ECTOPIC PREGNANCY 1

Blastocyst – implants the endometrial lining o Bleeding persists as long as products remain in the
Ectopic – implantation elsewhere tube
- 0.5-1.5% o If fimbriae is occluded – fallopian tube become
- 3% of all pregnancy-related deaths distended by blood  hematosalpinx
- Diagnosis:
o Urine and serum B-hCG Ectopic pregnancies fail spontaneously and are reabsorbed
o Transvaginal sonography Acute ectopic pregnancy Chronic ectopic pregnancy
Trophobolast dies early
TUBAL RPEGNANCY High B-hCG Negative or low, static B-
CLASSIFICATION hCG
95% -in fallopian tube 5% - nontubal Rapid growth – leads to Forms a complex pelvic
- 70% - ampulla - Ovary timely dx mass – promts dx surgery
o Most frequent site - Peritoneal cavity Higher risk of tubal rupture Rupture late if at all
- 12% - isthmic - Cervix
- 11% - fimbrial - Cesarean scar CLINICAL MANIFESTATIONS
- 2% - interstitial tubal Later dx, the classic triad:
- Delayed menstruation
Heterotopic pregnancies – multifetal pregnancy with one - Pain
conceptus w/ normal uterine implantation that coexists with - Vaginal bleeding or spotting
one implanted ectopically Tubal rupture
- lower abdominal and pelvic pain is severe
D-negative women not sensitized + ectopic pregnancy o sharp, stabbing, or tearing
- Given IgG anti-D immunoglobulin - Abdominal palpation – tenderness
o 1st trimester – 50ug or 300ug dose - Bimanual pelvic exam – exquisite pain
o 300ug – later gestations - Posterior vaginal fornix may bulge or tender, boggy mass
may be felt
RISKS - Uterus – slightly enlarged
- Abnormal fallopian tube anatomy – underlies many cases - Diaphragmatic irritation - neck or shoulder pain
o Surgeries – highest risk Vaginal spotting or bleeding – 60-80%
- Recurrence after previous ectopic pregnancy – 5x Profuse vaginal bleeding – suggest incomplete abortion
- Prior STD or tubal infection – salpingitis - Responses to bleeding:
- Peritubal adhesions o No change in vital signs
- Salpingitis isthmica nodosa – epithelium-lined diverticula o Slight rise in blood pressure
extend into hypertrophied muscularis layer o Vasovagal response w/ bradycardia and hypotension
- Congenital fallopian tube anomalies – secondary to – only if bleeding continues and hypovolemia is
diethylstilbestrol (DES) exposure significant
- Infertility o Vasomotor disturbance – vertigo or syncope
- Use of assisted reproductive therapy (ART) After an acute haemorrhage
o Atypical implantations are more frequent – corneal, - Decline in Hb and Hct over several hours is a more valuable
abdominal, cervical, ovarian, heterotopic index
- Smoking – mechanism unclear - Leukocytosis – up to 30,000/uL
Decidua – endometrium that is hormonally prepared for
EVOLUTION AND POTENTIAL OUTCOMES pregnancy
Tubal pregnancy – fallopian tube lacks submuscular layer - Women w/ ectopic tubal pregnancy may pass decidual clot
- Fertilized ovum borrows through epithelium – entire sloughed endometrium
- Zygote – lies near or w.in muscularis o Takes form of endometrial cavity
- Embryo or fetus – absent or stunted - Decidual sloughing – also occur w uterine abortion
Outcomes: - No clear gestational sac + no villi histologically – possible
- Tubal rupture – invading conceptus and haemorrhage tear ectopic pregnancy
rents into the fallopian tube
- Tubal abortion – distal implantations are favoured MULTIMODALITY DIAGNOSIS
o Pregnancy may pass out of distal fallopian tube Differential dx for abdominal pain:
o Aborted fetus will implant on peritoneal surface and Uterine conditions Adnexal disease
become abdominal pregnancy Miscarriage, infxn, Ectopic pregnancy,
- Pregnancy failure leiomyoma, round-ligament haemorrhage, ruptured, or
Hemorrhage pain torted ovarian mass
o Haemorrhage may cease and symptoms disappear Appendicitis Cystitis
Gastroenteritis
RAT
ECTOPIC PREGNANCY 2
Algorithm key components to identify ectopic pregnancy – - Transvaginal sonography (TVS)
used only in hemodynamically stable women - Serum B-hCG level measurement – pattern
- Physical findings - Diagnostic surgery – laparoscopy, laparotomy

