This document discusses ectopic pregnancy, including: 1) It provides a brief history and definitions, noting the first successful surgery was performed in 1883 and that implantation outside the uterus can be caused by factors interfering with normal fertilization and nidation. 2) It discusses the rising incidence of ectopic pregnancy, noting it was 1 in 300 pregnancies in 1970 but had risen to 1 in 70-200 by 1990 in the US. 3) It describes ectopic pregnancy as potentially lethal, noting it was the leading cause of maternal death in the US in 1988 and carries a 5 times higher risk of death for teenagers. 4) It then covers definitions, sites of occurrence, aetiological factors,

1. ECTOPIC PREGNANCY
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

2. INTRODUCTION
• CASE DESCRIBED IN EGYPTIAN HEIRLOGRAPHICS
• DEFINITIVE SURGERY FIRST SUCCESSFULLY DONE
BY LAWSON TAIT IN 1883 AD - SALPINGECTOMY
• ANY FACTOR INTERFERING WITH NORMAL
FERTILISATION & NIDATION CAN CAUSE ECTOPIC
• INCIDENCE 1: 150-300 PREGNANCIES
• HIGHEST INCIDENCE REPORTED 1:28 WEST INDIES
(STD)
• ICMR 1990 INCIDENCE 3.2per1000 PREGNANCIES

3. Ectopic Pregnancy
The Rising Incidence
1per300 PREG-1970
1per70/200 PREG-1990
Trend of Ectopic Pregnancy Incidence in
the US
100 slide
80
Ectopics
60
40
20
0
1970 1975 1980 1985 1990

4. Ectopic Pregnancy
Potentially Lethal
• Leading cause of maternal death
• Accounted for 15% of all maternal deaths in the US in
1988 (1)
• Risk of deaths five times higher in teenagers (2)
(1) National Centre for Health Statistics. 1990; 38(13): 23
(2) Goldner T E et al. MMWR Morb Mortal. 1993; 42(SS-6): 73

5. DEFINITION
• Ectopic pregnancy is defined as implantation and
development of zygote at a site other than normal
implantation site

6. Then
what is the normal implantation site?
• Uterine cavity but does not include the angles of the
cavity and cervical canal.

7. SITES & INCIDENCE
 UTERINE (3%)  TUBAL (96%)
CERVICAL (0.2 %) AMPULLARY (80%)
ANGULAR ISTHMUS (12%)
FIMBRIAL (5%)
CORNUAL
INTERSTITIAL (2%)
DIVERTICULA  OVARIAN (0.2%)
RUDIMENTARY  ABDOMINAL (1.4%)
HORN  INTRALIGAMENTARY
 POST-HYSTERECTOMY
PROLAPSED TUBE
CERVICAL STUMP
VESICO-VAGINAL/RECTAL
SPACE
Bilateral tubal
HETEROTROPIC 1:10000

9. AETIOLOGICAL FACTORS
• TUBAL
• ANATOMICAL FACTORS
ABNORMAL TUBAL DEVELOPMENT / ATRESIA /
ACESSORY OSTIA / DIVERTICULA / ABNORMAL LENGTH /
KINKING
• PHYSIOLOGICAL FACTORS
TUBAL SPASM / IMPAIRED PERISTALSIS / IMPAIRED CILIARY
MOTION CILIARY DESTRUCTION / BLOCKAGE MUCUS PLUG
SYNECHIAE FORMATION  POCKETS & PARTIAL
OBSTRUCTION
• INFECTIONS  ENDOSALPINGITIS (tubercular, non tubercular) /
EXOSALPINGITIS
• ENDOMETRIOSIS
• PRIOR SURGERY  TUBECTOMY,TUBOPLASTY,PELVIC
SURGERY
• BROAD LIGAMENT FIBROID , peritubal adhesions, large
ovarian/paraovarian tumours causing stretching of tube
• DES EXPOSURE

10. AETIOLOGICAL FACTORS
OVARIAN FACTORS
FERTILISATION OF UNRUPTURED OVA
TRANSMIGRATION OF OVA
LATE OVULATION
OVUM ENLARGEMENT DRUGS

