Ectopic pregnancy

This is a laparoscopic view, where we see the forceps is holding the tube, and the
pregnancy is in the distal end of the fallopian tube.
This is ectopic pregnancy.
The white structure down there is the ovary, and the thing in brown or black color is
blood (not clearly seen in this picture).
In Most ectopic pregnancies we see a minimum of 500 cc of blood in the pelvic
cavity .
Ectopic means occurring in an abnormal position or place.

An ectopic pregnancy (extra-uterine pregnancy) is implantation of

an embryo (blastocyst) outside the uterine cavity. It is
implanted anywhere other than the endometrial lining of the
uterine cavity.

The importance of ectopic pregnancy is because

1) it is one of the leading causes of maternal death (around 10%) in the 1st
trimester of pregnancy in young otherwise healthy individual.
2) its incidence has increased (tripled 3x) in the last 10 years, from 0.3 % to 3
times this number (due to IVF) (0.9% or around 1 in 100 pregnancies).
Normally, fertilization of the ovum occurs in fimbrial (distal) end of the fallopian
tubes, (specifically in the ampulla which is the longest and widest part), and then the
cleavage of the zygote starts, 2-cell stage, 4-cell stage …. Till the morula stage (12-32 cells
or blastomeres) … the movement of the products of cleavage in the tube occurs by the
action of fluids, cilia and peristalsis till it reaches the uterine cavity.
The process from fertilization to implantation takes about 6 days.
The morula acquires a fluid-filled cavity and becomes a blastocyst.
The blastocyst usually implants within the posterior superior wall of the
uterus by day 6 after fertilization.

Implantation occurs in the functional layer of

the
endometrium during the secretory phase
of the menstrual cycle.

The morula reaches the uterus 4 days after

fertilization.
The inner cell mass of the morula (AKA embryoblast) are surrounded by a layer of
flattened blastomeres that forms the trophoblast.

The trophoblast proliferates and differentiates into an

inner cellular layer (the cytotrophoblast)
and an
outer multinucleated layer (syncytiotrophoblast).

The syncytiotrophoblast further invades the endometrium in the wall of the uterus by the
sixth day after fertilization. Formation of the placenta then begins.

So What happens in the ectopic pregnancy?

→ Any cause that will interfere with this movement of the conceptus toward the
Uterus (delay the passage >6 days bcz when it reach the blastocyst stage it will
implant), will lead to the blastocyst being implanted in the fallopian tube, which is
called ectopic pregnancy.
Sites:
 Tubes 95% ( or even more), Rt. > L (55% ampulla ,25% Isthmic)
 Cervix, Rudimentary Horn
 Ovaries
 Peritoneal – Abdominal

 sites of implantation: These numbers are old.??????

The ampulla is the most common (80%),
followed by the isthmus (12%),
fimbria (5%),
cornua (2%),
cervix (0.1%),
ovaries (0.5%)
Causes: (and risk factors)
What will cause delay of passage of the zygote to the endometrial cavity?
 Tubal abnormalities:
 Congenital anomalies; diverticulae, false passages.
 Abnormal Cilia
 Endosalpingitis, as recurrent infections will lead to fibrotic changes leading to mechanical infertility.
Salpingitis may not be so severe as to cause complete closing of the tube, but it may destroy tubal cilia,
kinking or narrowing the tube.

 Infertility and Assisted reproduction techniques; like IVF (In Vitro Fertilization), responsible for around
20% of cases  Not efficient peristalsis.

 Endocrine disorders >Delayed ovulation, Oest./Progest. Ratio

 Contraceptive failure
Tubal surgery (lig., constr.), IUCD(4-9%)< intrauterine contraceptive device> :::(because it protects the uterus
preventing normal intrauterine implantation, so if pregnancy happens, it will implant elsewhere).

Minipill <Progestogen-only pill>(4-6%) slows peristaltic movement toward the cavity > so delaying embryo
 Causes: (and risk factors) cont…

 Previous ectopic pregnancy; 10-20% (recurrence) of cases has previous episode of ectopic
pregnancy.

 PID (Pelvic Inflammatory Disease) or Endometriosis.

Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic
pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing
damage to cilia. Our problem with PID is that it may come as asymptomatic, such as
Chlamydia trachomatis or Neisseria gonorrhea infections, which causes massive adhesions
with no past history of abdominal pain or fever.

 Zygote abnormalities (? male factor) and other factors, such as abnormal embryo, which
has nothing to do with the path to the uterus.

