Ectopic pregnancy

Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE

Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
 Reference

• Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL,
Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter
19 Ectopic Pregnancy
 Outline

• Classification
• Risk factors
• Outcomes
• Clinical manifestations
• Diagnosis
• Management
• Other types of non-tubal ectopic pregnancies
 378 Early Pregnancy Complications

Classification Tubal 95 %
T

• ampulla is the most frequent Interstitial Ampullary 70%

SECTION 6
2–3%
site, followed by the isthmus. Isthmic 12%

• the remaining 5 percent of

nontubal ectopic pregnancies
implant in the ovary, peritoneal
cavity, cervix, or prior cesarean Cessaar
Ce are
rean
an ssca
car
ca
ar <<11% Fimbrial 11%
Ovarian 3%
scar.
Cervical <1%

Intraligamentous
or abdominal 1%

FIGURE 19-1 Sites of implantation of 1800 ectopic pregnancies from a 10-year population-based study. (Data from Callen, 2
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
Bouyer,BL,2003.)
 “Heterotopic pregnancy”

• one conceptus with normal uterine

implantation coexisting with one
conceptus implanted ectopically

Photo source: https://medicaldialogues.in/wp-content/uploads/2017/02/heterotop

pregnancy-1.jpg

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 1. Previous Tubal surgery (eg, salpingostomy for
a previous ectopic pregnancy, sterilization, or
fertility restoration (tubal reanastomosis)
2. Previous ectopic pregnancy:
**There is a 10% chance for a second ectopic
pregnancy immediately after a first ectopic
pregnancy.
Risk factors 3. Salpingitis/tubal infection
4. peritubal adhesions secondary to salpingitis,
appendicitis or endometriosis
5. Assisted reproductive techniques
6. Salpingitis isthmica nodosa : a condition in
which epithelium- lined diverticula extend
into a hypertrophied muscularis layer
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Tubal Pregnancy
because the fallopian tube lacks a submucosal
layer, the fertilized ovum promptly burrows
through the epithelium .

zygote comes to lie near or within the

muscularis, which is invaded in most cases by
rapidly proliferating trophoblast.

embryo or fetus in an ectopic pregnancy

is often absent or stunted. Photosource: www.webmd.com

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Outcomes
378 Early Pregnancy Complications

TTubal 95%
• Ectopic pregnancies may rupture and cause massive
hemorrhage:
• As a rule, if the affected fallopian tube ruptures in the first Interstitial Ampullary 70%

SECTION 6
2–3%
few weeks of pregnancy (approx. 8 wks or less), the ectopic Isthmic 12%

pregnancy is most likely located in the isthmic portion,

whereas the ampulla is slightly more distensible
• if the fertilized ovum implants within the interstitial
portion, rupture usually occurs at a later AOG Fimbrial 11%
Cessaar
Ce are
rean
an ssca
car
ca
ar <<11%
(approximately 10-14 weeks AOG) Ovarian 3%

• Tubal abortion: ectopic pregnancy may abort out the distal Cervical <1%
fallopian tube (usually happens in fimbrial and ampullary
Intraligamentous
pregnancies) à hemorrhage may cease and symptoms or abdominal 1%
eventually disappear.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
FIGURE 19-1 Sites of implantation of 1800 ectopic pregnancies from a 10-year population-based study. (Data from Callen, 20
 • acute ectopic pregnancies: high
serum β-hCG level and rapid
growth, leading to an immediate
diagnosis.
• higher risk of tubal rupture
Acute versus • chronic ectopic pregnancy:
Chronic ectopic abnormal trophoblast die early,
and thus negative or lower, static
pregnancy serum β-hCG levels are found
• typically rupture late
• commonly form a complex
pelvic mass

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
Clinical Manifestations
• triad of delayed menstruation (“missed menses”), pain, and
vaginal bleeding or spotting.
• If with tubal rupture: severe lower abdominal and pelvic pain
(sharp, stabbing, or tearing) PLUS tenderness on abdominal
palpation
*Symptoms of diaphragmatic irritation, characterized by pain
in the neck or shoulder, especially on inspiration, may develop
in women with massive hemoperitoneum.
**On internal exam:(+) cervical motion or wriggling
tenderness; (+) tender, boggy mass felt on one side of the
uterus ; (+) fullness in the culdesac; (+)uterus may also be
slightly enlarged due to hormonal stimulation.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Ectopic Pregnancy 379 Clinical
ated
may
usu-
Manifestations
ood

