Fig. 1. Possible locations of ectopic pregnancyectopic pregnancy

EpidemiologyEpidemiology Since the early 1970s, the incidence of ecSince the early 1970s, the incidence of ec

topic pregnancy has tripled, and currently topic pregnancy has tripled, and currently this condition represents the fourth leadinthis condition represents the fourth leading cause of maternal mortality overall (4g cause of maternal mortality overall (4%) and the most common cause of matern%) and the most common cause of maternal mortality in the first trimester. Several al mortality in the first trimester. Several factors have been implicated as contributifactors have been implicated as contributing to this increased incidence:ng to this increased incidence:

Improved technology, which has allowed Improved technology, which has allowed for earlier and more complete diagnosis ofor earlier and more complete diagnosis of some patients whose condition went undf some patients whose condition went undetected in the past.etected in the past.

The rising incidence of acute and chronic The rising incidence of acute and chronic salpingitis, induced abortion, tubal ligatiosalpingitis, induced abortion, tubal ligation, tubal reconstructive surgery, and consen, tubal reconstructive surgery, and conservative management of tubal pregnancy, arvative management of tubal pregnancy, all of which result in histologic and structull of which result in histologic and structural damage to the tubes.ral damage to the tubes.

The use of intrauterine contraceptive deviThe use of intrauterine contraceptive devices (IUDs). Women with IUDs are four tices (IUDs). Women with IUDs are four times more likely to suffer from an ectopic mes more likely to suffer from an ectopic pregnancy. This effect is due to the better pregnancy. This effect is due to the better protection afforded by IUDs against intraprotection afforded by IUDs against intrauterine compared with extrauterine pregnuterine compared with extrauterine pregnancy and the higher incidence of pelvic inancy and the higher incidence of pelvic inflammatory disease among IUD users. flammatory disease among IUD users.

The overall incidence of The overall incidence of ectopic pregnancy is estimated ectopic pregnancy is estimated to be at least one in every 200 to be at least one in every 200 pregnancies.pregnancies.

EtiologyEtiology Probably as many as 50% of cases result from Probably as many as 50% of cases result from

alteration of tubal transport mechanisms seconalteration of tubal transport mechanisms secondary to damage to the ciliated surface of the endary to damage to the ciliated surface of the endosalpinx caused by infections such as Chlamydosalpinx caused by infections such as Chlamydia and gonorrhea. Others are the result of intridia and gonorrhea. Others are the result of intrinsic abnormalities of the fertilized ovum and pnsic abnormalities of the fertilized ovum and possibly transmigration of the oocyte to the contossibly transmigration of the oocyte to the contralateral tube, with resulting delays in passage. ralateral tube, with resulting delays in passage.

EvolutionEvolution Tubal pregnancies rapidly invade the muTubal pregnancies rapidly invade the mu

cosa, feeding from the tubal vessels, whiccosa, feeding from the tubal vessels, which become enlarged and engorged. The segh become enlarged and engorged. The segment of the affected tube is distended as tment of the affected tube is distended as the pregnancy grows. Possible outcomes ohe pregnancy grows. Possible outcomes of such abnormal gestations are as follows:f such abnormal gestations are as follows:

The pregnancy is unable to survive owing The pregnancy is unable to survive owing to its poor blood supply, thus resulting in to its poor blood supply, thus resulting in a tubal a tubal abortionabortion and and resorptionresorption, or it is ex, or it is expelled from the fimbriated end into the abpelled from the fimbriated end into the abdominal cavity.dominal cavity.

The pregnancy continues to grow until thThe pregnancy continues to grow until the overdistended tube e overdistended tube ruptureruptures, with resultis, with resulting profuse intraperitoneal bleeding.ng profuse intraperitoneal bleeding.

In rare instances, a tubal pregnancy will bIn rare instances, a tubal pregnancy will be expelled from the tube and seed onto site expelled from the tube and seed onto sites in the abdominal cavity (e.g. the omentes in the abdominal cavity (e.g. the omentum, the small or large bowel, or the parietum, the small or large bowel, or the parietal peritoneum), and gives rise to a viable al peritoneum), and gives rise to a viable abdominal pregnancyabdominal pregnancy..