Beta-Human Chorionic Gonadtropin Initial B-HCG exceeds set discriminatory level + no evidence
Rapid and accurate determination of pregnancy for Intrauterine pregnancy (IUP):
- Use ELISAs – lower limit: - Failing IUP
o 20-25 mIU/mL – urine - Recent complete abortion
o <5 mIU/mL- serum - Ectopic pregnancy
Bleeding or pain + positive pregnancy = initial TVS - Early multifetal gestation
- Identify gestation location W/O clear evidence = serial B-hCG 48 hours later
- Nondiagnostic test - Avoids methotrexate administration
- Pregnancy of unknown location (PUL) – neither - Avoids early normal multifetal pregnancy
intrauterine or extrauterine pregnancy is identified D & C – another option to distinguish ectopic from failing IUP

Levels above the Discriminatory Zone Levels below Discriminatory Zone

Discriminatory B-hCG levels – above which failure to visualize If initial B-hCG is below discriminatory value = pregnancy
uterine pregnancy = pregnancy is not alive or is ectopic location is not discernible with TVS
- B-HCG discriminatory threshold - >=1500 mIU/mL or - Serial B-hCG level assays are done
>=2000mIU/mL

RAT
ECTOPIC PREGNANCY 3
o Levels that rise of fall outside expected parameters – Ring of fire – placental blood flow w/in periphery of adnexal
ectopic pregnancy mass
- Women w/ possible ectopic pregnancy – seen 2 days later - Seen with transvaginal color Doppler imaging
for further evaluation
Early normal progressing IUPS – 35% 48-hour rise in normal Hemoperitoneum
IUPs Blood in peritoneal cavity – identified using sonography
- Multifetal gestation – same anticipated rate of rise - Can also be made by culdocentesis
- NO single pattern characterizes ectopic pregnancy Anechoic or hypoechoic fluid – collects in retrouterine cul-de-
o Half show decreasing levels and half show increasing sac then surrounds the uterus as it fills the pelvis
levels - 50mL of blood can be seen using TVS
With failing IUP: - Transabdominal imaging – assess hemoperitoneum extent
- Spontaneous abortion Eventually fill Morton pouch near the liver
o decline by 21-35% @ 48h - 400-700mL blood
o Decline by 68-84% @ 7 days Peritoneal fluid + adnexal mass = highly predictive
- B-hCG percentages drop faster if initial B-hCG level is - Ovarian or other cancer = mimic
higher Culdocentesis – cervix is pulled outward and upward w/
Resolving PUI – greater rates of decline tenaculum and 18-gauge needle
Pregnancy w/o rise or fall – nonliving IUP or ectopic preg - Needle is inserted through posterior vaginal fornix 
- Aided by additional B-hCG levels retrouterine cul-de-sac  aspirate fluid
- D & C – provides quicker diagnosis - Old clots or bloody fluid that does not clot suggests
Serum Progesterone hemoperitoneum
Single serum progesterone – may clarify diagnosis - If it clots – obtained from adjacent blood vessel or from
- >25ng/mL – excludes ectopic pregnancy bleeding ectopic pregnancy
- <5ng/mL – only in 0.3% of progressing IUPs
o Nonliving IUP or ectopic pregnancy Endometrial Sampling
- 10-25 ng/mL – range of most ectopic pregnancy Lack coexistent trophoblast
Pregnancy achieved by ART – higher than usual progesterone - Confirmed by D&C before methotrexate is given
levels - Endometrial biopsy w/ Pipelle catheter – alternative to
D&C
Transvaginal Sonography (TVS)
Look for findings indicative or uterine or ectopic pregnancy Laparoscopy
Normal: - Direct visualization of fallopian tubes and pelvis – reliable
Structure Weeks diagnosis in most cases
Intrauterine gestational sac 4½ & 5 - Permits ready transition to definitive operative therapy
Yolk sac 5&6
Fetal pole w/ cardiac activity 5½ to 6 MEDICAL MANAGEMENT
Regimen options
Ectopic pregnancy patterns Methotrexate (MTX) – folic acid antagonist
- trilaminar endometrial – can be diagnostic - Binds to dihydrofolate reductase  de novo purine and
- In PUL = no normal IUP had a stripe thickness <8mm pyrimidine synthesis is halted  arrested DNA, RNA, and
- Anechoic fluid collections protein synthesis
o Pseudogestational sac – fluid collection b/n - Effective against rapidly proliferating tissue (trophoblast)
endometrial layers and conforms to cavity shape MTX drawbacks:
o Decidual cyst – anechoic area lying w/in endometrium - Bone marrow, GIT mucosa, and respiratory epithelium can
but remote from the canal be harmed
 Often at endometrial border o Leucovorin (Folinic acid) – blunts bone marrow
depression
Adnexal Findings  Activity similar to folic acid
- Visualization of an adnexal mass separate from ovary - Directly toxic to hepatocytes and is renally excreted
o Fallopian tube + ovaries + extrauterine yolk sac, - Potent teratogen
embryo or fetus – ectopic pregnancy is confirmed o MTX embryopathy
- Hyperechoic halo or tubal ring surrounding anechoic sac  craniofacial and skeletal abnormalities
- Inhomogenous adnexal mass – usually caused by  fetal-growth restriction
haemorrhage w/in ectopic sac - Excreted into breast milk – accumulate in neonatal tissues
Overall:  interfere with neonatal cellular metabolism
- 60% - inhomogenous mass
- 20% - hyperechoic ring PHARMACOKINETICS:
- 13% - obvious gestational sac - Albumin – binds to MTX

