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Ultrasound diagnosis of an ectopic pregnancy remains a challenge, and a systematic and thorough evaluation of the pelvis is imperative.
In the adnexa, the pathognomonic finding in an ectopic gestation is that of the embryo with or without fetal heart action.
In up to 25% of patients with ectopic pregnancy, TVS may be normal but the possibility of a non-tubal gestation (cornual, cervical or ovarian), although rare, should be considered.
Heterotopic pregnancy is the presence of a combined intrauterine and extrauterine pregnancy that occurs in ?1% of pregnancies resulting from in vitro fertilisation. Eating healthily during pregnancy will help your baby to develop and grow, and will keep you fit and well.
You don’t need to go on a special diet, but it's important to eat a variety of different foods every day in order to get the right balance of nutrients that you and your baby need.
Even if you have a multiple pregnancy with twins or triplets, it's the quality of food that's important, not the amount. Sandwiches or pitta bread filled with grated cheese, lean ham, mashed tuna, salmon or sardines and salad. Wash fruit, vegetables and salads to remove all traces of soil, which may contain toxoplasma, a parasite that can cause toxoplasmosis. Make sure that raw foods are stored separately from ready-to-eat foods, otherwise there's a risk of contamination.
Locally Healthy, Digital Life Sciences, Waterloo House, 20 Waterloo Street, Birmingham B2 5TBImportant NoticeThe information provided on this website including medical information, is for use as information or for educational purposes only and is not a substitute for professional medical care by a qualified doctor or other qualified healthcare professionals. Lawson Tait,1 the father of gynecologic surgery, reported the first successful operation for ectopic pregnancy in 1883. 3Westrom L, Bengtsson LPH, Mardh PA: Incidence trends, and risks of ectopic pregnancy in a population of women. 4Chung CS, Smith RG, Steinhoff PG et al: Induced abortion and ectopic pregnancy in subsequent pregnancies. 8Vessey MP, Johnson B, Doll R et al: Outcome of pregnancy in women using an intrauterine device. 9Tatum JH, Schmidt FM, Jain AK: Management and outcome of pregnancies associated with the copper T intrauterine contraceptive device. 20Lawson HW, Atrash HK, Saftlas AF et al: Ectopic pregnancy surveillance, United States 1970 - 1985. 28Gemzell G, Guillome J, Wang CF: Ectopic pregnancy following treatment with human gonadotropins. 29McBain JC, Evans JH, Pepperell RJ et al: An unexpectedly high rate of ectopic pregnancy following the induction of ovulation with human pituitary and chorionic gonadotrophin.
31Korenga M, Kadota T: Changes in mechanical properties of the circular muscle of the isthmus of the human fallopian tube in relation to hormonal domination and post-ovulatory time.
32Laufer N, Tarlatzis BC, DeCherney AH et al: Steroid secretion by human oocyte-corona-cumulus complexes associated with conceptions following in vitro fertilization. 34Steptoe PC, Edwards RG: Reimplantation of the human embryo with subsequent tubal pregnancy. 35Correy JF, Watkins RA, Bradfield GF et al: Spontaneous pregnancies and pregnancies as a result of treatment on an in vitro fertilization program terminating in ectopic pregnancies or spontaneous abortions. 36Olive DL, Taylor N, Cothran GE et al: Gamete intrafallopian transfer (GIFT) complicated by bilateral ectopic pregnancy. 42Reyftmann L, Vernhet H, Boulot P: Management of massive uterine bleeding in a cesarean scar pregnancy. 46Groycol Ruffolo EH: Ovarian pregnancy associated with intrauterine contraceptive devices. 48Budowick M, Johnson TR Jr, Genadry R et al: The histopathology of the developing tubal ectopic pregnancy. 51Romero R, Copel JA, Kadar N et al: Value of culdocentesis in the diagnosis of ectopic pregnancy. 54Romero R, Kadar N, Copel JA et al: The value of serial human chorionic gonadotropin testing as a diagnostic tool in ectopic pregnancy. 55Kadar N, Taylor KW Jr, Rosenfield A et al: The sonographic appearance of the uterus in ectopic pregnancy. It is widely accepted that the incidence is increasing worldwide and is linked to an elevated incidence of pelvic infection.
However, the advent and wide application of ultrasound now plays a vital role in early non-surgical diagnosis.