11. AETIOLOGICAL FACTORS
ZYGOTE ABNORMALITIES
ABNORMAL SPERM MOTILITY
ABNORMAL SPERMATOZOA MORPHOLOGY BODY /
TAIL
CHROMOSOMAL ABNORMALITIES

12. AETIOLOGICAL FACTORS
EXOGENOUS
INTRAUTERINE CONTRACEPTIVE DEVICE
6-8 FOLD INCREASE AS IT PREVENTS
INTRAUTERINE IMPLANTATION EFFECTIVELY
Cu-T : 3-4 times ; PROGESTASERT : 9-10 times
PROGESTERONE ONLY PILL / INJ DEPOT-PROVERA
REDUCED TUBAL PERISTALSIS, TUBAL
DECIDUALISATION
EMERGENCY CONTRACEPTION FAILURE, TUBAL
DECIDUALISATION

13. AETIOLOGICAL FACTORS
MISCELLANEOUS
ASSISTED REPRODUCTIVE TECHNIQUES  9.5%
INCIDENCE OF ECTOPICS
• SIFT
• ZIFT
• GIFT
• IVF-ET
ELONGATED CERVIX

14. PATHOLOGY
• INVASIVENESS OF TROPHOBLAST INTO THIN ANATOMICAL
STRUCTURE (MUSCULAR LAYER) LACK OF RESISTANCE LEADS TO
RUPTURE & HAEMORRHAGE
RECURRENT BLEEDING LAMINATIONS TUBAL MOLE
TUBAL ABORTION  PELVIC HAEMATOCELE,EXPULSION
OF RPOC
ABSORPTION
TUBAL EROSION/PENETRATION/ PERFORATION 
PERITUBAL HAEMATOMA 
BROAD LIGAMENT/SECONDARY ABDOMINAL
PREGNANCY
TUBAL RUPTURE 
BROAD LIGAMENT HAEMATOMA/PELVIC HAEMATOCELE
CONTINUATION OF PREGNANCY

20. OVARIAN PREGNANCY
• EXTRAOVULAR / INTRAOVULAR
• SPEIGELBERG’S CRITERIA
TUBES SHOULD BE INTACT ABSOLUTELY.
SAC MUST BE CONNECTED BY OVARIAN
& MESO-OVARIAN LIGAMENT.
OVARIAN TISSUE MUST BE COVER SAC.
SAC MUST BE IN POSITION OCCUPIED BY
OVARY.

22. CERVICAL PREGNANCY
• MORE COMMON AFTER MTP
• PROFUSE BLEEDING MAY OCCUR IN ASSOCIATION
WITH PAINLESS ABORTION
• D.D.  CA CX / ENDOCervical CA /DEGENERATING
FIBROID POLYP / INCOMPLETE ABORTION
• RX.  D&C WITH LIGATION DESCENDING CERVICAL
ARTERY OR SHIRODKAR’S CERVICAL SUTURE ;
TAMPONADE USING FOLEY’S CATHETER OR
SENGSTAKEN BLACKMORE TUBE ; HYSTERECTOMY .

23. STUDDIFORD CRITERIA
PRIMARY ABDOMINAL PREGNANCY
• TUBES SHOULD BE NORMAL
• OVARY SHOULD BE NORMAL
• NO PRESENCE OF UTERO-TUBAL FISTULA

24. SECONDARY ABDOMINAL
PREGNANCY
• History suggestive of Threatened Abortion/Ectopic
pain , bleeding , fainting .
• Minor ailments of pregnancy severely exaggerated .
• Fetus felt very easily , also fetal movements .
• Abnormal position in abdomen .
• No Braxton Hick’s contractions .
• Uterus separate from fetus .
• X-ray abdomen AP & Lateral :
Gas shadows & intestinal shadows overlie fetus
shadows
Fetal skeleton overlies maternal spine

