Ectopic pregnancy
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An ectopic pregnancy refers to the implantation of a fertilizedfertilised ovum outside of the uterine cavity.
Epidemiology
The overall incidence has increased over the last few decades and is currently thought to affect 1-2 % of pregnancies. There is an increased incidence in in-vitro fertilisation pregnancies (IVF).
Clinical presentation
Presentation is often with abdominal pain or bleeding. If unrecognised haemorrhage can be life threatening.
Pathology
Location of ectopics
-
tubal ectopic: 93-97%
- ampullary ectopic: most common ~70 % of tubal ectopics and ~ 65% of all ectopics
- isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics
- fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics
-
atypical ectopic pregnancies
- interstitial ectopic/cornual ectopic: 3-4%; also essentially a type of tubal ectopic
- ovarian ectopic: ovarian pregnancy; 0.5-1%
- cervical ectopic: cervical pregnancy; rare <1%
- scar ectopic: site of previous Caesarian section scar; rare
- abdominal ectopic: rare; ~1.4%
Markers
- serum beta HCG levels tend to increase at a slower rate
- serum progesterone levels can be not as elevated as for an intrauterine pregnancy 6; 5-25 ng/ml range although not absolute reference required
Radiographic features
It is essential to know a quantitative beta HCG prior to scanning as this will determine what you expect to see. At levels below 1000 IU a normal early pregnancy may well not be visible, and therefore should the scan prove negative, a repeat scan in a couple of days (along with a repeat beta HCG) is necessary (beta HCG should normally double approximately every 2two days).
Ultrasound
Positive findings in a beta HCG positive (over 1000 IU) patient include:
-
uterus
- empty uterine cavity
/ no/no evidence of intra-uterine pregnancy -
pseudogestational sac/decidual cyst
-: may be seen in~10- 20-20% of ectopic pregnancies - decidual cast
- empty uterine cavity
-
tube and ovary
- simple adnexal cyst: 10% chance of an ectopic
- complex adnexal cyst/mass: 95% chance of an tubal ectopic
-
tubal ring sign
- 95% chance of an tubal ectopic if seen
- described in 49% of ectopics and in 68% of unruptured ectopics 8
- ring of fire sign: can be seen on colour Doppler in a tubal ectopic
- live pregnancy: 100% specific, but only seen in a minority of cases
-
peritoneal cavity
- free pelvic fluid/haemoperitoneum in the pouch of Douglas
- the presence of free intra peritoneal fluid in the context of a positive beta HCG and empty uterus is
- ~70% specific for an ectopic pregnancy 4
- ~63% sensitive for an ectopic pregnancy 4
- the presence of free intra peritoneal fluid in the context of a positive beta HCG and empty uterus is
- live pregnancy: 100% specific, but only seen in a minority of cases.
- free pelvic fluid/haemoperitoneum in the pouch of Douglas
It is of utmost importance not to be reassured by the presence of a live intrauterine pregnancy, as this may delay the important diagnosis of a co-existing ectopic pregnancy (i.e. heterotopic pregnancy). This life-threatening condition for both mother and intrauterine child necessitates a high level of clinical suspicion, especially in cases of assisted reproduction (e.g. in-vitro fertilizationfertilisation) or former tubal surgery 9.
Complications
Complications somewhat depend on the type of ectopic. General complications for a typical (tubal) ectopic pregnancy include
-
tubal rupture
~15: 15-20%
Management
No single strategy can be employed as preferred management depends on the location of the ectopic. In general the options are:
- surgical: (in the case of tubal ectopics with open or laparoscopic salpingectomy or salpingotomy)
-
medical:
- methotrextate (a folate antagonist) either administered systemically or by direct ultrasound guided injection or potassium chloride (direct injection only obviously)
- usually considered if size small (e.g <4cm) and if no complication
- the gestational mass can paradoxically increase in size following methotrexate on subsequent scanning and does not necessarily imply failure of methotrexate therapy 3
- conservative or expectant management is being recognised as an option for those ectopics where rupture has not occurred (i.e. no haemoperitoneum ) and fetal demise has already taken place
Differential diagnosis
The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded with ultrasound. Other common diagnoses in this setting include:
In a clinically suspected ectopic pregnancy that is not confirmed on ultrasound, the differential is frequently that of a pregnancy of unknown location, with the alternative possibilities being of a very early pregnancy or a completed miscarriage.