The endometrial appearance of an early intrauterine pregnancy consists of the ‘double ring' sign whereas in ectopic gestation, appearances are variable. Another sonographic appearance is that of a well-defined ‘tubal ring' consisting of an echogenic rim and a hypoechoic centre or a poorly defined tubal ring. It is almost impossible to differentiate sonographically hypoechoic unclotted blood from serous peritoneal fluid. Cornual ectopics are characteristically eccentric to the endometrium and close to the serosal surface of the uterus. It is very difficult to diagnose ultrasonically and maintaining a high level of suspicion following assisted conception may aid in prompt detection. Early detection not only reduces mortality and morbidity rates but also allows minimally invasive management techniques with reduced hospital stay and recovery time.
Eat plenty of fruit and vegetables because these provide vitamins and minerals, as well as fibre, which helps digestion and prevents constipation. Dairy foods, such as milk, cheese, fromage frais and yoghurt, are important because they contain calcium and other nutrients that your baby needs. This includes all spreading fats, oils, salad dressings, cream, chocolate, crisps, biscuits, pastries, icecream, cake, puddings and fizzy drinks. This is to avoid other types of food poisoning from meat (salmonella, campylobacter and E.coli 0157).
We do not warrant that any information included within this website will meet your health or medical requirements.
His main difficulty lay in establishing the diagnosis.Until a little more than decade ago, little change had occurred in the diagnosis and management of ectopic pregnancy. In DeCherney AH, Polan ML (eds): Seminars in Reproductive Endocrinology, Vol 2, pp 175 - 185. Although maternal mortality from ectopic pregnancy is decreasing, 14 deaths resulted in the UK between 2003 and 2005. Transabdominal ultrasound scan (TAS) can exclude an intrauterine pregnancy in women with elevated human chorionic gonadotrophin (hCG) levels but where an ectopic gestation is suspected, images obtained by the higher frequency transvaginal ultrasound scan (TVS) offer better resolution and earlier diagnosis. The endometrium may appear thickened or a centrally-located ‘pseudosac' may be seen, consisting of both a thickened endometrium surrounding a fluid filled cavity and a homogenous uterine texture. Fluid or blood in the Pouch of Douglas may be a feature of a tubal pregnancy that is aborting or that has ruptured. Nevertheless, the coexistence of an adnexal mass separate from the ovary and fluid in the Pouch of Douglas is highly suggestive of an ectopic pregnancy. Cervical ectopics may be confused with inclusion cysts but typically have a thick choriodecidual periphery and a hypoechoic centre.
TVS in the hands of the managing clinician is a vital diagnostic tool provided satisfactory levels of competence have been attained, hence prior ultrasound training is critical to the successful diagnosis.
Cook vegetables lightly in a little water, or eat them raw but well washed, to get the benefit of the nutrients they contain. Choose lean meat, remove the skin from poultry (such as chicken and turkey), and cook it using only a little fat. The clinical use of sensitive pregnancy testing, transvaginal ultrasonography, and diagnostic laparoscopy has had a major impact on the preoperative diagnosis of this condition.
Factors implicated in the increased incidence of ectopic gestation include widespread use of intrauterine devices (IUDs), higher prevalence of pelvic inflammatory disease (PID), complications of infections, including therapeutic abortions, the wide clinical use of reconstructive tubal surgery, exposure to diethylstilbestrol, and the conservative surgical treatment of ectopic pregnancy itself (Table 1).3, 4, 5, 6 A critical review of the relative contributions of these factors is pertinent. Ovarian ectopics are rare and may present as masses of mixed echogenecity within the ovary. Try to eat two portions of fish a week, one of which should be oily fish such as sardines or mackerel.


The rate of ectopic rupture has declined, and the option of conservative surgical management of an unruptured fallopian tube is now a viable alternative.
It is widely accepted that when pregnancy occurs in a woman using an IUD, there is an increased likelihood of an ectopic pregnancy. If you eat a lot of fish, choose a variety of different kinds to make sure that your diet is balanced. This chapter briefly reviews the epidemiology of the disease and then focuses on the new diagnostic modalities, options, and therapeutic operations. Indeed, the ratio of ectopic pregnancy to intrauterine pregnancy has been reported to have increased sevenfold.7, 8Table 1. When accidental pregnancy occurs in a woman using an IUD, there is an increased likelihood that the pregnancy will be an ectopic one.PID is considered a major etiologic factor in ectopic pregnancy.