25. SECONDARY ABDOMINAL
PREGNANCY
• INV : sounding uterus, HSG , USG , Doppler , Placentography
• Terminate pregnancy when diagnosis confirmed, as it is
associated with 50%foetal malformation rate.
• Keep 4-5 Units blood available at laparotomy.
• Wait only if issueless , elderly primigravida , BOH , POG =32
weeks . NO CONGENITAL ANAMOLIES DETECTED .
• Placenta should not be removed from adherent invaded
tissues . Only separated parts of placenta or part attached to
omentum, may be removed along with omentum , leave drain
, give METHOTREXATE .
• Patients usually have failure to lactate due to placental
hormones

29. CLINICAL SYMPTOMATOLOGY &
SIGNS
• ABDOMINAL PAIN ILIAC FOSSAE 95% CASES
(Precedes Bleeding PV)
ill fitting pain/lancinating/pulsatile/colicky/ tenesmus
suprapubic–epigastric /shoulder tip
• AMENORRHOEA followed by BLEEDING PV 75% CASES
(Irregular around menses in 4-5%) Blood
Brownish-Violet with disintegrated granular endometrial tissue
• PREGNANCY SYMPTOMS i.e. NAUSEA/EMESIS
• PYREXIA MILD < 100.4*F
• 5 P’s :
PALLOR,PAIN,PROSTRATION,PULSE(TACHYCARDIA), PRE
SSURE(HYPOTENSION)
• LETHARGY / LISTLESS

30. Ectopic Pregnancy
The Masquerader & The Chameleon
• Varied presentations
• Features may change character even in the same
patient over time
• The ‘classic’ triad of pain, amenorrhea and
vaginal bleeding seen in less than half
• In a classic history, only 14% had ectopic
pregnancy
(1) Schwartz et al. Obstet Gynecol. 1980;56:197

31. CLINICAL SYMPTOMATOLOGY &
SIGNS
• ACUTE PRESENTATION (1%) 
PAIN ABDOMEN
AMENORRHOEA followed by BLEEDING PV
SHOCK FEATURES
• CHRONIC PRESENTATION 
AMENORRHOEA
BLEEDING PV
PAIN ABDOMEN
DYSURIA / TENESMUS / DIARRHOEA (increase frequency
of motion)
PALLOR
ICTERUS
ABDOMINAL TENDERNESS REBOUND/FIXED POINT
PV : ADNEXAL MASS

32. CLINICAL SYMPTOMATOLOGY &
SIGNS
• Abdomen :
Inspection – Reduced movements,
Peri umbilical discolouration (Cullen’s Sign)
Palpation – Guarding, tenderness, Rebound
tenderness, Fixed point tenderness(Adler’s Sign)
• Per Vaginal :
Cervical Rocking test + 20% Cases ? fallacious tenderness
Pulsatile Fornix , Boginess in fornix
Uterus enlargement < 6 weeks
TENDER ADNEXAL MASS

34. CLINICAL SYMPTOMATOLOGY &
SIGNS
SYMPTOM ACUTE CHRONIC
Pain Abdomen +++ Silent / Less severe
Bleeding PV +++ +
Syncope ++ -/+
Shoulder tip Pain ++ -
SIGNS
CVS Collapse +++ -
Abd Tender ++ -/+
PV Tender + +
Fornix Mass -/+ ++

35. Ectopic Pregnancy
A Diagnostic Dilemma
Net result of these vagaries of presentation of ectopic
pregnancy is that accuracy of the initial clinical evaluation
is less than 50%
Tuomivaara L et al. Arch Gynecol. 1986; 237: 135

36. Ectopic Pregnancy
How is the woman deceived?
• Does not suspect pregnancy at all
• She thinks she is normally pregnant
• She thinks she is aborting a uterine pregnancy

37. Ectopic Pregnancy
Nothing Characteristic About It
• Pain extremely variable in intensity, location and character
• Amenorrhea may be absent in a fourth of women
• Adnexal mass in only upto 50% women
• Cervical motion tenderness may not be present