RAT
ECTOPIC PREGNANCY 4
o Displacement by other medications – increases MTX - Folic acid – lowers MTX efficacy
- Renal clearance of MTX –impaired by: - Intramuscular MTX – used most often
o Aspirin
o Probenecid Single-dose therapy – simple, less expensive, less intensive
o Penicillin posttherapy monitoring, does not require leucovorin rescue

Patient Selection Laparoscopy – preferred surgical treatment for ectopic

Best candidate – asymptomatic, motivated, compliant woman pregnancy unless hemodynamically unstable
Classic predictors of success: - Lowered venous return and cardiac output w/
- Low initial serum B-hCG level – single best prognostic hemoperitoneum – factored into decision
indicator Before surgery, future fertility desires are discusses
- Small ectopic pregnancy size - Permanent sterilization – unaffected tube can be ligated
- Absent fetal cardiac activity or removed w/ salpingectomy for affected tube
Salpinostomy or salpingectomy – two options
Treatment Side Effects - Salpingostomy – in women w/ abnormal-appearing
- Adverse effects resolved by 3-4 days after MTX was contralateral tube
discontinued o Conservative option for fertility preservation
- Most common:
o Liver involvement – 12% Salpingostomy
o Stomatitis – 6% - Removes small unruptured pregnancy
o Gastroenteritis – 1% - 10-15 mm linear incision on antimesenteric border of
- Conceptions win first 6 months after MTX tx – not fallopian tube  pregnancy products are extruded 
associated w/ miscarriage, fetal malformations, or FGR flushed out or removed
- Increasing pain several days after therapy – reflect - Small bleeding sites – controlled w/ needlepoint
separation of ectopic pregnancy from tubal wall electrocoagulation
o “separation pain” – mild and relieved by analgesics - Incision is left unsutured  heal by secondary intention
- Serum B-hCG – monitors response
Monitoring Therapy Efficacy o Decline rapidly then gradually
Serum B-hCG at days 4 and 7 – monitoring single dose therapy o Mean resolution time: 20 days
- Mean serum may rise and fall during first 4d  decline Salpingotomy
- If levels fail to drop >15% b/n days 4 and 7 – 2nd dose MTX - Same but incision is closed w/ delayed-absorbable suture
48-h interval B-hCG – multidose MTX - Prognosis does not differ
- Until they fall >15%
- Up to four doses may be given Salpingectomy
In both, serum B-hCG is measured weekly until undetectable - Tubal resection
- Average time to resolution (levels <15 mIU/mL) – 34 days - Complete excision – Minimize rare recurrence of
- Longest time – 109 days pregnancy
Failure – B-hCG plateaus or rises or tube ruptures - Affected fallopian tube lifted held with atraumatic
Single dose – more frequently used d/t simplicity and grasping forceps
convenience o Bipolar grasping device placed across uterotubal
SURGICAL MANAGEMENT junction
RAT
ECTOPIC PREGNANCY 5
o Once dessicated tube is cut Undiagnosed interstitial pregnancy – usually ruptures w/in 8-
- Endoscopic suture loop – encircle and ligate the knuckle of 16 weeks of amenorrhea
involuted fallopian tube and its vascular supply - d/t greater distensibility of myometrium
Larger tubal pregnancies – placed in endoscopic sac to prevent - Hemorrhage can be severe d/t proximity to uterine and
fragmentation ovarian arteries
To remove all trophoblastic tissue – pelvis and abdomen TVS + Serum B-hCG – interstitial pregnancy dx
should be irrigated - TVS – appear similar to eccentrically implanted uterine
