Ectopic pregnancy.ppt university of Zambia

Ectopic Pregnancy: A Comprehensive Overview

Introduction

Ectopic pregnancy is a serious gynecological condition where a fertilized ovum implants outside the endometrial lining of the uterine cavity. While the normal site of implantation is within the uterine endometrium, an ectopic pregnancy most commonly occurs in the fallopian tube (approximately 95% of cases), but it can also occur in the ovary, cervix, abdominal cavity, or within a cesarean section scar. It is a life-threatening emergency that remains a leading cause of maternal morbidity and mortality in the first trimester.

With advances in diagnostic techniques and increased awareness, ectopic pregnancies can often be detected earlier, reducing the risk of complications. Nevertheless, ectopic pregnancy continues to present significant diagnostic and management challenges due to its variable and sometimes subtle clinical presentations.

This document provides a detailed exploration of ectopic pregnancy from definition and causes to diagnosis, treatment options, complications, and future reproductive outcomes.


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Definition

An ectopic pregnancy is defined as the implantation of a fertilized ovum outside the endometrial lining of the uterus. The term "ectopic" is derived from Greek roots meaning "out of place." These pregnancies are non-viable and, if left untreated, may cause life-threatening hemorrhage due to rupture of the implantation site.


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Sites of Ectopic Pregnancy

The distribution of ectopic pregnancies by location is as follows:

Tubal (95–97%)

Ampullary (70%)

Isthmic (12%)

Fimbrial (11%)

Interstitial/cornual (2–3%)


Non-tubal (3–5%)

Ovarian

Cervical

Abdominal

Cesarean scar



Each location has its own clinical features and potential complications. For example, interstitial pregnancies may present later and rupture with catastrophic hemorrhage due to proximity to uterine and ovarian vessels.


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Etiology and Pathophysiology

The primary cause of ectopic pregnancy is an interruption or delay in the passage of the fertilized ovum through the fallopian tube to the uterine cavity. Several pathophysiological mechanisms contribute:

1. Tubal Damage or Obstruction: Infections like pelvic inflammatory disease (PID), especially due to Chlamydia trachomatis or Neisseria gonorrhoeae, may damage the tubal mucosa, impairing ciliary function and delaying ovum transport.


2. Hormonal Influences: Abnormal hormonal signals may affect tubal motility or endometrial receptivity.


3. Assisted Reproductive Techniques (ART): IVF and ovulation induction increase the risk of ectopic and heterotopic pregnancies.


4. Congenital Abnormalities: Abnormalities like a rudimentary horn may result in implantation outside the endometrial cavity.


5. Surgical Adhesions: Pelvic or abdominal surgeries can cause anatomical distortions, increasing ectopic risk.




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Risk Factors

Some of the major risk factors include:

Previous ectopic pregnancy

History of pelvic inflammatory disease (

1. Ectopic pregnancyEctopic pregnancy
Dr Bellington VwalikaDr Bellington Vwalika
Consultant Obs/GynaeConsultant Obs/Gynae
University Teaching HospitalUniversity Teaching Hospital

2. 
Definition- implantation of pregnancy Definition- implantation of pregnancy
outside the uterine cavityoutside the uterine cavity

Incidence- 1 in 100 pregnanciesIncidence- 1 in 100 pregnancies
–After one ectopic risk of recurrence is After one ectopic risk of recurrence is
10-20%10-20%

Common cause of maternal Common cause of maternal
mortality> 10%mortality> 10%

3. 
Sites Sites
– tubal -95%tubal -95%

FimbrialFimbrial

AmpullaryAmpullary

IsthmicIsthmic

Cornual (interstitial)Cornual (interstitial)
–Abdominal (primary and secondary)Abdominal (primary and secondary)
–CervicalCervical
–OvarianOvarian

4. Risk factorsRisk factors

A history of infertilityA history of infertility

PIDPID

Pelvic operations( especially tubal)Pelvic operations( especially tubal)

Previous tubal pregnancyPrevious tubal pregnancy

Assisted conception(Patent and Assisted conception(Patent and
damaged tubes)damaged tubes)