CHAPTER 19
vity
bri-
ally

ne-
now • in addition to bleeding, women with
just ectopic tubal pregnancy may pass a
decidual cast, which is the entire
mon
CG
osis.
3c). sloughed endometrium that takes
die
are
FIGURE 19-3 This decidual cast was passed by a patient with a
tubal ectopic pregnancy. The cast mirrors the shape of the endo-
the form of the endometrial cavity
ally metrial cavity, and each arrow marks the portion of decidua that
lvic lined the cornua.
gery
Even after substantive hemorrhage, hemoglobin or hemato-
crit readings may at first show only a slight reduction. Hence,
after an acute hemorrhage, a decline in hemoglobin or hema-
tocrit level over several hours is a more valuable index of blood
nol- loss than is the initial level. In approximately half of women
ses, with a ruptured ectopic pregnancy, varying degrees of leukocy-
ven Cunningham
tosis up to FG, Leveno
30,000/µL may KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
be documented.
mes Decidua is endometrium that is hormonally prepared for
Diagnosis of Ectopic pregnancy
 Positive urine pregnancy test + abdominal
cramping or vaginal bleeding

SECTION 6
Clinical evaluation

Diagnosis Hemodynamically
stable
Hemodynamically
unstable

of Ectopic TVS Surgical treatment for

presumed ruptured
ectopic pregnancy

Pregnancy IUP

Prenatal care
Abnormal IUP

Treata
Nondiagnostic

Serum β-hCG
Ectopic pregnancy

Treat

> Discriminatory zone < Discriminatory zone

D&Cb
Serum β-hCG in 48 hours

Chorionic villi absent Chorionic villi

present Normal rise Expected Abnormal
decrease rise or fall

Treat ectopic
pregnancy TVS when serum β-hCG Serial β-hCG D&Cb
> discriminatory zone or D&C

IUP Ectopic pregnancy Abnormal IUP Nondiagnostic

Prenatal care Treat Treata D&Cb

Chorionic villi absent Chorionic

villi present

Treat ectopic pregnancy

th
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, FIGURE
Dashe JS, Hoffman
19-4 BL, Caseyalgorithm
One suggested BM, Sheffield JS (eds).William’s
for evaluation Obstetrics
of a woman with a 24 edition;
suspected 2014;pregnancy.
ectopic chapter 19 Expectant
Ectopic Pregnancy
a
management, D&C,
or medical regimens are suitable options. bSerial serum β-hCG levels may be appropriate if a normal uterine pregnancy or if completed
abortion is suspected clinically. β-hCG = beta human chorionic gonadotropin; D&C = dilatation and curettage; IUP = intrauterine preg-
 1. Beta Human Chorionic Gonadotropin
(bhCG)

• discriminatory β-hCG levels (discriminatory zone): minimum levels of β-hCG above which
failure to visualize an intrauterine pregnancy (IUP) indicates that the pregnancy either is
not alive or is ectopic.
• an empty uterus with a serum β-hCG concentration ≥ 1500 mIU/mL (discriminatory zone)
was 100-percent accurate in excluding a live uterine pregnancy.
• Some institutions set their discriminatory threshold higher at ≥ 2000 mIU/mL bhCG
• If the initial β-hCG level exceeds the set discriminatory level and no evidence for a uterine
pregnancy is seen with TVS, then the diagnosis is narrowed in most cases to a failed
uterine pregnancy, completed abortion, or an ectopic pregnancy.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 1. Beta Human Chorionic Gonadotropin
(bhCG)

• If the initial β-hCG level exceeds the set discriminatory level and no
evidence for a uterine pregnancy is seen with TVS, then the diagnosis is
narrowed in most cases to a failed uterine pregnancy, completed
abortion, or an ectopic pregnancy.