38. DIFFERENTIAL DIAGNOSIS
ALL ACUTE ABDOMEN EMERGENCIES
APPENDICITIS
DIVERTICULITIS
CHOLECYSTITIS
PERFORATED DUODENAL ULCER
PANCREATITIS
PYELO-NEPHRITIS
MESENTRIC CYST
COLITIS
THROMBOSIS MESENTRIC ARTERY
SPLENIC RUPTURE
HEPATIC RUPTURE
ANAEMIAS & VIRAL HEPATITIS IN CHRONIC ECTOPICS

39. DIFFERENTIAL DIAGNOSIS
• DYSMENORRHOEA WITH IRREGULAR PERIODS
• RETROVERTED GRAVID UTERUS
• ABORTION WITH SALPINGITIS
• THREATENED ABORTION
• RUPTURED / BLEEDING CORPUS LUTEUM CYST
• TORSION OF OVARIAN CYST / ADNEXAL MASS
• BLEEDING INTO ENDOMETRIOTIC CYST
• PREGNANCY WITH OVARIAN CYST / PEDUNCULATED
FIBROID
• RED DEGENERATION OF FIBROID

40. Ectopic Pregnancy
How to Diagnose It Then?
‘Be Ectopic Minded’
‘Keep a high index of suspicion’
‘Be paranoid about ectopic’ – after all, paranoia is but
a heightened sense of awareness!
Have no regrets that it wasn’t ectopic – even if you find that
after a laparoscopy or laparotomy!

41. INVESTIGATIONS
• BASIC 1. Hb, TLC, DLC, BT, CT, PCV
2. Blood Group ABO/Rh
3. Urine RE/ME
4. LFT
• DISEASE 1. Urine Pregnancy Test
2. Beta hCG Assay
3. Ultrasonography Abdominal / TVS
Plain 53% 70%
Doppler 73% 93%
Gestational Sac absent in uterus
Thickened Endometrium
Adnexal Mass
POD Collection
Ring of Fire
4. Diagnostic Laproscopy
5. Culdocentesis / Paracentesis
6. D & C

48. MANAGEMENT
FACTORS DETERMINING MODALITIES
PATIENT ‘s CLINICAL STATUS
AGE
PARITY
FERTILITY FUNCTION
PRIOR SURGERY

49. MANAGEMENT
• WATCHFUL EXPECTANT
INDN : Asymptomatic, Reliable, Stable Patient.
USG Diagnosed Unruptured sac <2cm /Missed Abortion (No
FHM in Ectopic Gestation).
Low Beta hCG <5000IU/ml.
PROCEDURE : Monitor patient
Serum Beta hCG document falling titre.
TVS demise of Ectopic & reduction in size.
Shift to Medical Management if Criteria not fullfill.

50. MANAGEMENT
• MEDICAL
INDN : Stable Patient . USG Gestation Sac < 3cms. No FHM.
Serum Beta hCG titre low preferably below 5000IU/ml.
PROCEDURE :
(a) Inject 20% KCl 0.5-1.0 ml near Fetal Cardiac Region.
(b) Inject Methotrexate 25 mg into Gestation Sac.
(c) Inject Methotrexate 50 mg/Sqm or 1mg/Kg IM.Dose apprx
50 mg per ampule.
30% Failure Rate, Require repeat doses.

51. MANAGEMENT
• ADVANCED OPERATIVE LAPROSCOPIC SURG
INDN : Stable Patient. Tubal Ectopic .
Gestation Sac <5cms. Preferably Unruptured.
PROCEDURE :
(a) Injection of Mrthotrexate into Gestational Sac via
laproscope.
(b) Linear Salpingotomy
(c) Linear Salpingostomy
(d) Partial / Complete Salpingectomy
(e) Segmental Resection & Anastomosis

52. MANAGEMENT
• EXPLORATORY LAPROTOMY
INDN : Unstable Patient. Adnexal Mass
USG Gestation Sac > 5cms . Massive Haemoperitoneum.
Cornual / Angular Ectopic pregnancy . Abdominal Pregnancy .
PROCEDURE :
RESUSCITATE the Patient aggressively . Replace Blood .
Autotransfusion . Cell Saver . MAST Suit .
Partial / Complete Salpingectomy with or without
Oophorectomy.