Because the incidence of PID has risen dramatically over the past two decades, it has been suggested that part of the increased incidence of ectopic gestation can be attributed to this disease. An extrauterine gestation is 50 times more likely to result in a maternal death than a first-trimester abortion and 10 times more likely than delivery in the third trimester.21A study of the clinical aspects of ectopic pregnancy mortality in the United States has shown that the most frequent direct causes of death are hemorrhage, infection, and anesthetic complications. In 50% of women, the condition was misdiagnosed or confused with other pathology such as gastrointestinal disorders, intrauterine pregnancies, spontaneous abortions, PID, sequelae of induced abortion, and psychiatric disorders. In 70% of cases, patients had either called or visited a physician within 1 week of development of symptoms. Diagnostic delay could be ascribed to physician delay in 53% of cases and to combined patient and physician delay in 8% of cases. In 5% of cases, the physician made the diagnosis but did not act promptly enough to prevent maternal death.
The four main possibilities are an anatomic obstruction to the passage of the zygote, an abnormal conceptus, abnormalities in the mechanisms responsible for tubal motility, and transperitoneal migration of the zygote.Anatomic distortion and obstruction of the fallopian tube are widely believed to be responsible for most ectopic implantations.
Obstruction could result from PID, salpingitis isthmica nodosa,5 tubal endometriosis, or postsurgical fibrosis.23 Scarring of the endosalpinx could lead to diverticuli formation, in which the zygote could be trapped, or to simple obstruction of the tubal passage.
Functional causes could include a defective conceptus, abnormalities in the motility of the fallopian tube, or transperitoneal migration.An abnormal conceptus could theoretically result in defective migration of premature implantation in an ectopic site. This possibility has been investigated by examining the chromosomal constitution of ectopic gestations.
Elias and co-workers26 found that the incidence of chromosomal abnormalities in ectopic pregnancies is no different from that in intrauterine pregnancies.
The bias with this type of study, however, is that a significant proportion of ectopic pregnancies cannot be adequately karyotyped because of the nonviability of their cells in culture. Similarly, Fedele and colleagues,27 in a case-control study, reported the risk of ectopic pregnancy (after adjustment for maternal age and parity) to be fourfold greater in women with a history of recurrent spontaneous abortion.Tubal motility seems to be influenced by the hormonal milieu. The suspicion that some cases of ectopic pregnancy may be due to endocrine abnormalities stems from clinical observations that have suggested an association in patients using a progesterone-only pill, an IUD,13, 15, 16 or human menopausal gonadotropins for ovulation induction.28, 29 It has been suggested that high estrogen levels noted in cases of hyperstimulation with human menopausal gonadotropins interfere with tubal transport.
An alternative explanation is that an increased number of eggs are released (superovulation) in hyperstimulated patients, resulting in an increased risk of ectopic implantation. Abnormal progesterone levels in the luteal phase of the cycle could theoretically lead to impaired motility. Laufer and associates32 have shown differences in the secretions of the cumulus cell mass surrounding the ovum in cleaved versus noncleaved eggs (Fig. It has been suggested that this inadvertent injection or migration of embryos into the fallopian tubes occurs more often than realized. Chicago, Year Book Medical Publishers, 1986)Cervical pregnancy is a rare cause of mortality today.41 Causes include an endometrial lining that may be unreceptive to implantation (as with infection), uterine fibroids, an atrophic endometrium, a septate uterus, current IUD use, endometrial scarring, and use of oral contraceptives. The ampullary portion of the fallopian tube is made up of lining epithelium, loose connective tissue, and an ill-defined muscularis and serosa. Therefore, ectopic pregnancies in this area rapidly erode through the tubal epithelium into this loose adventitious area surrounding the lumen; propagation then occurs in the space between the serosa and the tubal lumen, rendering the lining of the tube only partially damaged.
