Ectopic pregnancy ( diagnosis and management).

1. By
Dr. Sarah Mohamed Hamed Aboelsoud
Senior Registrar at Damietta General Hospital
ECTOPIC
PREGNANCY

2. ANATOMY OF THE FEMALE GENITAL
SYSTEM

3. DEFINITION OF ECTOPIC PREGNANCY
• Implantation of a conceputs outside the uterine
cavity it may be:
• Tubal 98%, abdominal, ovarian, cervical or in CS
scars.
• Incidence: 1-2/100 pregnancies and increasing.

4. SITES OF ECTOPIC PREGNANCY

5. CLINICAL PICTURE
• Asymptomatic.
• Amenorrhea (6-8 wks.).
• Lower abdominal pain classically unilateral.
• Vaginal bleeding.
• Diarrhea, vomiting ( this can not be discarded).
• Dizziness, lightheadedness.
• Shoulder tip pain
• Collapse if disturbed ectopic.

6. PHYSICAL EXAMINATION FINDINGS
• Often cervical excitation & adnexal tenderness.
• Adnexal mass in some cases.
• Signs of hemodynamic instability in cases of
disturbed ectopic: pallor, hypotension, tachycardia,
rapid weak pulse and loss of consciousness.
• There is no evidence that examining patients may
lead to rupturing ectopic. Though, it is better to avoid
pelvic examination in case of ruptured ectopic.

7. Negative
Rule
out
ectopic
positive
Pelvic ultrasound
Normal
IUP
No IUP
Normal
adnexa
Exclude
ectopic
Normal adnexa
Differentials include
normal IUP that is too
early to detect,
spontaneous abortion, and
unidentified ectopic
pregnancy. Follow-up US
and serial β-hCG are
recommended.
Extra uterine mass or
embryo
Confirm
ectopic
pregnancy
tubal wing
or adnexal
mass
without yolk
sac
High likely for ectopic
Premenopausal women with
amenorrhea, ABD pain, or vaginal
bleeding
Pregnancy test

8. ULTRASOUND SCANNING
• Normal TAS scan of the female pelvis

9. Transvaginal scan of the normal pregnancy

10. • Ectopic pregnancy seen as a hematoma. In this 21-year-old woman
with positive serum pregnancy test and vaginal bleeding, a complex
echogenic mass (arrow) is seen in the right adnexa, which separates
from the right ovary (open arrow) with applied pressure during
transvaginal ultrasound. The echogenic adnexal mass is
representative of a hematoma at the site of ectopic implantation. The
patient was treated surgically.

11. Live tubal ectopic pregnancy.
• A. In this 25-year-old woman with a positive pregnancy test and
vaginal bleeding, there was a gestational sac containing an embryo
in the
• left adnexa, outside the left ovary. B. The M-mode ultrasound of the
embryo in the left adnexa shows a fetal heart rate of 170 beats per
minute. These findings are confirmatory of a live tubal ectopic
pregnancy.

12. • Simple free fluid. In a 21-year-old woman presenting to the
emergency department with pelvic pain and a positive pregnancy
test, simple free fluid was found in the pelvic cul-de-sac. The patient
also had an echogenic left adnexal mass (not included in this figure),
which was confirmed to be an ectopic pregnancy intraoperatively.

13. • Complex free fluid or hemoperitoneum.
• In this 22-year-old woman with a prior history of ectopic pregnancy
presenting to the emergency department with pelvic pain and a
positive pregnancy test, a large volume of complex free fluid with
internal echogenicity was found in the pelvic cul-de-sac, most likely
representing hemoperitoneum. A ruptured tubal ectopic pregnancy
was confirmed intraoperatively.

