Description of Medical Condition

Extrauterine pregnancy — any pregnancy existing outside the confines of the uterine cavity
• Tubal pregnancy — pregnancy existing within the different portions of the fallopian tubes, i.e., ampullary (55%). isthmic (25%), fimbrial (17%), interstitial (cornual) (2%)
• Ovarian pregnancy — pregnancy existing within the confines of an ovary
• Abdominal pregnancy — pregnancy existing in the abdominal (peritoneal) cavity, most commonly within the cul-de-sac. Occasionally it may implant on the intestines, pelvic side-walls, omentum, or even on the surfaces of the liver or spleen.
• Cervical pregnancy — pregnancy is implanted in the substance of the cervix below the level of the internal os
• Intraligamentary pregnancy — after a tubal pregnancy ruptures, the surviving embryo secondarily implants within the confines of the anterior and posterior leaves of the broad ligament
System(s) affected: Reproductive
Genetics: N/A
Incidence/Prevalence in USA:
• 88,000 cases in 1987
• 16.8 per 1000 pregnancies (live birth, legally induced abortions, and ectopic pregnancies)
Predominant age: Over 40% occurred in women between ages 20 and 29
Predominant sex: Female only

Medical Symptoms and Signs of Disease

• Tubal pregnancy:
– Pelvic pain
– Amenorrhea followed by irregular vaginal bleeding
– Abdominal tenderness
– Adnexal tenderness or mass
– Tenesmus
– Shoulder pain
– Syncope
– Passage of decidual cast
• Ovarian pregnancy:
– Pain and cramps
– Pelvic mass
– Vaginal bleeding after a period of amenorrhea
– Clinical shock after rupture
• Abdominal pregnancy:
– History suggestive of tubal abortion or rupture
– Pregnancy complicated by unusual gastrointestinal symptoms
– Fetal movements very marked or painful
– Easy palpation of the fetal parts or movements
– Pregnancy described by a multipara as “different”
– False labor near term
– High lying fetus in abnormal presentation, often transverse
– Displacement of a firm, long cervix
– Palpation of the fetal parts through the vaginal fornix
– Unusually loud vascular souffle
• Cervical pregnancy:
– A soft and disproportionately enlarged cervix equal to or greater than the uterine corpus (hourglass effect)
– Extrusion of dark tissue through the external os
– Continuous vaginal bleeding after amenorrhea
• Intraligamentary pregnancy:
– History suggestive of tubal abortion or rupture
– Unilateral pelvic mass associated with pain

What Causes Disease?

• Tubal pregnancy:
– Previous tubal pregnancy
Pelvic inflammatory disease
– Endometriosis
– Previous tubal surgery
– Salpingitis isthmica nodosa
– Pelvic adhesions
– Pelvic tumors
• Ovarian pregnancy:
– Implantation of the fertilized ovum on the ovarian surface
– Tubal abortion with secondary implantation of the embryo on the tubal surface
• Abdominal pregnancy:
– Tubal abortion with secondary implantation
– Uteroperitoneal fistula following rupture of cesarean section or myomectomy scars
– External transmigration theory
– Menstrual regurgitation of a fertilized ovum theory
• Cervical pregnancy:
– Unreceptive endometrium to implantation due to infection
– Uterine myomas
– Atrophic endometrium
– Septate uterus
– Presence of intrauterine device (IUD)
– Scarring of the endometrium
– Oral contraceptive use
• Intraligamentary pregnancy:
– Rupture of a tubal pregnancy and secondary implantation between the anterior and posterior leaves of the broad ligament

Risk Factors

• Previous tubal surgery
• Previous pelvic inflammatory disease
• Pelvic adhesions
• Previous tubal pregnancy
• Previous uterine surgery
• Use of an intrauterine device
• History of endometritis
• Recipients of assisted reproductive technologies, e.g. in-vitro fertilization and embryo transfer