- Trendelenburg to reverse Trendelenburg positioning – pregnancy
assist in dislodging stray tissue and fluid - Aid differentiation:
o Empty uterus
Persistent Trophoblast o Gestational sac separate from endometrium and
- Rates are lower for laparotomy vs laparoscopic >1cm away from most lateral edge of uterine cavity
- Risk factors o Echogenic line aka “Interistial line sign” – extends
o Greater serum B-hCG from gestational sac to endometrial cavity
o Smaller ectopic size Laparoscopically – enlarged protuberance outside round
- Bleeding – most serious complication ligament w/ normal distal fallopian tube and ovary
- Incomplete removal – identified by stable or rising B-hCG
o Postop day 1 – values dropping <50% of preop – risk MANAGEMENT
of persistent trophoblast Surgical management w/ corneal resection or cornuostomy via
- Treatment laparotomy or laparoscopy
o Single dose MTX, 50mg/m2 body surface area – - Intraoperative intramyometrial vasopressin injection –
standard therapy limit surgical blood loss
o w/ rupture and bleeding – surgical intervention - B-hCG – monitored postop
- Cornual resection – removes gestational sac and
MEDICAL VS SURGICAL THERAPY surrounding myometrial myometrium
- No differences for tubal preservation and primary - Cornuostomy – incision of cornua and suction or
treatment success instrument extraction of pregnancy
o Pain, posttherapy depression, decreased perception - Both – require myometrial closure
of health – impaired after MTX Earlier diagnosis – medical management is considered
- Medical and conservative surgery = similar 2-year rates of - Women have higher initial B-HCG – longer surveillance is
attaining a uterine pregnancy needed
- MTX – better physical functioning immediately after tx Risk of uterine rupture w/ subsequent preg – unclear risk
o No difference in psychological functioning - Careful observation + elective caesarean
- Ectopic-resolution success rates were not significantly Angular pregnancy – implantation within endometrial cavity
different - But at one cornu and medial to uterotubal junction and
- Similar medical or surgical tx in women who are: round ligament
o hemodynamically stable o Displaces round ligament upward and outward
o w/ small tubal diameter - Carried to term but w/ increased risk of abnormal
o no fetal cardiac activity placentation
o serum B-hCG <5000 mIU/mL
CESAREAN SCAR PREGNANCY
EXPECTANT MANAGEMENT DIAGNOSIS
Observe very early tubal pregnancy assoc w/ - Implantation w/in myometrium of prior caesarean
- stable or falling serum B-HCG delivery
- resolved spontaneously o Pathogenesis likened to that for placenta acreta and
Subsequent tubal patency and IUP = comparable with surgical carries similar risk for serious hemorrhage
or medical management - Present early = pain and bleeding are common
- prolonged surveillance & risks of tubal rupture – used only - Sonographically differentiating cervicoisthmic IUP and CSP
in appropriately selected and counselled women is difficult
- TVS – typical first-line imaging tool
INTERSTITIAL PREGNANCY o MR – useful when sonography is inconclusive
DIAGNOSIS
Interstitial pregnancy – implants within proximal tubal MANAGEMENT
segment that lies w/in muscular uterine wall Expected management – an option
- incorrectly called “Cornual pregnancies” - Haemorrhage, placenta accrete, and uterine rupture –
- Risk factors – same w/ tubal risks
o previous ipsiilateral salpingectomy – specific Hysterectomy – acceptable initial choice w/ those desiring
sterilization

