ADVANCES IN THE

DIAGNOSIS AND
MANAGEMENT OF ECTOPC
PREGNANCY
DR. A.B.A. ANDE
MATERNO-FETAL UNIT
UNIBEN / UBTH
 ECTOPIC PREGNANCY

DEFINITION

Any pregnancy where the fertilised

ovum gets implanted and develops in
a site other than normal uterine
cavity.
 INCIDENCE
> 1 in 100 pregnancies

 Recent evidence indicates that the incidence of ectopic

pregnancy has been rising in many countries
- USA – 5 fold
- UK – 2 fold
- France – 15/1000
- India – 1 in 100 deliveries
- Nigeria – 2-3% of gynecological emergencies
 Recurrence rate – 15% after 1st, 25% after 2 ectopics
 HISTORY
 963 AD – Albucasis first described Ectopic
Pregnancy
 1884 -- Robert Lawson Tait of Birmingham
performed the forst successful
Salpingectomy operation
 1953 – Stromme – Conservatice surgery of
Salpingostomy
 1973 – Shapiro & Adller – Laparoscopic
Salpingectomy
 1991 – Young et al – Laparoscopic
Salpingotomy
 AETIOLOGY
 Any factor that causes delayed
transport of the fertilised ovum
through the fallopian tube favours
implantation in the tubal mucosa,
giving rise to a tubal ectopic
pregnancy.
 These factors may be Congenital or
Acquired.
 AETIOLOGY
 CONGENITAL – Tubal Hypolasia, Tortuosity,
Congenital diverticuli, Accessory ostia, Partial
stenosis.
 AQUIRED –
- Inflammatory: PID, Septic Abortion, Puerperal
Sepsis, MTP (Intraluminal adhesion)
- Surgical: Tubal reconstructive surgery,
Recanalisation of tubes
- Neoplastic: Broad ligament myoma, Ovarian
tumour.
- Miscellaneous Causes: IUCD, Endometriosis,
ART (IVF & GIFT), Previous ectopic.
 SITES OF ECTOPIC
PREGNANCY

1) Fimbrial 2) Ampullary 3) Isthmic 4) Interstitial 5)Ovarian 6) Cervical

7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligamen
10) Primary abdominal
 CLINICAL PRESENTATION
 Ectopic Pregnancy remains asymptotic
until it ruptures when it can present in two
variations – Acute and Chronic
 SYMPTOMS
- Amenorrhea
- Abdominal Pain
- Syncope
- Vaginal Bleeding
- Pelvic Mass
 DIAGNOSIS

“Pregnancy in the fallopian tube is a

black cat on a dark night. It may
make its presence felt in subtle ways
and leap at you or it may slip past
unobserved. Although it is difficult to
distinguish from cats of other colours
in darkness, illumination clearly
identifies it.”
-- Mc. Fadyen – 1981.
 DIAGNOSIS
 In recent years, in spite of an increase in
the incidence of ectopic pregnancy, there
has been a fall in the case fatality rate.
 This is due to the widespread introduction
of diagnostic tests and an increased
awareness of the serious nature of this
disease.
 This has resulted in early diagnosis and
effective treatment.
 Now the rate of tubal rupture is as low as
20 %.
 METHODS OF EARLY
DIAGNOSIS
 Immunoassy utilising monoclonal
antibodies to β-HCG.
 Ultrasound scanning – Abdominal &
Vaginal including Colour Doppler
 Laparoscopy
 Serum progesterone estimation not helpful

A combination of these methods have to

be employed.
 METHODS OF EARLY
DIAGNOSIS
 TVS can visualise a gestational sac as
early as 4 – 5 weeks from LMP.
 During this time, the lowest serum β HCG
is 2000 IU/L.
 When β HCG level is greater than this and
there is an empty uterine cavity on TVS,
ectopic pregnancy can be suspected.
 In such a situation, when the value of β
HCG does not double in 48 hours ectopic
pregnancy will be confirmed.
 METHODS OF EARLY
DIAGNOSIS
Ultrasound features of ectopic pregnancy
after 5 weeks can be any of the
following:
2. Demonstration of the gestational sac
with or without a live embryo (Begel’s
sign) – The GS appears as an intact well
defined tubal ring by 6 weeks when it
measures 5 mm in diameter. Afterwards
it can be seen as a complete sonolucent
sac with the yolk sac and the embryonic
pole with or without heart activity inside.
 METHODS OF EARLY
DIAGNOSIS
Ultrasound features of ectopic pregnancy after 5
weeks can be any of the following:
2. Poorly defined tubal ring possibly containing
echogenic structure and POD contaaining fluid
or blood.
3. Ruptured ectopic with fluid in the POD and an
empty uterus.
4. In Colour Doppler, the vascular colour in a
characteritic placental shape, the so-called fire
pattern, can be seen outside the uterine cavity
while the uterine cavity is cold in respect to
blood flow
 MANAGEMENT
 Depends on the stage of the disease
and the condition of the patient at
diagnosis.
 Options:
- Surgery – Laparotomy /
Laparoscopy
- Medical – Administration of
Trophotoxics at the site or
systemically
 MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
 Hospitalisation
 Resuscitation:
- Treatment of shock
- Lie flat with the leg end raised
- Analgesics
- Blood transfusion
 MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
Culdocentesis:
 Highly specific if performed and