14. • A 28-year-old woman with a positive pregnancy test presented to the
emergency department with right lower quadrant pain. A. A small amount
of free fluid is seen within the endometrial cavity, without evidence of a
yolk sac or embryo (arrow). It is irregularly-shaped and centrally located,
rather than in the eccentric location often seen with a normal gestational
sac. However, it should be noted that in a woman with a positive (β-hCG)
test, any intrauterine sac-like fluid collection seen on ultrasound is highly
likely to be a gestational sac. B. There is a right adnexal mass with an
echogenic ring (open arrow), suspicious for ectopic pregnancy. This patient
was followed clinically with serial β-hCG testing, and she was later
diagnosed with ectopic pregnancy and treated medically.
A B

15. UNDERSTANDING BETA- HCG
• It is a bi-peptide secreted by the trophoplasts almost identical to the
LH hormone except for one amino acid.
Patterns of B-HCG in pregnancy :
In Normal IUP it increase quickly and its main clinical use is between 4-
8 weeks.
it should rise ≥ 66% every 48 hours during this period.
• IUP should be seen by TVS at the level of 1500 IU (but this can
change it is only a guide number).
• When it is very high, it is suggestive of Molar pregnancy.
• If ˂ 66% B-hcg rise in 48 hours : possible ectopic or failing PUL.
• Falling hcg level : failing pregnancy regardless of location.
• Static B-hcg level : there is still active trophoblasts somewhere (
production = excretion) so consider most probable source given
the clinical picture.
• Remember you are treating the patient not the hcg level, always use
it as a part of the whole picture.
• It also can be used as a predictor of successful medical treatment if
˂ 1000IU

16. MANAGEMENT OF ECTOPIC PREGNANCY
1. Expectant management:
• Is based on the assumption that significant proportion
of all tubal pregnancies will resolve through regression
or a tubal abortion without any treatment.
RCOG selection criteria for expectant
management of ectopic pregnancy are:
• B-hcg at initial presentation is ˂ 1000 IU/L.
• Adnexal mass ˂ 4 cm on trans-vaginal scan.
• Less than 100 ml free fluid in the pelvis.
• Dedicated unit with facilities available for TV scan and
B-hcg monitoring.

17. FOLLOW UP OF EXPECTANT MANAGEMENT
• Twice weekly B-hCG and weekly TVS to ensure a
rapidly decreasing B-hCG level (ideally < 50% of its
initial level within 7 days) and a reduction in the size of
adnexal mass.
• Thereafter, weekly B-hCG and TV USS until serum
hCG levels are < 20 IU/L.
• Successful in 67% (2/3) of women.
• Favourable outcome with lower initial B-hcg and a
rapidly decreasing B-hcg level, lack of an identifiable
extra uterine. gestational sac on TVS, and a reduction
in the average diameter of the adnexal mass by day 7.

18. 2. Medical Treatment ( Methotrexate):
• Folic acid antagonist that inhibit DNA synthesis in the trophoblasts.
Indications:- corneal pregnancy.
persistent trophoblastic disease.
patient with one fallopian tube and fertility desired.
patient who refuses surgery or in whom risk of surgery is too high.
ectopic where trophoblasts are adherent to bowel or blood vessels.
Contraindications:
Chronic liver disease, chronic kidney disease or hematological
disorders.
Active infections
Immunodeficiency
Breast feeding
Dose:
Calculated from the patient body surface area 50 mg /m2 .

19. Side effects :–
• nearly 75% experience abdominal pain.
• Differentiating so-called ̔ separation pain’ owing to a
tubal abortion from pain because of tubal rupture can
be difficult, and women may need to be admitted for
observation and assessment.
• Other side effects such as conjunctivitis, stomatitis, and
gastrointestinal upset.
• Advise the patient to avoid sexual intercourse during
treatment and to use reliable contraception for 3
months after MTX because of possible teratogenic risk.

20. CRITERIA FOR MEDICAL TREATMENT
• Haemodynamically stable patient with no evidence
of haemoperitoneuim on ultrasound scan with
minimal or no pain or bleeding.
• B-HCG ˂ 3000 IU/L ( although some centers have
used multiple dose methotrexate successfully with
B-HCG between 5000 and 10000IU/L).
• No contraindications.
• Adnexal mass ˂ 3.5 cm size on ultrasound.
• No fetal cardiac activity in the ectopic sac.
• Patient compliance with follow up visits to the
hospital.

