PREGNANCY

1. ECTOPIC PREGNANCY

2. ECTOPIC PREGNANCY
 Definition. This is a pregnancy in which
implantation has occurred outside of the
uterine cavity.
 The most common location of ectopic
pregnancies is an oviduct. The most
common location within the oviduct is
the distal ampulla.

3. ECTOPIC PREGNANCY
 Differential Diagnosis
 With a positive pregnancy test, the differential
diagnosis consists of a threatened abortion,
incomplete abortion, ectopic pregnancy, and
hydatidiform mole.
 In a reproductive age woman with abnormal
vaginal bleeding, the possibility of pregnancy
or complication of pregnancy should always
be considered.

4. Risk Factors for Ectopic
Pregnancy
 The most common predisposing cause is previous
pelvic inflammatory disease (PID).
 Ectopic pregnancy risk is increased from any
obstruction of normal zygote migration to the uterine
cavity from tubal scarring or adhesions from any
origin: infectious (PID, IUD), postsurgical (tubal
ligation, tubal surgery), or congenital
(diethylstilbestrol [DES] exposure).
 One percent of pregnancies are ectopic pregnancies,
and if the patient has had one ectopic pregnancy, the
incidence becomes 15%.

5. Risk Factors for Ectopic
Pregnancy
Scarring or Adhesions Obstructing
Normal Zygote Migration
 Infectious - Pelvic inflammatory
disease
 Postsurgical -Tuboplasty/ligation
 Congenital - Diethylstilbestrol
 Idiopathic - No risk factors

6. Clinical Findings
Symptoms.
The classic triad with an unruptured ectopic pregnancy is
amenorrhea, vaginal bleeding, and unilateral pelvic-abdominal
pain.
 With a ruptured ectopic pregnancy, the symptoms will vary with
the extent of intraperitoneal bleeding and irritation.
Signs. The classic findings with an unruptured ectopic pregnancy
are unilateral adnexal and cervical motion tenderness.
- Uterine enlargement and fever are usually absent.
- With a ruptured ectopic pregnancy, the findings reflect peritoneal
irritation and the degree of hypovolemia.
Hypotension and tachycardia indicate significant blood loss.
 This results in abdominal guarding and rigidity.

7. Investigative findings.
 A P-hCG test will be positive.
 Sonography may or may not reveal an
adnexal mass;
 but most significantly no intrauterine
pregnancy (IUP) will be seen.

8. Diagnosis
The diagnosis of an unruptured ectopic pregnancy rests on the
results of a quantitative serum P-hCG titer combined with the
results of a vaginal sonogram.
 It is based on the assumption that when a normal intrauterine
pregnancy has progressed to where it can be seen on vaginal
sonogram at 5 weeks' gestation, the serum P-hCG titer will
exceed 1,500 mlU.
 With the lower resolution of abdominal sonography, an IUP will
not consistently be seen until 6 weeks' gestation.
 The P-hCG discriminatory threshold for an abdominal
ultrasound to detect an intrauterine gestation is 6,500 mlU
compared with 1,500 mlU for vaginal ultrasound.

9. Specific criteria.
 Failure to see a normal intrauterine
gestational sac when the serum p-hCG
titer is > 1,500 mlU is presumptive
diagnosis of an ectopic pregnancy.

10. Diagnosis is presumed when:
 P-hCG titer >1,500 mU
 No intrauterine pregnancy is seen with
vaginal sonogram

11. Management
 Ruptured ectopic. The diagnosis of ruptured
ectopic pregnancy is presumed with a history
of amenorrhea, vaginal bleeding, and
abdominal pain in the presence of a
hemodynamically unstable patient. Immediate
surgical intervention to stop the bleeding is
vital, usually by laparotomy.

12. Management
 Intrauterine pregnancy. If the sonogram
reveals an IUP, management will be based
on
the findings.
If the diagnosis is threatened abortion, the
patient should be placed on bed rest.
If the diagnosis is hydatidiform mole, the
patient should be treated with a suction
curettage and followed up on a weekly basis
with p-hCG.

13. Management
 Possible ectopic. If the sonogram does not reveal an
IUP, but the quantitative P-hCG is < 1,500 mlU, it is
impossible to differentiate a normal IUP from an
ectopic pregnancy.
Because P-hCG levels in a normal IUP double every 58
hours, the appropriate management will be to repeat
the quantitative P-hCG and vaginal sonogram every
2-3 days until the P-hCG level exceeds 1,500 mlU.
With that information an ectopic pregnancy can be
distinguished from an IUP.

14. Management
 Unruptured ectopic. Management can
be medical with methotrexate or
surgical with laparoscopy.
 Medical treatment is preferable
because of the lower cost, with
otherwise similar outcomes.

15. Management
 Methotrexate.
 This folate antagonist attacks rapidly proliferating tissues
including trophoblastic villi.
 Criteria for methotrexate include pregnancy mass <3.5 cm
diameter, absence of fetal heart motion, P-hCG level <6,000 mlU,
and no history of folic supplementation.
Patients with an ectopic pregnancy should be advised of the
somewhat increased incidence of recurrent ectopic
pregnancies. Follow-up with serial (i-ftCG levels is crucial to
ensure pregnancy resolution).
Rh-negative women should be administered RhoGAM.

16.  Laparoscopy.
 If criteria for methotrexate are exceeded, surgical
evaluation is performed through a laparoscopy or
through a laparotomy incision.
 The preferred procedure for an unruptured ampullary
tubal pregnancy is a salpingostomy, in which the
trophoblastic villi are dissected free preserving the
oviduct.
 Isthmic tubal pregnancies are managed with a
segmental resection, in which the tubal segment
containing the pregnancy is resected.
 Salpingectomy is reserved for the patient with a
ruptured ectopic pregnancy or those with no desire
for further fertility.
 After a salpingostomy P-hCG titers should be
obtained on a weekly basis to make sure that there is
resolution of the pregnancy.
 Rh-negative women should be administered
RhoGAM.