interpreted correctly: - Presence

of Free – Flowing, NON-Clotting
blood
 Negative tap inconclusive

 Remains controversial.
 MANAGEMENT OF ACUTE
ECTOPIC PREGNANCY
 Laparotomy should be done at
the earliest.
 Salpingectomy is the definitive

treatment.
 No benefit from removing Ovary

along with the tube.

 Blood Transfusion: Auto-

transfusion.
 MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
INVESTIGATIONS:
 Laboratory/Chemical test:

- Serial quantitative β HCG level by RIA

- Serum Progesterone level (<5 mg/ml in
ectopic pregnancy)
- Low levels of Trophoblastic Proteins such
as SPI and PAPP- Placental Protein 14 & 12
 USS – Usually haematocele is found

 Laparoscopy
 MANAGEMENT OF CHRONIC
ECTOPIC PREGNANCY
TREATMENT – ALWAYS SURGICAL
 Salpingectomy of the offending tube

 If pelvic haematocele is infected,

posterior colpotomy is to be done to

drain the prelvic abcess
 Salpingo-oophorectomy
 MANAGEMENT OF
UNRUPTURED ECTOPIC
PREGNANCY
OPTIONS:
 Surgical

 Surgically Administered Medical

(SAM) treatment
 Medical treatment

 Expectant management
 SURGICAL TREATMENT OF
ECTOPIC PREGNANCY
 Carried out either by Laparotomy /
Laparoscopy
 The procedures are:
-Salpingectomy / Cornual resection /
Excision
- Conservative Surgery (in cases of
infertility & desire for pregnancy)
• Linear salpingostomy
• Linear salpingotomy
• Segmental resection and anastomosis
• Milking out the tube
SURGICAL TREATMENT OF
ECTOPIC PREGNANCY
LAPAROTOMY?
VS
LAPAROSCOPY?

SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY
 COMPARING LAPAROTOMY Vs
LAPRAOSCOPY
L’tomy L’scopy
Hospital cost More? Less?
Post operative adhesions More
Less
Risk of futuer ectopic Same Same
Future fertility Same
Same
Experience of Surgeon Trained
Special
 SALPINGECTOMY Vs
SALPINGOSTOMY/SALPINGOTO
MY
 All tubal pregnancies can be treated by
partial or total Salpingectomy
 Salpingostomy / Salpingostomy is only
indicated when:
1. The patient desires to conserve her fertility
2. Patient is haemodynamically stable
3. Tubal pregnancy is accessibly
4. Unruputed and < 5 cm in size
5. Contra lateral tube is absent or damaged
 SALPINGECTOMY Vs
SALPINGOSTOMY/SALPINGOTO
MY
 The choice of surgical treatment does not
influence the post treatment fertily, but
prior history of infertility is associated with
a marked reduction in fertility after
treatment
 Making the choice: Chapron et al (1993)
have described a scoring system, based on
the patient's previous gynaecological
history and the appearance of the pelvic
organs, to deicde between salpingostomy /
salpingotomy and salpingectomy.
 SALPINGECTOMY Vs
SALPINGOSTOMY/SALPINGOTO
MY
Fertility reducing factor
Score
• Antecedent one Ectopic pregnancy
2
• Antecedent each further Ectopic pregnancy
1
• Antecedent adhesiolysis
1
• Antecedent Tubal micro surgery 2
• Solitary tube 2
• Antecedent Salpingitis
1
• Homolateral Adhesions
 SALPINGECTOMY Vs
SALPINGOSTOMY/SALPINGOTO
MY
 The rationale behind the scoring
system is to decide the risk of
recurrent ectopic pregnancy.
 Conservative surgery is indicated
with a score of less than 5, while
radical treatment is to be performed
if the score is 5 or more.
 LAPAROSCOPIC
SALPINGECTOMY
 It is carried out by laparoscopic
scissors and diathermy or Endo-loop.
 After passing a loop of No. 1 catgut
over the ectopic pregnancy, the
stitch is tightened and then the tubal
pregnancy is cut distal to the loop
stitch.
 The excised tissue is removed piece
meal or in a tissue removal bag.
 LAPAROSCOPIC
SALPINGOTOMY
 To reduce blood loss, first 10 – 40 IU of
Vasopressin diluted in 10 ml of normal
saline is injected into the mesosalpinx.
 Then the tube is opened through an
anitmesenteric longitudinal incision over
the tubal pregnancy by a
- Co2 laser (Paulson, 1992)
- Argon laser (Keckstein et al; 1992)
- Laparoscopic scissors snd ablating the
bleeding points with bipolar diathermy.
- Fine diathermy knife (Lundorff, 1992)
 LAPAROSCOPIC
SALPINGOTOMY
 The tubal pregnancy is then
evacuated by suction irrigation.
 Hemostasis of the trophoblastic