21. OUTPATIENT TREATMENT WITH MTX:
1- Offer as first-line treatment to women who are
able to return for follow-up and who have all of the
following:
no significant pain, an unruptured ectopic
pregnancy with an adnexal mass < 35 mm with no
visible heartbeat, hCG level of < 1500 IU/L.
• Women with large adnexal masses are more
likely to have already ruptured, and the presence
of cardiac activity in an ectopic pregnancy is
associated with a reduced chance of success;
therefore, do not use MTX.

22. FOLLOW UP MEDICAL TREATMENT
• Follow-up HCG levels on days 4 and 7 and give a
further dose if levels have failed to fall by >15%.
• About 14% require > one dose, 7% will experience
tubal rupture, and < 10% require surgical
intervention.
• Duration of follow-up, need for further doses of
MTX, and the likelihood of surgical intervention
increase with HCG concentration at presentation.

23. 3. SURGICAL TREATMENT
• Offer surgery as first-line treatment to
women who are unable to return for follow-
up or have any of the following:
1. Significant pain.
2. Fetal heartbeat visible on TVS.
3. Adnexal mass of ≥ 35 mm.
4. HCG level of ≥ 5000 IU/L.
5.Treatment with MTX is not acceptable.
• It is either by laparoscopy or laparotomy.

24. LAPAROSCOPY
• Patient : haemodynamically stable.
• Compared to laparotomy:
1. Shorter operation times.
2. Less intraoperative blood loss.
3. Shorter hospital stay.
4. Lower analgesic requirements.
• No difference in overall tubal patency rates, or
subsequent IUP rates, and a trend towards lower
repeat ectopic pregnancy rates.

25. LAPAROTOMY
• Haemodynamic instability – expedient resuscitation
and surgery.
• Experienced operators may be able to manage
women safely laparoscopically, even with a large
haemoperitoneum, but use the surgical procedure
that prevents further blood loss most. In most
cases, this will be laparotomy.

26. EVIDENCE BASED OUTCOME
• Surgical management compared with medical
management using systemic MTX:
1. Meta-analysis: No difference in success rate, in
future pregnancy rates, and in recurrent ectopic
pregnancy rates.
2. Resolution time is shorter, and the need for
further intervention is lower, and hospital stay is
longer with surgical management.

27. LAPAROSCOPY VS LAPAROTOMY:
Meta-analysis :
no difference in the incidence of subsequent viable
IUP, incidence of recurrent ectopic pregnancy, and
need for further surgery.
However; the length of hospital stay is longer with
laparotomy.
Incidence of abdominal pain, intraoperative blood
loss, and need for a blood transfusion is higher with
laparotomy.

28. SALPINGECTOMY VS SALPINGOTOMY:
• One study found that a subsequent live birth is significantly
less likely with salpingectomy compared with salpingotomy.
A further 7 studies did not find a statistically significant
difference in a subsequent live birth between the two groups.
• For the recurrent ectopic pregnancy, there is a general trend
that the incidence is lower with salpingectomy.
• For women without any coexistent fertility factors, future
reproductive potential is unlikely to be strongly affected by
which mode of surgery is performed.
However, for women with factors prognostic of infertility, the
evidence suggest that salpingotomy is associated with a higher
chance of a subsequent IUP.

29. CONCLUSION
• Management of ectopic pregnancy should be based on the
clinical presentation, BhCG, and ultrasound findings.
• Methotrexate is an option for a selected group of patients with
BhCG ˂ 5000 IU/L who are haemodynamically stable and
compliant.
• Surgical treatment will remain the main stay treatment modality
for ectopic pregnancy in most units.
• Laparotomy should be considered in the absence of adequate
laparoscopic expertise and/or the presence of haemodynamic
instability.