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Ectopic Pregnancy

3 min read

References:

  1. Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (pp. 117-195)
  2. Lecturer (V)

An ectopic pregnancy is a condition where pregnancy develops outside of the uterine cavity: extrauterine pregnancy in which the blastocyst implants anywhere other than the endometrial lining of the uterine cavity. Nearly 95% of ectopic pregnancies implant in the fallopian tube most commonly as a mechanism of abnormal fallopian tube anatomy that alters normal embryo transport.

The two leading predisposing factors for an ectopic pregnancy is PID and IUD use. PID can affect the cervix, ovaries, and fallopian tubes. The IUD commonly only affects the fallopian tubes (e.g. salphingitis).

  • Scar formation post-infection/inflammation results in obstruction of embryo transport. Stuck at the ampulla or other parts of the fallopian tube, it may become an extrauterine pregnancy.
  • IUDs, most commonly the Copper-T variant, attracts sperm until they die. If displaced, sperm may enter the fallopian tube, but the formed zygote will not be able to exit. This results in an interstitial ectopic pregnancy

There are four main types of ectopic pregnancies based on the location of extrauterine implantation:

  1. Tubal Ectopic Pregnancy: the most common form. The fallopian tubes rupture by 10 to 12 weeks because of their thinness. There are further classifications of tubal implantation based on the segment of the fallopian tube:
    • Ampullary Implantation: the most common, but is comparatively safer as only the fallopian tube is damaged in case of rupture and in treatment.
    • Interstitial Implantation: the more dangerous form, as the interstitial segment is the narrowest portion and is directly connected to the uterus, crossing the perimetrium, myometrium, and the endometrium. The uterus is also partially damaged.
  2. Ovarian Ectopic Pregnancy
  3. Abdominal Ectopic Pregnancy: the most dangerous form of ectopic pregnancy because of the involvement of abdominal organs. Implantation occurring on organs may damage the organ.
  4. Cervical Ectopic Pregnancy: a rare variant, and is the safest. Management is through administration of methotrexate. A D&C is not viable as the cervix is friable— easily bleeds.

Signs of Rupture

  1. Kehr’s Sign is the earliest sign of rupture, a sudden sharp stabbing pain from the low abdomen radiating to the shoulder or neck.
  2. Cullen’s Sign is the following sign of rupture, a bluish discoloration of the periumbilical area indicating pooling of blood.
  3. Shock is a late sign, appearing from the loss of circulating blood volume. Signs include cool clammy skin, tachycardia, tachypnea, hypovolemia, hypotension, and hypothermia.

Diagnosis of Ectopic Pregnancies

Diagnosis starts with clinical signs. Ectopic pregnancy is considered in any reproductive-aged woman with pain, uterine bleeding, and/or anemia.

  1. Ultrasonography is the study of choice for ectopic pregnancy. The initial ultrasound for a pregnant woman confirms the pregnancy, locates the pregnancy, and locates the placenta.

Management

In an unruptured ectopic pregnancy and in cervical implantations, methotrexate may be used to induce the separation of the abortus. Otherwise, resection/removal of the abortus and its affected site is done, e.g., a salpingectomy, oophorectomy, etc.

Complications of an Ectopic Pregnancy

  1. Hemorrhage
  2. Infection
  3. Rh Sensitization: RhoGAM prevents isoimmunization and is given to an Rh-negative mother with an Rh-positive ectopic pregnancy with a negative Coombs test.

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