bed is ensured.
 The tubal incision is left open.
 PERSISTENT ECTOPIC
PREGNANCY (PEP)
 This is a complication of
salpingotomy / salpingostomy when
residual trophoblastic continues to
survive because of incomplete
evacuation of the ectopic pregnancy.
 Diagnosis is made because of a
raised postoperative serum β HCG
 If untreated, can cause life
threatening hemorrhage
 PERSISTENT ECTOPIC
PREGNANCY (PEP)
 TREATMENT is by:
- Reoperation and futher evacuation
/ Salpingectomy
- Administration of IM / oral
Methotrexate in a single dose of 50
mg/m2 of body surface
 SAM TREATMENT
 Aim: Trophoblastic destruction but avoiding
the systemic side effects
 Technique: Injection of trophotoxic substance
into the ectopic pregnancy sac or into the
affected tube by-
- laparoscopy or
- Ultrasonographically guided
• Transabdominal (Porreco, 1992)
• Transvaginal (Feichtinger et al, 1989)
- With Falloposcopic control (Kiss et al, 1993)
- Hysteroscopic control (Goldenberg et al, 1992)
- Hysterosalpingographic control (Risquez et al,
1990)
 SAM TREATMENT
 Trophotoxic substances used:
- Methotrexate (Pansky et al, 1989)
- Potassium Chloride (Robertson et al,
1987)
- Mifepristone (RU 486)
- PGF2α (Lindblom et al, 1987)
- Hyper osmolar glucose solution (Lang et
al, 1992)
- Actinomycin D
 MEDICAL TREATMENT WITH
METHOTREXATE
 Resolution of tubal preganancy by
systemic administration of Methotrexate
was first described by Tanaka et al (1982)
 Mostly used for early resolution of
placental tissure in abdominal pregnancy.
Can be used for tubal pregnancy as well
 Mechanism of action- Interferes with the
DNA synthesis by inhibiting the synthesus
to pyrimidines leading to trophoblasic cell
death. Auto enzymes and maternal
tissues then absorb the trophoblast.
 MEDICAL TREATMENT WITH
METHOTREXATE
 Ectopic pregnancy size should be <3.5 cm.
 Can be given IV/IM/Oral, usually along with
Folinic acid
 Recent concept is to give Methotrexate IM
in a single dose of 50mg/m2 without Folinic
acid. If serum HCG does not fall to 15%
within 4 – 7 days, then a second dose of
Methotrexate is given and resolution is
confirmed by HCG estimation
 MEDICAL TREATMENT WITH
METHOTREXATE
 Advantages:
- Minimal hospitalisation. Usually
outpatient treatment: Reduces cost.
- Quick recovery
- 90% success if cases are properly
selected
 Disadvantages:
- Side effects like GI & Skin
- monitoring is essential- Total blood
count, LFT & serum HCG once weekly till it
becomes negative
 EXPECTANT TREATMENT
 Tubal Pregnancies are known to Abort /
Resolve
 Before the advent of salpingectomy in
1884, ectopic pregnancies were being
treated expectanly with 70% mortality.
(Parry, 1876) Diagnosis made at PM!
 Today only selected cases are managed
expectantly: screened and identified by
high relolution ultrasound scanner and
monitored by serial serum β HCG assay
 EXPECTANT TREATMENT
 Identification criteria (Ylostalo et al,
1993):
- Falling level of serum β HCG at 2 day
intervals - No sign of intrauterine
pregnancy
- Diameter of ectopic pregnancy <4 cm
- No sign of rupture or of acute bleeding
by TVS
 If any deviation from the above criteria
 EXPECTANT TREATMENT
 Spontaneous resolution occurs in 72%,
while 28% will need laparoscopic
salpingostomy
 In spontaneous resolution, it may take 4 –
67 days (mean 20 days) for the serum
HCG to return to non pregnant level.
 The percentage fall in serum HCG by day 7
is a better indicator than the percentage
fall by day 2.
 Warning:- Tubal pregnancies have been
known to rupture when when serum HCG
levels are low.
 SUMMARY – KEY POINTS
 Incidence of ectopic pregnancy is rising while
maternal mortality from it is falling.
 Early diagnosis is the key to less invasive
treatment.
 The choice today is Laparoscopic treatment of
unruptured ectopic pregnancy.
 The trend is towards conservative treatment.
 Careful monitoring and proper councelling of
patients is mandatory.
 Ruptured ectopics should be unususal with
compliant patients and appropriate medical care.