Symptoms and Clinical DiagnosisSymptoms and Clinical Diagnosis

High risk factors can be High risk factors can be summarized as follows:summarized as follows:

A history of tubal infection (ectopic rate of A history of tubal infection (ectopic rate of 1 in 24, as opposed to 1 in 200 in noninfect1 in 24, as opposed to 1 in 200 in noninfected patients)ed patients)

Prior ectopic pregnancy (15% to 50% increPrior ectopic pregnancy (15% to 50% increase in incidence of ectopic gestation in subase in incidence of ectopic gestation in subsequent pregnancies)sequent pregnancies)

History of tubal sterilization within the pasHistory of tubal sterilization within the past 1 to 2 years (higher incidence if cauterizat 1 to 2 years (higher incidence if cauterization was used)tion was used)

History of tubal reconstructive surgery (tuHistory of tubal reconstructive surgery (tuboplasty or end-to-end reanastomosis for boplasty or end-to-end reanastomosis for sterilization reversal)sterilization reversal)

Pregnancy with an IUD in place or a histoPregnancy with an IUD in place or a history of IUD use.ry of IUD use.

Infertility.Infertility.

More than one therapeutic abortion (contrMore than one therapeutic abortion (controversial)oversial)

Pregnancy resulting from failed postcoital Pregnancy resulting from failed postcoital contraception (probably associated with acontraception (probably associated with abnormal tubal transport)bnormal tubal transport)

The classic symptom triad The classic symptom triad amenorrhea, amenorrhea,

vaginal bleeding, vaginal bleeding,

abdominal pain.abdominal pain.

Abdominal pain, usually in the lower abdomen Abdominal pain, usually in the lower abdomen in early cases, or generalized in ruptured ectopin early cases, or generalized in ruptured ectopics with a hemoperitoneum. Amenorrhea or a hics with a hemoperitoneum. Amenorrhea or a history of an abnormal last menstrual period is fistory of an abnormal last menstrual period is found in 75% to 90% of ectopic pregnancies. Vound in 75% to 90% of ectopic pregnancies. Vaginal bleeding, from spotting to the equivalenaginal bleeding, from spotting to the equivalent of a menstrual period, results from a low humt of a menstrual period, results from a low human chorionic gonadotropin (hCG) production ban chorionic gonadotropin (hCG) production by the ectopic trophoblast and is seen in 50% to y the ectopic trophoblast and is seen in 50% to 80% of patients.80% of patients.

Making the diagnosis of an acutely ruptuMaking the diagnosis of an acutely ruptured ectopic pregnancy is fairly straightforred ectopic pregnancy is fairly straightforward. The patient presents with symptomward. The patient presents with symptoms of increasing abdominal pain, abdominas of increasing abdominal pain, abdominal distention, and hypovolemia. The entire l distention, and hypovolemia. The entire abdomen is acutely tender with guarding abdomen is acutely tender with guarding and rebound tenderness.and rebound tenderness.

Physical examination in patients with an unruptured ePhysical examination in patients with an unruptured ectopic pregnancy may be extremely variable. Ninety ctopic pregnancy may be extremely variable. Ninety percent have abdominal tenderness, but only 45% havpercent have abdominal tenderness, but only 45% have positive rebound tenderness, and only 50 % have an e positive rebound tenderness, and only 50 % have an adnexal mass on pelvic examination. In half the cases,adnexal mass on pelvic examination. In half the cases, the mass is contralateral to the ectopic pregnancy and the mass is contralateral to the ectopic pregnancy and represents the corpus luteum. Twenty percent present represents the corpus luteum. Twenty percent present with bilateral adnexal masses owing to the presence owith bilateral adnexal masses owing to the presence of a contralateral coupus luteum cyst. The uterus is soft f a contralateral coupus luteum cyst. The uterus is soft and either of normal size or slightly enlarged.and either of normal size or slightly enlarged.

Differential DiagnosisDifferential Diagnosis

Many gynecologic and nongynecoloMany gynecologic and nongynecologic disorders have symptoms in comgic disorders have symptoms in common with ectopic pregnancy. Gynecomon with ectopic pregnancy. Gynecologic disorders to be considered inclulogic disorders to be considered includede::

Threatened or incomplete abortion (also prThreatened or incomplete abortion (also presenting with pain, bleeding, and a positivesenting with pain, bleeding, and a positive pregnancy test)e pregnancy test)

A ruptured corpus luteum cyst (abdominal A ruptured corpus luteum cyst (abdominal pain, moderate to severe, at times coexistipain, moderate to severe, at times coexisting with a history of amenorrhea, vaginal sng with a history of amenorrhea, vaginal spotting, and presence or absence of pregnapotting, and presence or absence of pregnancy, and evidence of hemoperitoneum)ncy, and evidence of hemoperitoneum)

Acute pelvic inflammatory disease with fAcute pelvic inflammatory disease with fever, abdominal pain, leukocytosis, and, aever, abdominal pain, leukocytosis, and, at times, adnexal masses.t times, adnexal masses.