• If the initial β-hCG level is below the set discriminatory value, pregnancy
location is often not technically discernible with TVS

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 • serum and urine pregnancy tests that use
enzyme-linked immunosorbent assays
(ELISAs) for β-hCG are sensitive to levels of 10
to 20 mIU/ mL and are positive in > 99
Beta Human percent of ectopic pregnancies

Chorionic • For cases where pregnancy test is positive,

Gonadotropin but Transvaginal ultrasound could not detect
any intrauterine or extrauterine à the term
(bHCG) Pregnancy of Unknown Location (PUL) is
used until additional clinical information
allows determination of pregnancy location.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 cates that the pregnancy either is not alive or is ectopic. Barnhart (Zee, 2013). Also, uterine curettage is an option. Barnhart and
and colleagues (1994) reported that an empty uterus with a associates (2003b) reported that endometrial biopsy was less sen-
serum β-hCG concentration ≥ 1500 mIU/mL was 100-percent sitive than curettage. Before curettage, a second TVS examina-
accurate in excluding a live uterine pregnancy. Some institutions tion may be indicated and may display new informative findings.

1. Beta Human Chorionic Gonadotropin

set their discriminatory threshold higher at ≥ 2000 mIU/mL.
Moreover, Connolly and associates (2013) reported evidence to Serum Progesterone
suggest an even higher threshold. They noted that with live uter- A single serum progesterone measurement may clarify the diag-

(bhCG)
ine pregnancies, a gestational sac was seen 99 percent of the time
with a discriminatory level of 3510 mIU/mL.
nosis in a few cases (Stovall, 1989, 1992b). A value exceeding
25 ng/mL excludes ectopic pregnancy with 92.5-percent
If the initial β-hCG level exceeds the set discriminatory level
and no evidence for a uterine pregnancy is seen with TVS,
then the diagnosis is narrowed in most cases to a failed uter- TABLE 19-1. Expected Minimum Percentage Decline of
ine pregnancy, completed abortion, or an ectopic pregnancy. Initial Serum β-hCG Levels to Subsequently
• For PULs à serial β-hCG level assays are
Early multifetal gestation also remains a possibility. If there is Drawn Values for Nonliving Pregnancies
done to identify patterns that indicate
a suspicion in a stable patient that a PUL could be a normal Initial hCG By day 2: By day 4: By day 7:
pregnancy, it is prudent to continue expectant management
either a growing or failing uterine
with serial β-hCG level assessment to avoid harming an early
(mIU/mL) (% decline) (% decline) (% decline)
50 12 26 34
pregnancy. normal pregnancy. If patient history or extruded uterine tissue
suggests a completed abortion, then serial β-hCG levels will 100 16 35 47
• If β-hCG level doubles every 48 hours
drop rapidly. Otherwise, curettage will distinguish an ectopic 300
500
22
24
45
50
62
68
from a nonliving uterine pregnancy. Some do not recommend
àVIABLE INTRAUTERINE PREGNANCY
diagnostic curettage because it results in unnecessary surgi- 1000 28 55 74
2000 31 60 79
• if failing intrauterine pregnancy, β-hCG
cal therapy (Barnhart, 2002). This is countered by concern
for methotrexate toxicity if this drug is given erroneously to 3000 33 63 81
level decline à rates of decline
women with a presumed ectopic pregnancy. 4000
5000
34
35
64
66
83
84
expected approx. 21- 35 %
Levels below the Discriminatory Zone. If the initial
Data from Barnhart, 2004; Chung, 2006.
β-hCG level is below the set discriminatory value, preg-

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 1. Beta Human Chorionic Gonadotropin
(bhCG)

• In pregnancies without these expected rises or falls in β-hCG

levels, distinction between a nonliving intrauterine and an
ectopic pregnancy may be aided by repeat β-hCG level evaluation

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 1. Beta Human Chorionic Gonadotropin
(bhCG)

• If there is a suspicion in a stable patient that a PUL could be a normal

pregnancy à continue expectant management with serial β-hCG level
assessment to avoid harming an early normal pregnancy.
• If patient history or extruded uterine tissue suggests a completed
abortion, then serial β-hCG levels will drop rapidly.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 2. Serum Progesterone

• A serum progesterone value exceeding 25 ng/mL excludes ectopic

pregnancy
• Serum progesterone values < 5 ng/mL suggest either a nonliving
uterine pregnancy or an ectopic pregnancy.
• Because in most ectopic pregnancies, progesterone levels range
between 10 and 25 ng/mL, the clinical utility is limited (American
College of Obstetricians and Gynecologists, 2012).