-<p>An <strong>ectopic pregnancy</strong> refers to the implantation of a fertilized ovum outside of the uterine cavity. </p><h4>Epidemiology</h4><p>The overall incidence has increased over the last few decades and is currently thought to affect 1-2 % pregnancies. There is an increased incidence in in-vitro fertilisation pregnancies (IVF).</p><h4>Clinical presentation</h4><p>Presentation is often with abdominal pain or bleeding. If unrecognised haemorrhage can be life threatening.</p><h4>Pathology</h4><h5>Location of ectopics</h5><ul>- +<p>An <strong>ectopic pregnancy</strong> refers to the implantation of a fertilised ovum outside of the uterine cavity. </p><h4>Epidemiology</h4><p>The overall incidence has increased over the last few decades and is currently thought to affect 1-2 % of pregnancies. There is an increased incidence in in-vitro fertilisation pregnancies (IVF).</p><h4>Clinical presentation</h4><p>Presentation is often with abdominal pain or bleeding. If unrecognised haemorrhage can be life threatening.</p><h4>Pathology</h4><h5>Location of ectopics</h5><ul>
-<a href="/articles/interstitial_ectopic_pregnancy">interstitial ectopic</a> - <a href="/articles/interstitial_ectopic_pregnancy">cornual ectopic</a>: 3-4%; also essentially a type of tubal ectopic</li>- +<a href="/articles/interstitial-ectopic-pregnancy">interstitial ectopic</a>/<a href="/articles/interstitial-ectopic-pregnancy">cornual ectopic</a>: 3-4%; also essentially a type of tubal ectopic</li>
-<li>serum <strong>progesterone</strong> levels can be not as elevated as for an intrauterine pregnancy <sup>6</sup>; 5-25 ng/ml range although not absolute <sup>reference required</sup>- +<li>serum progesterone levels can be not as elevated as for an intrauterine pregnancy <sup>6</sup>; 5-25 ng/ml range although not absolute <sup>reference required</sup>
-</ul><h4>Radiographic features</h4><p>It is essential to know a quantitative <a href="/articles/beta-hcg">beta HCG</a> prior to scanning as this will determine what you expect to see. At levels below 1000 IU a normal <a href="/articles/early_pregnancy">early pregnancy</a> may well not be visible, and therefore should the scan prove negative, a repeat scan in a couple of days (along with a repeat beta HCG) is necessary (beta HCG should normally double approximately every 2 days).</p><h5>Ultrasound</h5><p>Positive findings in a beta HCG positive (over 1000 IU) patient include:</p><ul>- +</ul><h4>Radiographic features</h4><p>It is essential to know a quantitative <a href="/articles/beta-hcg">beta HCG</a> prior to scanning as this will determine what you expect to see. At levels below 1000 IU a normal <a href="/articles/early-pregnancy">early pregnancy</a> may well not be visible, and therefore should the scan prove negative, a repeat scan in a couple of days (along with a repeat beta HCG) is necessary (beta HCG should normally double approximately every two days).</p><h5>Ultrasound</h5><p>Positive findings in a beta HCG positive (over 1000 IU) patient include:</p><ul>
-<li>empty uterine cavity / no evidence of intra-uterine pregnancy</li>- +<li>empty uterine cavity/no evidence of intra-uterine pregnancy</li>
-<a href="/articles/pseudo-gestational-sac">pseudogestational sac</a> / <a href="/articles/decidual-cyst">decidual cyst</a> - may be seen in ~ 10 - 20 of ectopic pregnancies</li>- +<a href="/articles/pseudo-gestational-sac">pseudogestational sac</a>/<a href="/articles/decidual-cyst">decidual cyst</a>: may be seen in 10-20% of ectopic pregnancies</li>
-<a href="/articles/tubal_ring_sign">tubal ring sign</a><ul>- +<a href="/articles/tubal-ring-sign">tubal ring sign</a><ul>