RAT
ECTOPIC PREGNANCY 6
- Necessary w/ heavy uncontrolled bleeding
Systemic or locally injected MTX alone or w/ conservative Suction curettage or hysterectomy – may be selected
surgery – fertility-preserving options - Hysterectommy – required with bleeding uncontrolled by
- Surgical – completed solely or w/ MTX conventional methods
o Guided suction curettage o Urinary tract injury is a concern d/t close proximity of
o Hysteroscopic removal ureters
o Isthmic excision - Curettage – intraoperative bleeding lessened by:
- Minimize haemorrhage: o UAF
o Uterine artery embolization (UAE) – used preop o Intracervical vasopressing
o Foley balloon catheter – another option o Cerclage placed at internal cervical os
- Following conservative tx: o Cervical branches of uterine artery – ligated w/ vaginal
o Placenta accrete and recurrent CSP – risk placement of hemostatic cervical sutures on lateral
o Uterine arteriovenous malformations – long-term aspects of cervix at 3 and 9 o’clock
complication - Folley balloon – placed to tamponade bleeding
- Suction curettage – favoured in heterotopic pregnancy of
CERVICAL PREGNANCY cervical and IUP
DIAGNOSIS
Definition: ABDOMINAL PREGNANCY
- Cervical glands histologically opposite the placental DIAGNOSIS
attachment site Definition:
- placenta found below entrance of uterine vessels or below - Implantation in peritoneal cavity exclusive of tubal,
peritoneal reflection ovarian, or intraligamentous implantation
- Endocervix – eroded Risk:
o Pregnancy develops in fibrous cervical wall - Thought to follow early tubal rupture or abortion w/
Risks: reimplantation
- ART Symptoms:
- Prior uterine curettage - First symptoms may be absent or vague
Symptoms: - Lab tests uninformative – AFP can be elevated
- Painless vaginal bleeding - Abnormal fetal positions may be palpated
- Distended, thin-walled cervix w/ partially dilated external - Cervix is displaced
os may be evident - Oligohydramnios – common but nonspecific
- Slightly enlarged uterine fundus can be felt - Fetus seen separate from the uterus or eccentrically
Diagnosis: positioned
- Speculum examination - Lack of myometrium
- Palpation - Extrauterine placental tissue
- TVS - Bowel loops surrounding gestational sac
MR imaging – help confirm diagnosis
MANAGEMENT
Medically or surgically MANAGEMENT
Conservative management: Conservative management – maternal risk for sudden and
- Minimize haemorrhage dangerous haemorrhage
- Resolve pregnancy Termination – indicated when diagnosis is made
- Preserve fertility
MTX – first-line therapy in stable women SUGERY
- MTX infusion + utereine embolization = - Principal objectives:
chemoembolization o Delivery of fetus
- Resolution and uterine preservation <12 weeks o Careful assessment of placental implantation
- Higher risk of systemic MTX tx-failure in: - Unnecessary exploration is avoided
o AOG > 9 weeks - Placental removal
o B-hCG >10,000 mIU/mL o may precipitate torrential haemorrhage
o CRL > 10mm  hemostatic mechanism of myometrial contraction
o Fetal cardiac activity is lacking
- Dose = 50-75 mg/m2 BSA is typical o Blood vessels supplying placenta – ligated first
Adjunct – uterine artery embolization Placenta left in abdominal cavity
- Response to bleeding or preprocedural preventive tool - Becomes infected  abscess, adhesions, obstruction,
- 26F Foley catheter w/ 30 mL balloon – remains inflated for wound dehiscence
24-48h  gradually decompressed o Involution may be monitored using TVS and B-hCG
Conservative treatment – feasible

RAT
ECTOPIC PREGNANCY 7
o Color and Doppler sonography – assess changes in
blood flow
- Postop methotrexate – controversial
o Hastens involution but also accelerates placental
destruction w/ accumulation of necrotic tissue and
infxn  abscess

OVARIAN PREGNANCY
Diagnosed if 4 criteria are met:
1. Ipsilateral tube is intact and distinct from the ovary
2. Pregnancy occupies the ovary
3. Pregnancy is connected by uteroovarian ligament
4. Ovarian tissue can be demonstrated histologically
Risk factors:
- Same w/ tubal pregnanceis
- ART
- IUD
Rupture at early stage – usual consequence

Diagnosis:
Transvaginal sonography – more frequent dx of unruptured
ovarian pregnancies
- Internal anechoic area surrounded by wide echogenic ring
w/c is surrounded by ovarian cortex
At surgery, early ovarian pregnancy may be considered to be
hemorrhagic corpus luteum

Management:
- Surgical:
o small incisions by ovarian wedge resection or
cystectomy
o Large lesions – oophorectomy
- Conservative – B-hCG should be monitored

OTHER ECTOPIC SITES

Implanted toward the mesosalpinx
- Consequences:
o may rupture into space formed b/n broad ligament
o become intraligamentous or broad ligament
pregnancy
- Risk factor – rents in prior caesarean scars
- Clinical findings and management – mirror those in
abdominal pregnancy
o Laparotomy
Rare:
- In omentum, liver, retroperitoneum
- Intramural uterine implantation – women w/ prior
surgeries, ART, or adenomyosis
- Laparotomy – preferred
o Laparoscopic excision – gaining acceptance

RAT