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 3. Transvaginal ultrasound (TVS)

• In ectopic pregnancy, TVS can detect:

1. Absence of intrauterine gestational sac / fetal pole
2. Complex adnexal mass or extrauterine GS with “ring of fire” pattern (Placental blood
flow within the periphery of the complex adnexal mass)
3. a trilaminar endometrial pattern
4. a pseudosac: fluid collection between the endometrial layers and conforms to the
cavity shape
5. a decidual cyst: anechoic area lying within the endometrium but remote from the
canal and often at the endometrial-myometrial border
6. Hemoperitoneum: for ruptured ectopic pregnancy (as 50 mL can be seen in the cul-
de-sac using TVS )
• For significant hemorrhage, fluid in seen to fill Morison pouch near the liver. (free fluid in this
pouch typically is not seen until accumulated blood reaches 400 to 700 mL)

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 adnexal mass—the ring of fire—can
e be seen with transvaginal pic pregnancy. A number of studies have challenged its use-
color Doppler imaging. Although this can aid in the diagnosis, fulness, and culdocentesis has been largely replaced by TVS
this finding can also be seen with a corpus luteum of preg- (Glezerman, 1992; Vermesh, 1990).
nancy, and differentiation can be challenging.
Laparoscopy

4. Culdocentesis
Hemoperitoneum. In women with suspected ectopic Direct visualization of the fallopian tubes and pelvis by lapa-
pregnancy, evaluation for hemoperitoneum can add valu- roscopy offers a reliable diagnosis in most cases of suspected

• simple technique used commonly in the past to identify

hemoperitoneum.
• a long 18-gauge needle is inserted through the posterior vaginal
fornix into the retrouterine cul-de-sac.
• a failure to aspirate fluid is interpreted only as unsatisfactory entry
into the cul-de-sac and does not exclude ectopic pregnancy.
• Fluid containing fragments of old clots or bloody fluid that does
not clot is compatible with the diagnosis of hemoperitoneum.
• if the blood sample clots, it may have been obtained from an
adjacent blood vessel or from a briskly bleeding ectopic pregnancy.
A B

FIGURE 19-7 Techniques to identify hemoperitoneum. A. Transvaginal sonography of an anechoic fluid collection (arrow) in the retro-
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
uterine cul-de-sac. B. Culdocentesis: with a 16- to 18-gauge spinal needle attached to a syringe, the cul-de-sac is entered through the
 5. Laparoscopy

• Direct visualization of the

fallopian tubes and pelvis by
laparoscopy offers a reliable
diagnosis in most cases of
suspected ectopic pregnancy

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Treatment
Medical versus Surgical
 Medical Treatment
• Patients eligible for medical treatment:
1. low initial serum β-hCG level (single best prognostic indicator of successful
treatment)
2. small ectopic pregnancy size (< 3.5 cm)
3. absent fetal cardiac activity.
• Eligible patients may be given methotrexate (highly effective against rapidly proliferating
tissues such as trophoblast)
• Toxic to bone marrow, gastrointestinal mucosa, respiratory epithelium, hepatocytes
• toxicity to bone marrow can be blunted by early administration of leucovorin,
which is folinic acid and has activity equivalent to folic acid.
• renally excreted.
• Methotrexate is a potent teratogen, and methotrexate embryopathy is notable for
craniofacial and skeletal abnormalities and fetal-growth restriction

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
TABLE 19-2. Medical Treatment Protocols for Ectopic Pregnancy
Single Dose Multidose
Dosing One dose; repeat if necessary Up to four doses of both drugs until serum
β-hCG declines by 15%
Medication Dosage
Methotrexate 50 mg/m2 BSA (day 1) 1 mg/kg, days 1, 3, 5, and 7
Leucovorin NA 0.1 mg/kg days 2, 4, 6, and 8
Serum β-hCG level Days 1 (baseline), 4, and 7 Days 1, 3, 5, and 7
Indication for additional If serum β-hCG level does not decline If serum β-hCG declines < 15%, give
dose by 15% from day 4 to day 7 additional dose; repeat serum β-hCG in
Less than 15% decline during weekly 48 hours and compare with previous
surveillance value; maximum four doses
Posttherapy surveillance Weekly until serum β-hCG undetectable
Methotrexate Contraindications
Sensitivity to MTX Intrauterine pregnancy Peptic ulcer disease
Evidence of tubal rupture Hepatic, renal, or hematological Active pulmonary disease
Breast feeding dysfunction Evidence of immunodeficiency