Presence of IUDPresence of IUD

5. Signs and symptomsSigns and symptoms

following ‘classic’ signs and symptoms following ‘classic’ signs and symptoms
are not always presentare not always present
–Short period of amenorrhoea (6-8 weeks Short period of amenorrhoea (6-8 weeks
perhaps)perhaps)
–Slight PVB after onset of painSlight PVB after onset of pain
–Shoulder tip pain due to irritation of the Shoulder tip pain due to irritation of the
diaphragm by blood leaking from ectopicdiaphragm by blood leaking from ectopic
–Enlarged uterus with cervical excitation and Enlarged uterus with cervical excitation and
tendernesstenderness
–Small tender mass on side of uterus Small tender mass on side of uterus

6. 
NB- IF HISTORY IS STRONGLY NB- IF HISTORY IS STRONGLY
SUGGESTIVE OF AN ECTOPIC SUGGESTIVE OF AN ECTOPIC
PREGNANCY DO NOT CARRY OUT PREGNANCY DO NOT CARRY OUT
A VAGINAL EXAMINATION UNLESS A VAGINAL EXAMINATION UNLESS
RAPID ACCESS CAN BE GAINED TO RAPID ACCESS CAN BE GAINED TO
AN OPERATING THEATRE . THE AN OPERATING THEATRE . THE
TUBE MAY RUPTURE , THE PATIENT TUBE MAY RUPTURE , THE PATIENT
BEING PUT AT SEVERE RISKBEING PUT AT SEVERE RISK

7. diagnosisdiagnosis

Non-rupture of tubal pregnancy a Non-rupture of tubal pregnancy a
positive association with future fertility. positive association with future fertility.
Early diagnosis and conservative surgical Early diagnosis and conservative surgical
management are therefore importantmanagement are therefore important

Diagnosis is not made in 20-25%Diagnosis is not made in 20-25%

If when it is made, the presentation-to-If when it is made, the presentation-to-
treatment interval is over 48 hours in 40-treatment interval is over 48 hours in 40-
50%, and over 1 week in 20-25%50%, and over 1 week in 20-25%

8. 
When a woman of reproductive age When a woman of reproductive age
presents with unexplained presents with unexplained
abdominal pain with or without abdominal pain with or without
vaginal bleeding , do not allow vaginal bleeding , do not allow
home until ectopic pregnancy has home until ectopic pregnancy has
been excluded been excluded

9. Differential diagnosisDifferential diagnosis

Threatened or incomplete abortion. In Threatened or incomplete abortion. In
the former there is no pain and in the the former there is no pain and in the
later pain follows vaginal bleedinglater pain follows vaginal bleeding

Bleeding corpus luteumBleeding corpus luteum

Accident to an ovarian cystAccident to an ovarian cyst

PIDPID
# appropriate intervention must be based # appropriate intervention must be based
on index of suspicion- on index of suspicion- ‘think ectopic‘think ectopic’ ’

10. investigationsinvestigations

For women in clinically stable For women in clinically stable
conditions with no evidence of intra-conditions with no evidence of intra-
abdominal bleeding abdominal bleeding
–Beta hcg estimation( can detect hcg at Beta hcg estimation( can detect hcg at
a level of 1IU/La level of 1IU/L

most women with ectopic pregnacy have most women with ectopic pregnacy have
serum beta hcg levels <3000IU/L.The rate serum beta hcg levels <3000IU/L.The rate
of rise – doubling time around 2 days of rise – doubling time around 2 days
suggests a normally placed pregnacy suggests a normally placed pregnacy

11. 
If urine or serum test is positive but If urine or serum test is positive but
neither an intra- nor extrauterine neither an intra- nor extrauterine
pregnancy can be confirmed by pregnancy can be confirmed by
ultrasound , repeat test in 48hoursultrasound , repeat test in 48hours

Levels rise slowly if pregnancy is Levels rise slowly if pregnancy is
extrauterinextrauterin

Laparascopy – is gold standard for Laparascopy – is gold standard for
diagnosis, indicated if index of suspicion diagnosis, indicated if index of suspicion
is high is high