 Previous pelvic surgeries which result in adhesions

 Cigarette smoking
“The muscular walls of the tube do not allow the embryo to grow beyond a
certain size. The trophoblast gradually invades and erodes the tubal wall which,
unlike the endometrium, is not prepared for implantation”.

“In a typical ectopic pregnancy, the embryo adheres to the lining of the
fallopian tube and burrows into the tubal lining. Most commonly this invades
vessels and will cause bleeding.

This intratubal bleeding hematosalpinx expels the implantation out of the tubal
end as a tubal abortion. Blood vessels are damaged and eventually bleeding
takes place.”
Progress
1. Tubal abortion (sub-acute)
o Absorption in tube
o Incomplete tubal abortion
o Tubal blood mole

2. Tubal rupture (acute)

o Intraperitoneal bleeding
o Broad ligaments hematoma
Progress
1. Tubal abortion (sub-acute)

o Incomplete tubal abortion (disconnects from the outside, and falls in the abdomen, with minimal bleeding)
Most ectopics in the distal end (which is wider in diameter) of the tube, they stay longer, till between 6 – 10
weeks of gestational age. Plus because of the fact that they are distally, its separation will lead to bleeding,
and the pregnancy will get out (expelled out of the tube into the peritoneal cavity), which is what we call
tubal abortion. It may get out partially or completely.

o Absorption in tube it doesn’t get out, it just dies and stays there .

o Tubal blood mole (20 years later you go inside and find it)
The embryo dies in the tube, with a small amount of bleeding, and is partly absorbed. and we discover these
incidentally when doing routine hysterectomies, appearing like a black nodule, which represents neglected
undiagnosed ectopic pregnancy, and become a mole (tubal blood mole). Tubal mole is the gestational sac that
is surrounded by a blood clot and retained in the tube.
Progress
2. Tubal rupture (acute)

o Intraperitoneal bleeding
The worst outcome results when the pregnancy is in the proximal part of the tube, which is
narrower, majority of these will present as tubal rupture. This is acute presentation, which
means more blood loss, and higher mortality, and fortunately these are not as common.
There is acute intraperitoneal hemorrhage from erosion of an artery. The pregnancy is often
implanted in the narrower isthmus of the tube.
Rupture may occur in the anti-mesenteric border of the tube. Usually profuse bleeding occurs
→ intraperitoneal hemorrhage.

o Broad ligaments hematoma (Bleeding into the broad ligament)

If rupture occurs in the mesenteric border of the tube, a broad ligament hematoma will occur.
Clinical presentation:

- Silent –On routine examination or laparotomy

- Acute (often rupture)

- Subacute (Variable presentations) usually tubal abortion

Silent Presentation:
→ In the silent (asymptomatic) type, the female patient comes to the
clinic with amenorrhea, positive pregnancy test, and complains of
nothing. So how do we know that she has ectopic pregnancy?
From the patient history as we said, we look for risk factors, if she had
previous ectopic, had done IVF, tubal surgery, then we suspect it and
have to rule it out.

Around 15-20 % of ectopics are silent, depending on our history, hCG

values, and ultrasound.
Acute Presentation:

In the Acute (sudden onset) type as we mentioned is usually a tubal

rupture, the female patient suddenly develops severe abdominal pain
(continuous & localized) , and then dizziness, and she will collapse. In the
hospital, her blood pressure will be (e.x 70/30 hypotension), pulse (e.x 140
tachycardia), no urine output, cold clammy skin, distended rigid abdomen >>so
the diagnosis is RUPTURED ectopic pregnancy.
Fortunately this is not common.
Symptoms& Signs of subacute
Amenorrhea (6-10 wks)
Symptoms of pregnancy
Abdominal pain (99%): - Generalised 45%
- Unilateral 35%
- Shoulder tip 25%
Abnormal uterime bleeding (75%) Any form
Syncopal symptoms (35%)
Adnexal tenderness (96%)
Adnexal mass (90%)
Uterine size - Normal 70%
- 6 to 8 wks 25%
D&C curettings : -Proliferative, secretory
- Arias-stella phenomenon
Subacute Presentation:
→ The more common is the subacute, which means it is not that emergent, it may be there for days. The
subacute has variable presentation.
Why variable ? because ectopic pregnancy is called the greatest masquerader ‫المتخفي االعظم‬patients present in
many different ways and the most important step in diagnosing it is by suspecting it.
How to suspect it? .. the patient has something suspicious in her profile (history and risk factors that we talked
about) in addition to the presentation, which is typically:
abdominal pain 99% of patients (central or unilateral 35%, and could be generalized 45%, or shoulder tip when
lying supine 25%, continuous constant pain in nature unlike pain due to uterine contractions, or menses, or
bowels, where pain is intermittent.)
following a period of amenorrhea the most important (between 6-10 weeks usually)
with symptoms of pregnancy (most important one of it is breast fullness (not tenderness which is a sign) which
is due to progesterone) also vaginal discharge, nausea and vomiting might be present.

