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Definition and Site of Implantation

An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity.



Cause of fetal death in ectopic pregnancy:


- Vascular accident

Risk factors for ectopic pregnancy:


High risk

  1. Tubal corrective surgery                    - 4%
  2. Tubal sterilization                              - 9%
  3. Previous ectopic pregnancy                - 10-15%
  4. Artificial reproductive technology        - 5-7%
  5. Pelvic inflammatory disease (PID)
  6. - After one episode of PID                  - 13%
  7. - After two episode of PID                  - 35%
  8. - After three episode of PID                - 75%
  9. Documented tubal pathology              - 3.8 – 21%

Moderate risk


Infertility - 2.5-3%


Contraception failure


- IUD- it prevents intrauterine pregnancy effectively, tubal implantation to a lesser extent and ovarian pregnancy not a at all. There is relative increase in tubal pregnancy (7 times more) with IUD in situ. CuT 380A and levonorgestrel devices have got the lowest rate of ectopic and Progestasert has highest one.

- Sterilization operation - 15-50-%

- POP – Increase risk


Previous genital infection - 2-4%


Multiple partners - 1.6-3.5%

Slight risk


Previous pelvic or abdominal surgery - 1-2.1%


Smoking - 1.7-4%

Extra Edge:

  1. Most common cause of ectopic pregnancy is PID
  2. Maximum ectopic pregnancy is after tubal damage either due to previous ectopic pregnancy or tubal surgery.
  3. POP have slight increase rate because they decrease tuber mortality.
  4. Use of ART has a 0.8% incidence of ectopic per transfer and 2.2% per clinical pregnancy.
    GIFT 3.7%, cryopreserve embryo 3.2%, IVF 2.2%.

Important Facts

  1. Rates of tubal pregnancy are increased following gamete intrafallopian transfer (GIFT) and in vitro fertilization (IVF). Moreover, "atypical" implantations such as cornual, abdominal, cervical, ovarian, and heterotypic (concomitant uterine and extra-uterine pregnancy) are more common following assisted reproductive procedures. Risk of ectopic is 5-7% and that of heterotypic pregnancy is 1% in contrast to 1 in 5000 in spontaneous pregnancy.
  2. With any form of contraceptive, the absolute number of ectopic pregnancies is decreased because pregnancy occurs less often. In contraceptive failure, however, the relative number of ectopic pregnancies is increased.
  3. Examples include tubal sterilization, intra-uterine devices, and progestin-only mini pills.
  4. The modem copper IUD does not increase the risk of ectopic pregnancy. However, there is a relative increase in tubal pregnancy (7 times more) should pregnancy occur with IUCD in situ. Only Progestasert has a rate of ectopic pregnancy higher than that for women not using any form of contraception.
  5. There is 15-50% chance of ectopic pregnancy if pregnancy occurs after tubal ligation. The risk is highest with bipolar coagulation.
  6. A patient with a previous ectopic pregnancy has a 10-25% chance of a future tubal pregnancy.
  7. If an early conceptus is expelled essentially undamaged into the peritoneal cavity, it may reimplant almost anywhere, establish adequate circulation, survive, and grow. This however, occurs rarely. Most small coneptuses are resorbed. Occasionally, if larger, they may remain in the cul-de-sac for years as an encapsulated mass or even become calcified to form a lithopedion.
  8. Implantation within the tubal segment that penetrates the uterine wall results in an interstitial pregnancy.
  9. These account for about 3% of all tubal gestations. Rupture may not occur until up to 16 weeks.
  10. Ampullary pregnancy generally ruptures at 8-12 weeks and isthmic at 6 -8 weeks.
  11. Infundibulum part of tube mostly resulting tubal abortion.
  12. TVS is the most useful investigation in cases of suspected ectopic pregnancy.
  13. The most frequently experienced symptoms of ectopic pregnancy are pelvic and abdominal pain (95%) an amenorrhea with some degree of vaginal spotting or bleeding (60-80%).
  14. When the β-hCG is positive but the uterus is empty on USC, the possibilities are:
    1. Very early intra-uterine pregnancy (sine the β-hCG is positive as early as day 22 of the cycle but the gestational sac within the uterus is seen earliest at 4 weeks 5 days on TVS)
    2. Ectopic pregnancy
    3. Complete abortion

In such situations the next best step to be done is to repeat β-hCG after 48 h. If the β-HCG decreases then the diagnosis is abortion. If it increases by 66% or more, it suggests a viable intra-uterine pregnancy and less than 66% increase suggests ectopic pregnancy.

Kadar and Romero demonstrated that in women with normal pregnancies, mean doubling time for β-hCG in "serum was approximately 48 h and the lowest normal value for this increase was 66%.