Adnexal torsionAdnexal torsion Degenerating leiomyoma (common in preDegenerating leiomyoma (common in pre

gnancy)gnancy)

The key to the successful management of The key to the successful management of ectopic pregnancy is early diagnosis. Although ectopic pregnancy is early diagnosis. Although the number of new cases has increased the number of new cases has increased threefold, fewer are arriving at the hospital threefold, fewer are arriving at the hospital ruptured, with the patient already in ruptured, with the patient already in hemorrhagic shock. This decrease is evidence hemorrhagic shock. This decrease is evidence that a high index of suspicion and vigorous that a high index of suspicion and vigorous efforts at early diagnosis are effective.efforts at early diagnosis are effective.

β-hCG testingβ-hCG testing

Human chorionic gonadotropin is consisting of Human chorionic gonadotropin is consisting of two linked subunits, αandβ. β-hCG is secreted two linked subunits, αandβ. β-hCG is secreted by both the cytotrophoblast and the syncytiotrby both the cytotrophoblast and the syncytiotrophoblast and has the sole function of supportiophoblast and has the sole function of supporting the corpus luteum. Abnormalβ-hCG can not ng the corpus luteum. Abnormalβ-hCG can not provide information on the location of the pregprovide information on the location of the pregnancy. Ultrasonography must be used to locate nancy. Ultrasonography must be used to locate the gestation.the gestation.

The sensitivity of the current methods for The sensitivity of the current methods for detection of β-hCG in the maternal serum detection of β-hCG in the maternal serum allows the confirmation of pregnancy eveallows the confirmation of pregnancy even before a missed period. n before a missed period.

UltrasonographyUltrasonography This field has shown rapid technological improThis field has shown rapid technological impro

vements in recent years, and its application to tvements in recent years, and its application to the diagnosis of ectopic pregnancy, alone and ihe diagnosis of ectopic pregnancy, alone and in combination with hCG testing, is now the stan combination with hCG testing, is now the standard of care. Transvaginal ultrasonography hndard of care. Transvaginal ultrasonography has allowed the detection of an intrauterine gestas allowed the detection of an intrauterine gestational sac at as early as 5 weeks of amenorrheational sac at as early as 5 weeks of amenorrhea (2 mm diameter).a (2 mm diameter).

If the sac is not visualized at the uterine cIf the sac is not visualized at the uterine cavity, special attention is needed to differavity, special attention is needed to differentiate between a true sac and a pseudosaentiate between a true sac and a pseudosac, which is a ring-like structure produced c, which is a ring-like structure produced on ultrasound by a prominent decidual econ ultrasound by a prominent decidual echo. Evidence of hemoperitoneum may be ho. Evidence of hemoperitoneum may be inferred by the sonographic description of inferred by the sonographic description of “free fluid in the cul-de-sac.”“free fluid in the cul-de-sac.”

CuldocentesisCuldocentesis Culdocentesis is the technique by which a needle, attaCuldocentesis is the technique by which a needle, atta

ched to a syringe, is inserted transvaginally through tched to a syringe, is inserted transvaginally through the posterior vaginal fornix into the pouch of Douglas he posterior vaginal fornix into the pouch of Douglas to detect any fluid within the peritoneal cavity (Fig. to detect any fluid within the peritoneal cavity (Fig. 2). Although the procedure is simple, inexpensive, an2). Although the procedure is simple, inexpensive, and rapid, it is quite uncomfortable for the patient and is d rapid, it is quite uncomfortable for the patient and is of limited use in an unruptured ectopic pregnancy. It iof limited use in an unruptured ectopic pregnancy. It is unnecessary when the diagnosis is obvious and has s unnecessary when the diagnosis is obvious and has a high false-negative rate. a high false-negative rate.

Fig. 2. Technique for culdocentesisFig. 2. Technique for culdocentesis

ManagementManagement Emergency treatmentEmergency treatment Surgical treatmentSurgical treatment LaparotomyLaparotomy

laparoscopylaparoscopy

Medical treatmentMedical treatment Expectant managementExpectant management

Emergency treatmentEmergency treatment

Immediate surgery is indicated when the Immediate surgery is indicated when the diagnosis of ectopic pregnancy with diagnosis of ectopic pregnancy with hemorrhage is made. Transfusion with hemorrhage is made. Transfusion with whole blood or an appropriate blood whole blood or an appropriate blood component therapy as soon possible is component therapy as soon possible is indicated when the patient is in shock. indicated when the patient is in shock.