12. 
Management of acute situationManagement of acute situation
–IV access,Group and X-matchIV access,Group and X-match
–If if shock urgent laparotomy asapIf if shock urgent laparotomy asap
–Priorities are to stop haemorrhage and Priorities are to stop haemorrhage and
prevent further bleedingprevent further bleeding
–?autotransfusion?autotransfusion
–Conservative surgery is less likely to be Conservative surgery is less likely to be
possible under these circumstancespossible under these circumstances

13. Surgical approach if Surgical approach if
unrupturedunruptured

Operative laparoscopy for unruptured Operative laparoscopy for unruptured
ampullary or infundibular pregnancy less ampullary or infundibular pregnancy less
than 3cm diamete with little or no than 3cm diamete with little or no
bleedingbleeding

AdvantagesAdvantages
–Reduces adhesionsReduces adhesions
–Reduces post op stayReduces post op stay
–Subsequent fertility is at least as good as for Subsequent fertility is at least as good as for
laplap

14. 
Potential hazardsPotential hazards
–Delayed hemorrhage Delayed hemorrhage
–Continued trophoblast growthContinued trophoblast growth

ContraindicationsContraindications
–ShockShock
–Anaesthetic contraindicationsAnaesthetic contraindications
–Haematosalpinx >6cmHaematosalpinx >6cm

15. 
Conservative surgery – must be Conservative surgery – must be
attempted whenever possibleattempted whenever possible
–Linear salpingostomy along anti-Linear salpingostomy along anti-
mesenteric border(left open or closed)mesenteric border(left open or closed)
–Resection and anastomosisResection and anastomosis

16. Cornual(interstitial) Cornual(interstitial)
pregnancypregnancy

Has serious consequences – Has serious consequences –
difficulty to diagnose- rupture leads difficulty to diagnose- rupture leads
to profuse intraperitoneal bleedingto profuse intraperitoneal bleeding

Surgical removal is difficultySurgical removal is difficulty

17. Ovarian pregnancyOvarian pregnancy

To make diagnosis these 3 features To make diagnosis these 3 features
should be presentshould be present
–Fallopian tube must be intactFallopian tube must be intact
–Gestation sac must occupy the Gestation sac must occupy the
anatomical site of the ovaryanatomical site of the ovary
–Ovarian tissue must be demostrable Ovarian tissue must be demostrable
histologically in the specimenhistologically in the specimen

18. Abdominal preganacyAbdominal preganacy

Both primary and secondary Both primary and secondary
abdominal pregancies are rare abdominal pregancies are rare
eventsevents

Fetus may develop and survive but Fetus may develop and survive but
the woman usually presents as an the woman usually presents as an
acute emergency in the second acute emergency in the second
trimester trimester

19. 
It may be possible to make It may be possible to make
prospective diagnosis if:prospective diagnosis if:
–h/o episode of abdominal pain and slight h/o episode of abdominal pain and slight
PVB early in pregnancy which settlesPVB early in pregnancy which settles
–Raised maternal AFPRaised maternal AFP
–Scan shows no oligohydramnios and no Scan shows no oligohydramnios and no
clear uterine outline. Separate mass clear uterine outline. Separate mass
related to GS( this is the uterus)related to GS( this is the uterus)

20. 
When lap is carried out it advisable When lap is carried out it advisable
not to remove the uterusnot to remove the uterus

21. Cervical pregancyCervical pregancy

Rare but may cause profuse vaginal Rare but may cause profuse vaginal
bleedingbleeding

Hysterectomy may be indicatedHysterectomy may be indicated

Injection of methotrexate into the Injection of methotrexate into the
sac is an alternative if diagnosis is sac is an alternative if diagnosis is
made earlymade early

22. Medical treatmentMedical treatment

Option in some centersOption in some centers

Injection of cytotoxic eg potassium Injection of cytotoxic eg potassium
chloride, methotrexatechloride, methotrexate

CriteriaCriteria
–No heart activityNo heart activity
–Fluid less than 50ccFluid less than 50cc
–GS less than 4cmGS less than 4cm

23. 
DangersDangers
–Requires monitoringRequires monitoring
–Persistent trophoblastPersistent trophoblast

24. SummarySummary

ManagementManagement
–Depends on presentationDepends on presentation

RupturedRuptured

Non rupturedNon ruptured
–Future fertility needsFuture fertility needs
–Follow up Follow up