This phenomenon was first described by Budowick and co-workers.48 The zygote also usually spends a very brief time in the isthmic portion of the tube. This portion has a very well-defined and functional muscularis, and its primary function is to squeeze the zygote into the waiting endometrial cavity. This compact muscularis causes the embryo to grow within the lumen of the tube, because this is the path of least resistance. The growth of the ectopic pregnancy in this portion of the tube destroys the surrounding luminal epithelium. Also reported as the second most common sign was adnexal tenderness, occurring in 85–95% of patients. These are rare occurrences and are more a curiosity than a helpful adjunct in diagnosing an ectopic pregnancy.
Physical findings, although helpful, are inconsistent other than in the case of hemorrhagic shock, and a pelvic mass is palpable in only approximately 50% of cases.50 This leads to a need for more objective criteria. Under these circumstances, culdocentesis is an inexpensive, rapid, and easily performed means of patient evaluation that often provides the impetus for immediate intervention.The results of a culdocentesis can be classified as negative, positive, or nondiagnostic.
In our series, 86% of all positive culdocenteses performed in the emergency room were associated with an ectopic pregnancy.51 Other causes of positive culdocentesis included ruptured ovarian cysts, retrograde menstruation, endometriosis, torsion of the fallopian tube, and bleeding of unknown etiology.
It should be emphasized that a nondiagnostic culdocentesis should not lower the suspicion of an ectopic pregnancy.
However, we prefer to use the sensitive blood pregnancy testing in the form of a radioimmunoassay against β-hCG.
Unfortunately, this is a rare and late finding, and awaiting its appearance would delay the diagnosis and conceivably increase the risk of tubal rupture.
In practice, ultrasonography is used to identify an intrauterine pregnancy, which would render the simultaneous presence of an ectopic pregnancy extremely unlikely (1:30,000). Confirmation of the presence of an intrauterine pregnancy can be made by identifying either a gestational sac or a fetal pole within the endometrial cavity.Ultrasonographically, ectopic pregnancies can show a single-ring sac due to the presence of blood within the endometrial cavity in association with a significant decidual reaction. There is a double ring given by the separation of the decidual capsularis and the decidual parietalis.
There is a single ring.Nyberg and colleagues64 and Bradley and associates65 have proposed morphologic criteria to distinguish the pseudogestational sac of ectopic pregnancy from the gestational sac of a normal intrauterine pregnancy. They have described the normal intrauterine gestational sac as having a double contour produced by the decidua capsularis and the decidua parietalis. When levels are higher than this, the absence of a sac is associated with an ectopic pregnancy in 86% of cases. Additionally, management can be based upon ultrasonographic findings of the adnexa and clinical suspicion.
Proximity of the ultrasound transducer to both the adnexa and the cul-de-sac allows increased resolution and image quality with the detection of an intrauterine pregnancy up to 7 days earlier than with the classic transabdominal approach (Fig.
The increased sensitivity of transvaginal (right) versus transabdominal (left) ultrasonography in detecting an ectopic pregnancy. Unfortunately, using this proposed criterion and similar ultrasonographic equipment, Fossum and associates71 may have inadvertently surgically investigated several pregnancies that proved to be normal intrauterine gestations (Fig. Reprinted with permission of the publisher, The American Fertility Society)If ultrasonography is indeterminant, the value of serial hCG determinations cannot be overemphasized. However, this data was based upon a study of 20 patients in 1980 using an 85% confidence interval.72 More recent data indicate the potential for a slower rate of rise in viable intrauterine gestations.
Approximately 30% of patients with abnormally rising quantitative hCG values will have an abnormal intrauterine pregnancy. The presence or absence of a gestational sac above these hCG levels should be supportive either of an ectopic or an intrauterine gestation.
The fact that clinical assessment and evaluation of the contralateral tube during the initial surgery correlates poorly with postoperative hysterosalpingographic findings underscores the importance of intraoperative conservative management whenever feasible.81 It is not recommended that a test of tubal patency be done during the operation for an ectopic pregnancy in order to evaluate the status of the contralateral tube. The information provided can be erroneous because decidual reaction around the cornual portion might give a false impression of an occluded tube.
Pouly and associates85 reported on 321 women with ectopic pregnancies who underwent conservative laparoscopic treatment. Of the women who did not have a history of infertility or a previous ectopic pregnancy, 86% had a subsequent intrauterine pregnancy.The advantages of laparoscopic removal of an ectopic pregnancy are a shortened operating time, convalescence, and hospital stay.