BSA = body surface area; β-hCG = β-human chorionic gonadotropin; MTX = methotrexate; NA = not applicable.
From American College of Obstetricians and Gynecologists, 2012; Practice Committee of American Society for
Reproductive Medicine, 2013.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
Surgical Management

• Laparoscopy is the preferred surgical

treatment for ectopic pregnancy unless a
woman is hemodynamically unstable.
• Before surgery, future fertility desires of
the patient should be discussed.
• In those desiring permanent sterilization,
the unaffected tube can be ligated
concurrently with salpingectomy for the
affected fallopian tube.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
Surgical management
Conservative
• Salpingostomy: incision made over the
fallopian tube to evacuate the ectopic
pregnancy, without suturing it close
(heal by secondary intention)
• Salpingotomy: incision made over the
fallopian tube to evacuate the ectopic
pregnancy, and suturing it close after
evacuation.
• Preferred for small unruptured ectopic
pregnancies (< 2 cm)
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
Surgical management

Radical surgery

• Salpingectomy : permanent
removal of a fallopian tube
• Preferred for large and/or ruptured
ectopic pregnancies
• Partial vs complete

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Expectant Management

• Criteria:
• tubal ectopic pregnancies only
• decreasing serial β-hCG levels
• diameter of the ectopic mass ≤ 3.5 cm
• no evidence of intraabdominal bleeding or rupture by transvaginal
sonography.
• American College of Obstetricians and Gynecologists (2012), 88
percent of ectopic pregnancies will resolve spontaneously if the
β-hCG is < 200 mIU/mL.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 • Regardless of location, D-negative
women with an ectopic pregnancy who
are not sensitized to D-antigen should
be given IgG anti-D immunoglobulin
IgG anti-D (American College of Obstetricians and
Gynecologists, 2013).

immunoglobulin • In first-trimester pregnancies, a 50-μg

or a 300-μg dose is appropriate,
whereas a standard 300-μg dose is
used for later gestations

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Non-tubal ectopic pregnancies
Pregnancy Complications

Tubal 95 %
T

Interstitial Ampullary 70%

2–3%
Isthmic 12%

Ces
Cesaare
ar
rean
an s
sca
car
ca
ar <
<11% Fimbrial 11%
Ovarian 3%

Cervical <1%

Intraligamentous
or abdominal 1%

RE 19-1 Sites of implantation of 1800 ectopic pregnancies from a 10-year population-based study. (Data from Callen, 2000;
 Interstitial or Cornual pregnancy

• Ectopic pregnancy implant within the proximal tubal

segment that lies within the muscular uterine wall
• Undiagnosed interstitial pregnancies usually rupture
following 8 to 16 weeks of amenorrhea, which is
later than for more distal tubal ectopic pregnancies
à due to greater distensibility of the myometrium
covering the interstitial fallopian tube segment.
• Because of the proximity of these pregnancies to the
uterine and ovarian arteries, there is a risk of severe
hemorrhage
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Interstitial or Cornual pregnancy

• Criteria for ultrasound diagnosis:

1. an empty uterus
2. a gestational sac seen separate from the endometrium
and > 1 cm away from the most lateral edge of the
uterine cavity
3. thin, < 5-mm myometrial mantle surrounding the sac
4. echogenic line, known as the “interstitial line sign,”
extending from the gestational sac to the endometrial
cavity

Photo source: https://radiologykey.com/wp-content/uploads/2016/08/FF29.2.1.jpg

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Interstitial or Cornual pregnancy