Lower normal limits for percentage increase of serum β-hCG during early uterine pregnancy:


Sampling Interval (Days)

Increase from Initial Value (%)









Serum progesterone levels: A single progesterone measurement can be used to establish that there is a normally developing pregnancy with high reliability. A value exceeding 25 ng/mL excludes ectopic pregnancy with 97.5% sensitivity.

Values below 5 ng/mL occur in only 0.3% of normal pregnancies. Thus, such low values suggest either an intra- uterine pregnancy with a dead fetus or an ectopic pregnancy.

Ring of fire appearance (on color Doppler) of an adnexal mass suggests ectopic pregnancy.



Diagnostic modality

Important features


Urinary hCG or Gravindex

• Positive in 50 % cases of ectopic


Not specific

Serum βhCG Measurement

• Abnormally low level of 13 hCG for

gestational age

• Rise in 13 hCG < 66% in 48 hours

• Inappropriately rising or static serum beta hCG levels only indicate dying pregnancy not its location.

• False positive hCG results are obtained in presence of phantom hCG - which are Heterophile antibodies or proteolytic enzymes.

Serum progesterone

• Levels are lower in ectopic pregnancy than in viable pregnancy

• Levels> 20 ng = normal I/U pregnancy

• Levels < 5ng = abnormal pregnancy be it intrauterine or ectopic

• 50% of ectopic pregnancies 20% mis-carriages & 70% of viable I/U pregnancies are associated with progesterone evels between 5-20ng.

Sonography (TVS/TAS)

• Specific: fetal pole 1 cardiac activity / yolk sac seen outside the uterus in tubal ring (Bagel sign)

• Nonspecific: absence of intrauterine gestational sac, complex adnexal mass, fluid in pouch of douglas.

• Gestational sac 1 fetal heart outside the uterus is seen in only 5 - 15% cases

• USG findings alone may resemble that of PID & endometriosis but still

• Transvaginal USG is the logical first step for diagnosing ectopic pregnancy

Doppler sonography combination of βhCG & sonography

• Ring of fire pattern (placenta) & blood flow pattern outside uterus

• β HCG levels above the discriminatory zone & no intrauterine gestational sac visualized.

• Rise in β HCG < 66% in 48 hours

• Viable I/U pregnancies can be visualized by TVS at β HCG = 1000-2000 mlU/ml & by TAS for serum HCG levels higher than 1500 mlU/ml (Discriminatory zone).

• Inability to detect an I/U gestation with hCG levels >1500 mlU/ml means an abnormal (failed I/U or ectopic) pregnancy

• I/U sacs seen at HCG levels below discriminatory zone are abnormal and represent either failed intrauterine pregnancies or the pseudogestational sacs of ectopic pregnancy.


• Reserved for emergency situation when USG is not possible

• Positive culdocentesis means hemoperitoneum

• Positive result indicates emoperitoneum not ectopic pregnancy); negative result does not rule out ectopic.


• Direct visualization of pelvis specially the tube

• Also identifies endometriosis, adhesions

• "Gold standard" for identification of ectopic preg.

• Feasible in hemodynamically stable patient.

Therapeutic management can also be done at the same time.

Management of Ectopic pregnancy:


Treatment modalities available with their indications

Expectant management

Medical management

Surgical management

Only observation is done in hope of spontaneous resolution.


• Decreasing serial β HCG titres

• Tubal pregnancies only

• No evidence of intra- abdominal bleeding or rupture assessed by vaginal sonography

• Diameter of the ectopic mass <3.5 cms

Additional criteria:

• Baseline HCG < 1000lU/L & falling for best results.

• According to ACOG 88% of ectopic, pregnancies will resolve if P hCG is < 200 mlU/L

• Using methotrexate

• Criteria

Absolute requirements

• Hemodynamic stability

• No evidence of acute intra- abdominal bleeding

• Reliable commitment to comply with required

• follow-up care

• No contraindications to treatment.

Preferable requirements

• Absent or mild pain

• Serum beta HCG level less than 10,000 lU/L (best results seen with HCG < 2000 lU/L)

• Absent embryonic heart activity

• Ectopic gestational mass less than 4cms in diameter.

• It is done in all those patients who do not fulfill the criteria laid down for medical management

• It should be done in all cases of

ruptured ectopic

Surgical management:

- Laparoscopy indicated in hemodynamically stable patients

- Laparotomy indications

- Patient is hemodynamically unstable pregnancy

- Ruptured ectopic pregnancy

- Extensive abdominal & pelvic

- adhesion making laparoscopy

- difficult

- Cornual pregnancy / interstitial

- pregnancy Abdominal I ovarian

- pregnancy.

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