It is imperative, however, that proper case selection be exercised.86 If laparoscopic therapy is to be warranted, the first criterion is the expertise of the operator in performance of a laparoscopic surgical procedure.


One of the complications of conservative surgery via laparoscopy, persistent ectopic pregnancy, appears to be higher with laparoscopy (5–20% vs.
The theory behind this is that all ovulations would be into the good tube; this discounts the importance of transmigration.
The incision for a salpingostomy is made on the antimesenteric border of the tube over the area of maximal bulge; as small an incision as possible is made, but a surgeon must make sure that the products of conception are removed entirely. There seems to be no quantitative difference between use of a laser, scalpel, or electrocautery to make the incision. Preincisional serosal surface injection of vasopressive agents often reduces incisional bleeding, but may distort the area of maximal tubal bulge. If bleeding continues, vessels in the broad ligament can be ligated with fine suture material (4-0), but remember that this ligation devascularizes the tube and may cause some ischemia in the tube that may lead to decreased reproductive function and adhesion formation.90 Fig. Expulsion of products of conception after the incision is made.The controversy surrounding salpingectomy versus salpingostomy was based on two assumptions. Those in support of salpingectomy feared (1) that patients undergoing salpingostomy would be more likely to have a repeat ectopic pregnancy, and (2) that salpingostomy is a tedious surgical procedure because tubal hemorrhage during surgery is difficult to control. Reproduced with permission of the publisher, The American Fertility Society) There are no substantial data to support the role of cornual resection in conjunction with a salpingectomy.
A review of the literature by Kalchman and Meltzer98 demonstrated only 75 cases of interstitial pregnancy following a salpingectomy, leading to the conclusion that this is a rare occurrence and should not dictate surgical technique. Hallatt has suggested that the procedure has some inherent risks secondary to increased bleeding at the time of the original surgery and the possibility of a rupture in the course of a subsequent intrauterine pregnancy.89 Uterotubal fistula formation after this procedure is also a possibility. Therefore, for aesthetic reasons, only a small, shallow cornual resection should be performed.Salpingostomy versus Salpingotomy The primary difference between a salpingostomy and a salpingotomy is that, in the latter, the fallopian tube is closed by primary intention.
This procedure involves an antimesenteric incision over the ectopic pregnancy, excising the products of conception and closing the tube in either one or two layers with fine suture material after hemostasis is achieved. Seven of the eight were done for gonorrheal salpingitis and one for tuberculous salpingitis. At 4 weeks, the gaping incision was beginning to be bridged by fibrous tissue, and at 8 weeks the organs appeared totally healed, with “fusion of the tunica propria as well as a conjunction of the circular muscle layer. Disappearance curve of hCG in patients treated by salpingectomy versus conservative surgical treatment for ectopic pregnancy.
This similarity demonstrates the clearance of the hormone rather than the persistence of viable trophoblastic tissue. A recent histopathologic comparison of ampullary and isthmic ectopic pregnancies noted preservation of the ampullary muscularis in 85% of the former cases and only a 43% preservation rate of the muscularis in isthmic pregnancies.
The disruption of the tubal wall was also more extensive in isthmic pregnancies.107 This is why patients with isthmic ectopic pregnancies are believed to be the only ectopic pregnancy patients who develop a tuboperitoneal fistula after linear salpingostomy (Fig. Total peritoneal fistula following salpingostomy for an isthmic ectopic pregnancy.The option then becomes to close the tube by primary intention, which has been done successfully by Stangel and colleagues,109 or to perform a second procedure and do an anastomosis at that time. The major advantage of doing an anastomosis at the time of resection of the ectopic pregnancy is that the wide lumen of the tube facilitates the anastomosis. Normal intrauterine pregnancies are achieved regardless of the mode of anastomosis employed. It is recommended that patients waiting for a secondary anastomosis be placed on birth control pills so that they do not form an ectopic pregnancy in the blind distal portion of the tube that has been created (Fig. 10).110 In either event, the anastomosis is performed in two layers using the operating microscope.