-</ul><p>It is of utmost importance <strong>not to be reassured by the presence of a live intrauterine pregnancy</strong>, as this may delay the important diagnosis of a co-existing ectopic pregnancy (i.e. <a href="/articles/heterotopic-pregnancy">heterotopic pregnancy</a>). This life-threatening condition for both mother and intrauterine child necessitates a high level of clinical suspicion, especially in cases of assisted reproduction (e.g. in-vitro fertilization) or former tubal surgery <sup>9</sup>. </p><h4>Complications</h4><p>Complications somewhat depend on the type of ectopic. General complications for a typical (tubal) ectopic pregnancy include</p><ul><li>-<a href="/articles/tubal-rupture">tubal rupture </a> ~15-20% </li></ul><h4>Management</h4><p>No single strategy can be employed as preferred management depends on the location of the ectopic. In general the options are:</p><ul>-<li>-<strong>surgical</strong>: (in the case of <a href="/articles/tubal-ectopic-pregnancy">tubal ectopics</a> with open or laparoscopic <a href="/articles/salpingectomy">salpingectomy</a> or <a href="/articles/salpingotomy">salpingotomy</a>)</li>-<li>-<strong>medical</strong>: <ul>- +</ul><p>It is of utmost importance not to be reassured by the presence of a live intrauterine pregnancy, as this may delay the important diagnosis of a co-existing ectopic pregnancy (i.e. <a href="/articles/heterotopic-pregnancy">heterotopic pregnancy</a>). This life-threatening condition for both mother and intrauterine child necessitates a high level of clinical suspicion, especially in cases of assisted reproduction (e.g. in-vitro fertilisation) or former tubal surgery <sup>9</sup>. </p><h4>Complications</h4><p>Complications somewhat depend on the type of ectopic. General complications for a typical (tubal) ectopic pregnancy include</p><ul><li>
- +<a href="/articles/tubal-rupture">tubal rupture</a>: 15-20% </li></ul><h4>Management</h4><p>No single strategy can be employed as preferred management depends on the location of the ectopic. In general the options are:</p><ul>
- +<li>surgical: (in the case of <a href="/articles/tubal-ectopic-pregnancy">tubal ectopics</a> with open or laparoscopic <a href="/articles/salpingectomy">salpingectomy</a> or <a href="/articles/salpingotomy">salpingotomy</a>)</li>
- +<li>medical: <ul>
-<li>the gestational mass can paradoxically increase in size following methotrexate on subsequent scanning and <strong>does not</strong> necessarily imply failure of methotrexate therapy <sup>3</sup>- +<li>the gestational mass can paradoxically increase in size following methotrexate on subsequent scanning and does not necessarily imply failure of methotrexate therapy <sup>3</sup>
-<li>-<strong>conservative or expectant management</strong> is being recognised as an option for those ectopics where rupture has not occurred (i.e. no <a href="/articles/haemoperitoneum">haemoperitoneum</a> ) and fetal demise has already taken place</li>-</ul><h4>Differential diagnosis</h4><p>The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded with ultrasound. Other common diagnoses in this setting include</p><ul>- +<li>conservative or expectant management is being recognised as an option for those ectopics where rupture has not occurred (i.e. no <a href="/articles/haemoperitoneum">haemoperitoneum</a> ) and fetal demise has already taken place</li>
- +</ul><h4>Differential diagnosis</h4><p>The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded with ultrasound. Other common diagnoses in this setting include:</p><ul>
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