• Surgical management with either cornual resection or cornuostomy may be

performed via laparotomy or laparoscopy, depending on patient hemodynamic
stability and surgeon expertise
• intraoperative intramyometrial vasopressin injection may limit surgical blood
loss, and β-hCG levels should be monitored post-operatively to exclude
remnant trophoblast.
• Cornual resection removes the gestational sac and surrounding cornual
myometrium by means of a wedge excision
• Alternatively, cornuostomy involves incision of the cornua and suction or
instrument extraction of the pregnancy.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Abdominal Pregnancy
Ectopic Pregnancy 389

preparation, assurance of sufficient blood prod-

ucts, and availability of a multidisciplinary surgical
• implantation of ectopic pregnancy in the peritoneal
team or elective transfer to a tertiary care facility.
In many ways, surgical management is similar to

CHAPTER 19
cavity exclusive of tubal, ovarian, or intra-ligamentous
that for placenta percreta, which is detailed in
Chapter 41 (p. 807).
Placenta
implantations.
The principal surgical objectives involve deliv-
ery of the fetus and careful assessment of placen-
tal implantation without provoking hemorrhage.
• Clinically, abnormal fetal positions may be palpated, or
Unnecessary exploration is avoided because the
anatomy is commonly distorted and surrounding
Uterus
the cervix is displaced
areas will be extremely vascular. Importantly, pla-
cental removal may precipitate torrential hemor-
rhage because the normal hemostatic mechanism

Bladder
• Ultrasound findings:
of myometrial contraction to constrict hypertro-
phied blood vessels is lacking. If it is obvious that
1. Oligohydramnios is common but nonspecific.
the placenta can be safely removed or if there is
already hemorrhage from its implantation site,
then removal begins immediately. When possible,
2. a fetus seen separate from the uterus or
blood vessels supplying the placenta should be
ligated first.
eccentrically positioned within the pelvis;
Some advocate leaving the placenta in place
as the lesser of two evils. It decreases the chance
3. lack of myometrium between the fetus and the
of immediate life-threatening hemorrhage, but

maternal anterior abdominal wall or bladder

at the expense of long-term sequelae. If left in
FIGURE 19-11 Sagittal view of an abdominal pregnancy at term. The placenta the abdominal cavity, the placenta commonly
is implanted on the posterior surface of the uterus and broad ligament. The becomes infected, with subsequent formation of
enlarged, flattened uterus is located just beneath the anterior abdominal wall
and to the level of the umbilicus. The cervix and vagina are pulled up and are
tion,
4. extrauterine placental tissue
abscesses, adhesions, intestinal or ureteral obstruc-
and wound dehiscence (Bergstrom, 1998;
dislodged anteriorly and superiorly by the large fetal head in the cul-de-sac.
Martin, 1988). In many of these cases, surgical
removal becomes inevitable. If the placenta is left,
(Sherer, 2007). If additional anatomical information is needed, its involution may be monitored using sonography and serum
MR imaging can be used to confirm the diagnosis and pro- β-hCG levels (France, 1980; Martin, 1990). Color Doppler
vide maximal information concerning placental implantation sonography can be used to assess changes in blood flow. In
th
Cunningham
(Bertrand, 2009; Mittal,FG, Leveno KJ, Bloom SL, Spong CY,
2012). someDashe JS, usually
cases, and Hoffman BL, Casey
depending BM,placental
on its size, Sheffield
func-JS (eds).William’s Obstetrics 24 edition; 2014; chapter 19 Ectopic Pregnancy
tion rapidly declines, and the placenta is resorbed. However,
 Abdominal Pregnancy

• An abdominal pregnancy can be life-threatening, and management depends

on the gestational age at diagnosis.
• most common fetal malformations were limb deficiency and central
nervous system anomalies; most common deformations were facial and/or
cranial asymmetry and various joint abnormalities.
• Conservative management also carries a maternal risk for sudden and
dangerous hemorrhage.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Abdominal Pregnancy

• Principal surgical objectives involve delivery of the fetus and careful

assessment of placental implantation without provoking hemorrhage
(surrounding areas will be extremely vascular).
• Placental removal may precipitate torrential hemorrhage because the
normal hemostatic mechanism of myometrial contraction to constrict
hypertrophied blood vessels is lacking.
• If it is obvious that the placenta can be safely removed or if there is already
hemorrhage from its implantation site, then removal begins immediately.
When possible, blood vessels supplying the placenta should be ligated first.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Abdominal Pregnancy