Four to six 8-0 polyglycolic acid or polydioxanone sutures are placed approximating the muscularis. Pouly and associates85 accordingly treated 22 isthmic ectopic pregnancies by laparoscopic linear salpingostomy, yielding a 54.5% subsequent intrauterine pregnancy rate. DeCherney and Boyers,112 however, showed that treating isthmic pregnancy with linear salpingostomy by laparotomy resulted in subsequent occlusion of the tube in three of four patients.A rare form of ectopic pregnancy occurs in the infundibular portion of the tube between the fimbria and the ampulla. Schermers49 reported a higher incidence of delayed hemorrhage after the milking-out procedure. As early as 1955, Lund114 reported on a series of 119 women with ectopic pregnancies treated with observation. In this series, 55% of the cases resolved without intervention; the remainder required laparotomy. More recently, several investigators have reported their experience with expectant management of unruptured ectopic pregnancy.
In Maymon's115 review of 8 series of patients (total of 81 patients) managed expectantly, 76% resolved spontaneously, 23% required laparotomy for rupture, and 79% demonstrated ipsilateral tubal patency on follow-up hysterosalpingogram.
In all these studies, patients were rigorously selected, with documented unruptured ectopic pregnancies at laparoscopy, with no active bleeding. It is most commonly administered intramuscularly, though reports of oral administration are available.122 Patients receiving medical therapy must be hemodynamically stable and desire future fertility.
Contraindications include a ruptured ectopic, ectopic mass greater than 3.5 cm, fetal cardiac activity, high level hCG value (10,000 IU), breastfeeding, immunodeficiency, elevated creatinine or liver function tests, alcoholism, and active pulmonary or gastrointestinal disease. In this series, the author reported a success rate of 94%, with subsequent tubal patency rates similar to those quoted for conservative surgical treatment. Follow-up hCG levels should be obtained on days 4 and 7, with an expected 15% drop between the two latter values. Treatment failure is indicated by a less than 15% drop in hCG values between days 4 and 7, worsening abdominal pain concerning for rupture, and increasing or plateauing hCG values after the first week of therapy.
If the patient is hemodynamically stable, a second injection of methotrexate can be given with weekly follow-up.
Tubal rupture may occur in up to 8% of patients requiring subsequent surgery.129 Patients should be counseled regarding the side effects of medical therapy. A review of the literature summarizing 467 cases operated on for ectopic pregnancy is summarized in Table 4.131 Of these patients, 46% had a subsequent intrauterine pregnancy and 12% had a repeat ectopic pregnancy. These results do not differ greatly from older statistics based on the results after radical surgery. DeCherney and Oelsner131 reviewed 1630 cases treated radically and found a 41% intrauterine pregnancy rate and a 14% repeat extrauterine pregnancy rate.
It is hoped that over time, with the use of modern microsurgical techniques, the intrauterine pregnancy rate will increase and the repeat ectopic pregnancy rate will decrease in these patients.Table 4. Toronto, BC Decker, 1986) Based on the similar findings in radically and conservatively treated patients, an important question is whether salpingostomy works at all. This begs the question that perhaps those patients who conceive are using the tube that was not operated on.
This possibility has been reviewed, and the intrauterine pregnancy rate and the repeat ectopic pregnancy rate seem to be the same in patients who had salpingostomies performed on only one fallopian tube with an ectopic pregnancy for both the group receiving radical treatment and the group receiving conservative treatment.47These statistics do not hold, however, for patients who have had two or more ectopic pregnancies. Fertil Steril 50:164, 1988, Reproduced with permission of the publisher, The American Fertility Society)With the advent of effective medical therapy for ectopic pregnancy, there exist a wide variety of available treatment choices.
A recent review compared laparoscopic salpingostomy, multiple-dose methotrexate, single-dose methotrexate, and expectant management. Although 50% of ectopic pregnancies are attributable to infection, the remainder remain unexplained. Clinical findings such as adnexal tenderness, irregular bleeding, and abdominal pain still represent reliable but imperfect clues that a patient has an ectopic pregnancy.
It is the advent of newer diagnostic techniques, including laparoscopy, serial β-hCG testing, and transvaginal ultrasonography, that has allowed for the earlier diagnosis of ectopic pregnancy.
Previously, 85% of ectopic pregnancies were diagnosed as ruptured and 15% as unruptured.135 Today, this ratio is reversed. The diagnosis of many cases of small, unruptured ectopic pregnancies has led to a reversal from surgical management to medical management with methotrexate especially in patients desirous of future fertility.



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