Why is the pain continuous all the time?

→ Because of the continuous irritation of the peritoneum by the bleeding after separation of the conceptus,
so it is peritonism due to irritation by blood. Blood, urine, pus, mucus, all of them will cause irritation to the
peritoneum.
Where does the bleeding come from?
→ It came from the trophoblast separation, because the tube is not prepared for the
implantation. Trophoblast secretes hCG hormone, and hCG act on the corpus luteum
stimulating the release of progesterone and estrogen, to maintain endometrium during the 1st
12 weeks in pregnancy, and then the placenta takes over.

So when the trophoblast separates, the hCG levels will drop >>> corpus luteum will undergo
luteolysis >>>> progesterone levels will drop >>>> endometrial lining and decidua will shed,
and vaginal bleeding will occur (75%). That’s why vaginal bleeding is the main other
symptom in ectopic pregnancy. Decidua is endometrium during pregnancy.

In ectopic pregnancy, it is very unusual to see a female with abdominal pain and vaginal
bleeding at the same time, we usually see her with abdominal pain, and later on the bleeding
occurs which is withdrawal bleeding. So bleeding in ectopic is withdrawal bleeding, the same as
menses.
→ Syncope & dizziness (35%) depends on the amount of blood lost, and occurs if the amount of
blood lost is enough to cause severe hypovolemia and collapse.
→ Blood in the abdomen is free, if it is collected in the pouch of douglas, it will
irritate the rectum, causing what we know as bathroom sign, in which the
patient feels uncomfortable going to the bathroom.

→ When the patient lies supine, blood in the peritoneum - if high amount – will
irritate the diaphragm, causing referred shoulder pain by the phrenic nerve
(shoulder tip sign).
→ In examination, we should NOT do bimanual examination looking for adnexal masses.
Rather we do what is called cervical excitation (adnexal tenderness) 96%, if we have
an ectopic pregnancy in the tube, when moving the cervix gently, if you pull the cervix to
one side, the opposite tube will extend, and patient will feel severe pain. Pulling the tube
will lead to its rupture and this is fatal. Also there may be dark blood oozing from the
external os of the cervix. <<<< In books it is written that in bimanual examination we can
feel adnexal masses and tenderness in some cases.!!!
 Adnexal mass (90%)
→ Uterine size, which is an important sign, will be of normal non-gravid size in 70% not
consistent with duration of amenorrhea, as there is no pregnancy inside, or it will be 6-8
wks in size in 25% of patients.

In the differential diagnosis of normal size uterus is threatened abortion or incomplete

abortion, and sometimes doctors misdiagnose ectopic pregnancy for those.
D&C curetting:
- Proliferative, secretory
- Arias-stella phenomenon
→ Suppose the doctor didn’t diagnose ectopic pregnancy, he diagnosed it as
miscarriage, did D & C (Dilation and Curettage), took biopsy (curetting) of the
endometrium and then sent it to the lab for histology, the histology result revealed
something called Arias-Stella’s phenomenon. biopsy of the endometrium take it
When doctors suspect incomplete abortion, but the result ectopic pregnency)

Arias-Stella’s phenomenon. >>It is a reaction that happens in the lab characteristic of

ectopic pregnancy. “It is focal, unusual, decidual changes in endometrial epithelium,
consisting of intraluminal budding, and nuclear enlargement and hyperchromatism with
cytoplasmic swelling and vacuolation; may be associated with ectopic or uterine
pregnancy.” So when you get the results, you have to call your patient and make her come
back urgently because her life is in danger, she is your responsibility.
So we diagnose ectopic pregnancy by History:
1) patient profile
2) risk factors
3) type of pain
4) symptoms of pregnancy
5) presence or absence of vaginal bleeding.

Examination by cervical excitation.