Surgical treatmentSurgical treatment Rapid entry into the abdomen should be accoRapid entry into the abdomen should be acco

mplished, as control of hemorrhage can be lifemplished, as control of hemorrhage can be lifesaving. Careful, fast exploration of the abdomisaving. Careful, fast exploration of the abdominal cavity should be done at once. Remove pronal cavity should be done at once. Remove products of conception, clots, and free blood. At oducts of conception, clots, and free blood. At operation the damaged tube is usually removed. peration the damaged tube is usually removed. This procedure is the most common for ectopiThis procedure is the most common for ectopic pregnancy.c pregnancy.

The type of procedure performed by eitheThe type of procedure performed by either laparoscopy or laparotomy will be dictatr laparoscopy or laparotomy will be dictated by local findings at the time of surgery ed by local findings at the time of surgery and the desire of the woman for future ferand the desire of the woman for future fertility. In patients who with to conserve fertility. In patients who with to conserve fertility, a linear tility, a linear salpingostomysalpingostomy is the treatm is the treatment of choice in unruptured ampullary preent of choice in unruptured ampullary pregnancies. In ampullary pregnancies that hgnancies. In ampullary pregnancies that have already ruptured, a segmantal resectiave already ruptured, a segmantal resection or on or partial salpingectomypartial salpingectomy can be offere can be offered, which implies the removal of only the ad, which implies the removal of only the affected segment of tube, leaving the rest iffected segment of tube, leaving the rest intact.ntact.

Medical treatmentMedical treatmentUnruptured ectopic pregnancy Unruptured ectopic pregnancy

can be treated with Methotrexcan be treated with Methotrexate (MTX).ate (MTX).

Indications Indications

no contraidications to MTXno contraidications to MTX type of unruptured or abortiontype of unruptured or abortion unruptued mass <4 cm at its greastesunruptued mass <4 cm at its greastes

t dimensiont dimension β-hCG level <2000mIU/mlβ-hCG level <2000mIU/ml without signs of hemoperitoneumwithout signs of hemoperitoneum

Expectant managementExpectant management

As many as 80% of ectopic pregnanciAs many as 80% of ectopic pregnancies with hCG levels of 1000mIU/ml or es with hCG levels of 1000mIU/ml or less will not ruture spontaneously or less will not ruture spontaneously or bleed profusely but will undergo spobleed profusely but will undergo spontaneous resolution. Expectant manntaneous resolution. Expectant management is generally reserved for relagement is generally reserved for reliable, relatively asymptomatic patieniable, relatively asymptomatic patients in whom the hCG titers are <200mIts in whom the hCG titers are <200mIU/ml and delining.U/ml and delining.

Treatment of Uncommon Treatment of Uncommon Types of Ectopic Types of Ectopic

PregnanciesPregnancies Ectopic pregnancy and tubal Ectopic pregnancy and tubal

pregnancy are terms used pregnancy are terms used interchangeably because other sites interchangeably because other sites of ectopic implantation are rare. A of ectopic implantation are rare. A pregnancy can implant on the pregnancy can implant on the surface of the ovary. The treatment surface of the ovary. The treatment is aimed at removing the pregnancy is aimed at removing the pregnancy and sacrificing as little as possible of and sacrificing as little as possible of the ovarian tissue. the ovarian tissue.

Cervical pregnancy usually presents wiCervical pregnancy usually presents with profuse vaginal bleeding, and attemth profuse vaginal bleeding, and attempts at removal of the pregnancy are oftpts at removal of the pregnancy are often unsuccessful. Hysterectomy is freqen unsuccessful. Hysterectomy is frequently indicated and is usually quite diuently indicated and is usually quite difficult. In more recent years, methotrefficult. In more recent years, methotrexate and arterial embolization have bexate and arterial embolization have been used to manage cervical pregnancy.en used to manage cervical pregnancy.

All of the following therapeutic All of the following therapeutic procedures are recommended for procedures are recommended for

ectopic pregnancy EXCEPT:ectopic pregnancy EXCEPT:

A salpingectomyA salpingectomyB salpingo-oophorectomyB salpingo-oophorectomyC partial salpingectomyC partial salpingectomyD salpingostomyD salpingostomy

Likely reasons for the establishment of Likely reasons for the establishment of an ectopic tubal pregnancy include all an ectopic tubal pregnancy include all

of the following EXCEPT:of the following EXCEPT:

A pelvic infectionA pelvic infection B peritubal adhesionsB peritubal adhesions C transmigration of fertilized ovumC transmigration of fertilized ovum D uterine myomaD uterine myoma