1. Danforth’s Obstetrics and Gynecology Tenth edition
ECTOPIC PREGNANCY
Danforth’s Obstetrics and Gynecology
Tenth edition

2. Etiology and Risk Factors
Ectopic pregnancy, the implantation of a fertilized ovum outside of the endometrial cavity
a leading cause of life-threatening first-trimester morbidity
Incidence
Pathogenesis
Sites of implantation
Etiology and Risk Factors

3. Tubal Damage and Infection
Salpingitis Isthmica Nodosa
Diethylstilbestrol
Cigarette Smoking
Contraception:
IUD
Tubal ligation
OCP
Barrier contraception

5. Previous ectopic pregnancy 8.3 In utero exposure to DES 5.6 Use of IUD
Risk Factor
Odds Ratioa
High risk
Tubal surgery
21.0
Tubal ligation
9.3
Previous ectopic pregnancy
8.3
In utero exposure to DES
5.6
Use of IUD
4.2–45.0
Tubal pathology
3.8–21.0
Assisted reproduction
4.0
Moderate risk
Iinfertility
2.5–21.0
Previous genital infections
2.5–3.7
Multiple sexual partners
2.1
Salpingitis isthmica nodosa
1.5
Low risk
Previous pelvic infection
0.9–3.8
Cigarette smoking
2.3–2.5
Vaginal douching
1.1–3.1
First intercourse <18 y
1.6

6. Clinical Manifestations
Symptoms:
abdominal or pelvic pain
vaginal bleeding or spotting
a positive pregnancy test(mensturation delay)
Signs:
Abdominal tenderness
rebound tenderness
cervical motion tenderness
tender adnexal mass

7. Diagnosis: serial measurements of B-hCG ultrasonography
Ectopic pregnancy can be diagnosed as early as 4.5 weeks gestation
serial measurements of B-hCG
ultrasonography
uterine sampling via manual vacuum extraction or curettage
serum progesterone levels

8. Sonography Human Chorionic Gonadotropin ( B -hCG)
The B-hCG, produced by trophoblastic cells in normal pregnancy, has long been accepted to rise at least 66% and up to twofold every 2 days
Eight-five percent of abnormal pregnancies, whether intrauterine or ectopic, have impaired B-hCG production with an abnormal rate of B-hCG rise
Sonography
transvaginal ultrasonography reliably detects intrauterine gestations when the B-hCG levels are between 1,500 and 2,500 mIU/mL
Diagnosis of an ectopic pregnancy can be made with 100% sensitivity but with low specificity (15% to 20%) if an extrauterine gestational sac containing a yolk sac or embryo is identified
Some sonographic images, such as the pseudogestational sac, may mislead even an experienced examiner to falsely diagnose a gestational sac
Ultrasonography should be used to document the presence or absence of an intrauterine pregnancy when the B-hCG levels have risen above the designated discriminatory cutoff zone

10. Progesterone Uterine Evacuation
Although progesterone levels are higher in intrauterine pregnancies than in ectopic pregnancies, there is no established cutoff to use to discriminate between these two entities
a low progesterone level of less than 5 ng/mL can rule out a normal pregnancy with almost 100% accuracy but does not differentiate whether that pregnancy is an abnormal one in the uterus or at an ectopic site
Uterine Evacuation
necessary when a transvaginal ultrasonogram and a rising or plateauing B-hCG level below the cutoff value are not sufficient for diagnosis

12. Treatment for Ectopic Pregnancy
Medical Management:
Methotrexate therapy
The folic acid antagonist, methotrexate, inhibits de novo synthesis of purines and pyrimidines, interfering with DNA synthesis and cell multiplication
methotrexate directly impairs trophoblastic production of hCG with a secondary decrement of corpus luteum progestin secretion
1-unruptured ectopic pregnancy measuring less than or equal to 4 cm by ultrasonography
2-Hemodynamically stable
3-B-HCG<10,000
4-Exist of FHR
Methotrexate treatment regimens include:
the multiple dose, single dose,two-dose protocol

13. Methotrexate by Direct Injection
Side Effects
bone marrow suppression, hepatotoxicity, stomatitis, pulmonary fibrosis, alopecia, and photosensitivity
Fortunately, the side effects reported with methotrexate used to treat ectopic pregnancy have mostly been minor
Direct Injection of Cytotoxic Agents
Prostaglandins, hyperosmolar glucose, potassium chloride, and saline by direct injection have been tried as therapeutic alternatives to methotrexate

14. Surgical Treatment Ruptured Ectopic Pregnancy
laparotomy or laparoscopy with salpingectomy is the first choice for rupture
Stable Ectopic Pregnancy
If methotrexate is contraindicated, laparoscopic salpingostomy is the first surgical choice
Persistent Ectopic Pregnancy Following Salpingostomy:
drop of <50% from the preoperative level of B-HCG on postoperative day 1
prophylactic methotrexate administration is recommended

15. Ectopic Pregnancy and Assisted Reproductive Technology
Other methods
segmental excision followed by intraoperative or delayed microsurgical anastomosis
Manual fimbrial expression
Ectopic Pregnancy and Assisted Reproductive Technology
Incidence
Location
Tubal Pathology
Ovulation Induction

16. Rare Types of Ectopic Pregnancy
Abdominal Pregnancy
Incidence
Clinical manifestations
Diagnosis
treatment
Ovarian Pregnancy
Cornual Pregnancy
Cervical Pregnancy
Heterotopic Pregnancy

17. Summary Points
In most circumstances, ectopic pregnancy can be diagnosed before symptoms develop and treated definitively with few complications.
Quantitative B-hCG testing, ultrasonography, and curettage allow early diagnosis of ectopic pregnancy and use of medical therapy as the initial therapy option.
Conservative surgical therapy and medical therapy for ectopic pregnancy are comparable in terms of success rates and subsequent fertility. Medical therapy is the preferred choice because of the freedom from surgical complications and lower cost.
Surgery is the treatment of choice for hemorrhage, medical failures, neglected cases, and when medical therapy is contraindicated.
Multiple-dose methotrexate is preferable to single-dose methotrexate, direct injection, or tubal cannulation and is the first choice for unruptured, uncomplicated ectopic pregnancy.
Laparoscopic salpingostomy or salpingectomy is favored for cases of intra-abdominal hemorrhage, medical failure, neglected cases, and complex cases when medical therapy is contraindicated