Investigations & ttt:

1. Pregnancy test
2. Transvaginal U/S
3. Laparoscopy
4. Laparotomy
5. Blood hemoglobin, grouping :
We take blood samples for CBC, Group and Cross match, and Rh group, β-hCG,
progesterone. In cross match, 2 units of blood must be available.
- Pregnancy test And by this we are not referring to the urine test, here we are talking about the serum β-
We can use hCG levels to suspect ectopic pregnancy. We have an equation that says that the
hCG.
size of the pregnancy (trophoblast cell mass) correlates with serum hCG level.
Ectopic pregnancy rarely present before this value, so Ectopic rarely ruptures when cell mass is
small or B.CG levels are low.
In a normal pregnancy it doubles every two days (2.2 days), but this doesn’t occur in ectopic
pregnancy.
 as we know that the minimum value for β-hCG to detect pregnancy by transvaginal ultrasound is
1500 mIU/mlml (this value differ between institutions).
a patient with serum β-hCG of 1500 and by transvaginal ultrasound you don’t find a gestational
sac, then you must think of an ectopic pregnancy.
 In normal pregnancy values, serum B.HCG > 1500 mlu/mL, Must see gestational sac
Then if we don’t find the sac we do serum progesterone if it is lower than 15mg then this
confirms that it is an ectopic pregnancy.
So if I did a vaginal ultrasound to a female, and hCG levels were 600, maybe I will not see a pregnancy, but if it was 1500
for example, we will see pregnancy (gestational sac), and then we do transvaginal ultrasound.
TVUS: >> Intrauterine pregnancy >> (unlikely ectopic)
evidence of ectopic pregnancy, like blood in pouch of douglas, empty uterus, sac
inside the tube, adnexal mass.
– Intrauterine sac:
• Pseudo sac (10-20%): irregular, long & thin
• True sac: regular, thick wall, double ring, presence of yolk sac, fetal pole & fetal heart.
The doctor pointed again to the point that we are
– Adnexial mass (90%): talking about vaginal ultrasound, but in abdominal
• Sac with fetus or no fetus ultrasound we need at least an hCG level of 5000
• Echogenic mass (DDx. C.L) mIU/ml to detect gestational sac, but in transvaginal
ultrasound, at 1500 we can see evidence of
intrauterine pregnancy.
– Fluids in P.O.D (pouch of doglas)
• Ruptured ectopics (80%)
• Normal pregnancy (20%)

** If Gest sac > 20 mm or (5-6 wk), you must see yolk sac and fetal pole(True sac ). if not
seen we should suspect either ectopic or blighted ovum
when we don’t find the sac or find adenxial mass or fluid in the pouch of Douglas. So a
patielnt with serum β-hCG of 1500 and by a transvaginal ultrasound you don’t find a
gestational sac, then you must think of an ectopic pregnancy. So do serum progesterone
& if it is lower than 15mg then this confirms the diagnosis.

“It is difficult to diagnose an ectopic pregnancy by ultrasound alone. However,

all viable intrauterine pregnancies can be visualized by transvaginal ultrasound
at a gestational age greater than 5.5 to 6 weeks. Therefore, the best way to
diagnose an ectopic pregnancy is to rule out the presence of an intrauterine
pregnancy (heterotopic pregnancies are extremely rare).
If an intrauterine pregnancy is detected on ultrasound, then ectopic pregnancy
has essentially been excluded.
If an ectopic pregnancy is visualized, then treatment may be pursued.
 If the ultrasound is nondiagnostic, then further evaluation is required.
If an intrauterine pregnancy is not identified by transvaginal ultrasound when
the quantitative hCG level is higher than the discriminatory zone (1500 mIU/ml),
then the gestation is, by definition, nonviable (either an abnormal intrauterine
pregnancy or an ectopic pregnancy).”
Management:
1. I.V. line (wide pore) & do blood grouping & cross- matching
2. Expectant management with serial β-HCG level

>>Once diagnosed
3. Surgical management (laparoscopy or laparotomy)
- Linear Salpingostomy (linear incision, removal of sac & incision closes by secondary intention or it may be
sutured)
- Segmental resection (removal of the affected part of the tube)
- Salpingectomy (removal of the whole affected tube)
4. Medical management (Methotrexate IM 50 ml single dose & Folic acid)

Always when suspicion of ectopic pregnancy, bring 2 large-bore cannulas, 1 in each

hand, why ? we know that the patient is stable, but in any second there may be
deterioration, sudden onset and collapse, and we might lose the patient, 10% mortality,
50% of it is during resuscitation.
We use this cannula at first to draw blood for blood grouping and cross matching, and
later for resuscitation when needed if rupture occurs.
Patients who present with an unruptured ectopic pregnancy can be treated
either surgically as above or medically.