• Some advocate leaving the placenta in place to decrease the chance of

immediate life-threatening hemorrhage
• If left in the abdominal cavity, the placenta commonly becomes infected, with
subsequent formation of abscesses, adhesions, intestinal or ureteral obstruction,
and wound dehiscence
• If the placenta is left, its involution may be monitored using sonography and
serum β-hCG levels
• In some cases, and usually depending on its size, placental function rapidly
declines, and the placenta is resorbed. However, placental resorption may take
years
• If the placenta is left in place, postoperative methotrexate can be used to
hasten involution but has been reported to cause accelerated placental
destruction with accumulation of necrotic tissue and infection with abscess
formation

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Intraligamentous or broad ligament pregnancy

• When gestational contents are extruded

into a space formed between the broad
ligament leaves and become an intra-
ligamentous or broad ligament pregnancy.

• Clinical findings and management are same

as for abdominal pregnancy

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Ovarian pregnancy

• Ectopic implantation of the fertilized egg in the ovary

• four clinical criteria (Spiegelberg criteria):
(1) the ipsilateral tube is intact and distinct from the ovary;
(2) the ectopic pregnancy occupies the ovary;
(3) the ectopic pregnancy is connected by the uteroovarian
ligament to the uterus;
(4) ovarian tissue can be demonstrated histologically amid the
placental tissue
• Sonographically, an internal anechoic area is
surrounded by a wide echogenic ring, which in turn is
surrounded by ovarian cortex www.sciencephoto.com

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Ovarian pregnancy

• Maybe mistaken as hemorrhagic corpus luteum cyst or a

bleeding corpus luteum.
• Management for ovarian pregnancies has been surgical.
Small lesions have been managed by ovarian wedge
resection or cystectomy, whereas larger lesions require
oophorectomy.
• systemic or locally injected methotrexate has been used
successfully to treat small unruptured ovarian
pregnancies à β-hCG levels should be monitored to
exclude remnant trophoblast.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Cervical pregnancy

• defined by cervical glands noted histologically opposite the placental

attachment site and by part or all of the placenta
• Painless vaginal bleeding is reported by 90 percent of women with a cervical
pregnancy—a third of these have massive hemorrhage
• As pregnancy progresses, a distended, thin-walled cervix with a partially
dilated external os may be evident.
• Above the cervical mass, a slightly enlarged uterine fundus can be felt.
• Identification of cervical pregnancy is based on speculum examination,
palpation, and TVS.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Cervical pregnancy

• Transvaginal sonographic findings may include:

(1) an hourglass uterine shape and ballooned cervical canal;
(2) gestational tissue at the level of the cervix (black arrow);
(3) absent intrauterine gestational tissue (white arrows);
(4) a portion of the endocervical canal seen interposed between the gestation and the
endometrial canal.
• Cervical pregnancy may be treated medically or surgically.
• Methotrexate has become the first-line therapy in stable women
• induce fetal death with intracardiac or intrathoracic injec- tion of potassium chloride.
• Suction curettage
• hysterectomy may be required with bleed- ing uncontrolled by conservative methods

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 CS Scar pregnancy (CSP)

• describes implantation within the myometrium of a prior cesarean

delivery scar
• pathogenesis of cesarean scar pregnancy (CSP) has been likened to that
for placenta accreta and carries similar risk for serious hemorrhage
• Women with CSP usually present early, and pain and bleeding are
common. However, up to 40 percent of women are asymptomatic, and
the diagnosis is made during routine sonographic examination

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 CS Scar pregnancy (CSP)

• four sonographic criteria:

1. An empty uterine cavity
2. An empty cervical canal
3. an intrauterine mass is seen in the anterior part of the uterine isthmus
4. Myometrium between the bladder and gestational sac is absent.
• Fertility-preserving options for management include systemic or locally injected
methotrexate, either alone or combined with conservative surgery
• Surgeries include visually guided suction curettage or transvaginal aspiration,
hysteroscopic removal, or isthmic excision.
• Hysterectomy is done for patients who do not wish to conserve their uterus.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 19 Ectopic Pregnancy
 Summary

• Classification
• Risk factors
• Outcomes
• Clinical manifesations
• Diagnosis
• Management
• Other types of non-tubal ectopic pregnancies
Thank you!
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