Surgically >> The ectopic is being opened, removed, and we make sure
there is no bleeding, and then you either close it or leave it opened.
 When Medical treatment can be used? Methotrexate/folic antagonist
• Minimal symptoms (no shock)
• Sac < 4 cm
• No fetal heart activity
• βhCG < 1500
Medical therapy: Sometimes the treatment is very difficult, for example a female
patient with mild abdominal pain, and ectopic pregnancy that is visible in the
tube, size < 4cm, β-hCG values < 5000, these patients may be given medical
therapy, which is methotrexate (which is antimetabolite) single injection, and
then you follow the patient weekly for β-hCG levels, that rise in the 1st few days
but should fall by 10% to 15% between days 4 and 7 of the treatment.
Success rate of medical therapy is high, and most patients require no additional
treatment, with no further sequences, and they have good fertility rates.
If large ectopic, or β-hCG are high >5000, mostly we go for surgical treatment.
→- Laparoscopy (DX + ttt) :
(diagnostic & therapeutic), but it is reserved for stable patients with a doubtful diagnosis.
It is for definitive diagnosis, and treatment.
 if the pregnancy already ruptured you must do laparotomy as the blood will block your
laparoscopy limited sight, so you need exploratory laparotomy to feel with your hands and
stop the bleeding.

Either we remove the tube and we call it salpingectomy, or we open it and remove the sac
and we call it salpingotomy (tube resection), or we open it and remove the pregnancy and
leave the tube open to close by secondary intention, which we call salpingostomy. The
results later carry no deleterious effects, although the fertility will be slightly reduced.
If the patient is stable with a likely ruptured ectopic pregnancy, the procedure of
choice at many institutions is an exploratory laparoscopy that can be performed
to evacuate the hemoperitoneum, coagulate any ongoing bleeding, and resect
the ectopic pregnancy.
Indications for Laparotomy (rupture >blood block the sight by laparoscopy)
• Profuse hemorrhage
• Inadequate visualization or exposure with laparoscope
• Certain locations of the ectopic (abdominal, cornual, interstitial, ovarian)

If a patient presents with a ruptured ectopic pregnancy and is unstable, the

first priority is to stabilize with intravenous fluids, blood products, and
pressors if necessary. The patient should then be taken to the operating
room where exploratory laparotomy (most imp to be done) can be
performed to stop the bleeding and remove the ectopic pregnancy.
 Differential diagnosis:
• Threatened miscarriage
• Corpus luteum cyst
• pelvic inflammatory disease
• Acute appendicitis
• Urinary tract infection
• Ovarian cyst
 Differential diagnosis:
Threatened miscarriage (bleeding due to placental separation comes first then colicky pain due to uterine contraction)
in this and ectopic, both have amenorrhea, abdominal pain, positive pregnancy test hCG, but the difference is that
1) in ectopic there is continuous pain due to irritation, and in miscarriage it is colicky intermittent pain, always
centered,
2) bleeding with pain start together in miscarriage, bleeding 1st due to separation of placenta then pain due to uterine
contractions
3) and in miscarriage uterine size is equivalent to amenorrhea duration.
4) Cervix in miscarriage is soft, short, often is open, but in ectopic pregnancy it is firm, long, with cervical excitation.

•Corpus luteum cyst

•Amenorrhea
•unilateral pain
•spotting
•Preg. Symptoms None,
•Negative HCG
•If ruptured – Same treatment as ruptured ectopic pregnancy (laparotomy)

 Corpus luteum cyst (this cyst is formed as a result of a ruptured corpus luteum that is filled with fluid rather than regressing at the
end of the menstrual cycle, it resembles an ectopic pregnancy by forming a mass, and causing amenorrhea and breast fullness by
releasing progesterone thus preventing normal menstrual bleeding. It also may also cause unilateral pain that is continuous in nature
caused by torsion or intra-cystic hemorrhage, yet we have a negative β-hCG. Anyway we don’t have to differentiate between the two
conditions since the treatment for both conditions is the same).
•Pelvic inflammatory disease:
•Bilateral
•No amenorrhea or symptoms
•May have signs of infection (50%)
•fever, abdominal pain, vaginal discharge
• Negative pregnancy test

Acute appendicitis: No symptoms or signs of pregnancy , we find

anorexia, fever, always pain in the right side, No symptoms or signs
of pregnancy

•Urinary tract infection : no amenorrhea, no symptoms of pregnancy,

frequency, urgency, nocturia, negative pregnancy test

Ovarian cyst
Abdominal pregnancy:
PROGNOSIS:
• Mortality (7-10%) because of Wrong diagnosis, Undiagnosed or
Resuscitation attempts
• 10% of ectopics are in vascular shock at time of diagnosis
• 60% of ectopic have >500ml free blood in abdomen at time of laparatomy
The doctor showed a picture, saying that there is a needle on the pregnancy itself, for the purpose of
aspiration. He also showed another picture of salpingotomy.