Diagnosis of Disease

Differential Diagnosis

• Uterine abortion
• Appendicitis
• Salpingitis
• Ruptured corpus luteum cyst
• Cornual myoma or abscess
• Ovarian tumor
• Endometrioma
Cervical cancer
• Cervical phase of uterine abortion
• Placenta previa

Laboratory

• Urine pregnancy test
• Human chorionic gonadotropin (HCG) — serial quantitative serum beta
• Serial blood counts to quantify blood loss
• Serum progesterone level
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

Pathological Findings

• Tubal pregnancy:
– Presence of chorionic villi within the tubal wall
• Ovarian pregnancy (Spiegelberg’s criteria):
– The pregnancy must occupy the position of the ovary
– The pregnancy must be connected to the uterus by the utero-ovarian ligament
– The ipsilateral oviduct must be normal
– The pregnancy sac must show the presence of ovarian tissue
• Abdominal pregnancy — primary form:
– Both ovaries and oviducts must be normal
– There is no uteroperitoneal fistula
– Attachment of the conceptus is exclusively to the peritoneal surface
• Abdominal pregnancy — secondary form:
– Fetal or placental tissue is found within the abdominal cavity beyond the ovaries or oviducts
• Cervical pregnancy:
– Chorionic villi are implanted within the substance of the uterine cervix below the level of the internal os
– The uterine cavity above the internal os is free of the products of conception
• Intraligamentary pregnancy:
– The products of conception are within the confines of the broad ligament

Special Tests

• Culdocentesis
• Endometrial biopsy and/or dilatation and curettage

Imaging

• Vaginal and abdominal ultrasonography
• CT scan
• MRI
• Endovaginal color Dopplerflow imaging

Diagnostic Procedures

• Laparoscopy
• Laparotomy

Treatment (Medical Therapy)

Appropriate Health Care

• Outpatient for most evaluation and treatment
• Outpatient surgery for unruptured tubal pregnancy
• Inpatient surgery for unstable hemodynamic conditions after resuscitation

General Measures

N/A

Surgical Measures

• Laparotomy is often required for ovarian, abdominal, and intraligamentary pregnancy
• Careful curettage, packing of the cervix and uterine cavity, bilateral internal iliac artery ligations, or even hysterectomy may be necessary as treatment for cervical pregnancy
• Unruptured tubal pregnancy may be treated by salpin-gostomy
• Unruptured tubal pregnancy of less than 4 cm. diameter may be treated through laparoscopy. With methotrexate, best results obtainable when unruptured tubal pregnancy is less than 2 cm diameter or HCG less than 10000 mlU/mL, and before ultrasound evidence of fetal heart beats.

Activity

Variable

Diet

Variable

Patient Education

American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG

Medications (Drugs, Medicines)

Drug(s) of Choice

• Methotrexate as primary treatment for unruptured tubal pregnancy and for persistent disease after salpingos-tomy
• Methotrexate as supplementary treatment for retained placenta after delivery of the fetus in abdominal pregnancy
• Dosage: Methotrexate 1 mg/kg IM every other day with leucovorin 0.1 mg/kg IM in between. Maximum of 4 doses of methotrexate or methotrexate x 1 without leucovorin, at 50 mgm per square meter of body surface area; may repeat once if unsatisfactory response.
Contraindications: Pregnant women with psoriasis
Precautions: Methotrexate has toxic effects on the hematologic, renal, gastrointestinal, pulmonary, and neurologic systems
Significant possible interactions: Refer to manufacturer’s profile of each drug

Alternative Drugs

Dactinomycin

Patient Monitoring

• Serial serum quantitative B-HCG until level drops to near zero
• Followup pelvic ultrasonogram for persistent or recurrent masses
• Followup imaging studies for retained placenta in abdominal pregnancy, e.g., ultrasonography, CT scan. And MRI

Prevention / Avoidance

• Reliable contraception
• Repeat tubal pregnancies occur in about 12%. For patient who becomes pregnant again, use ultrasound to verify intrauterine pregnancy.

Possible Complications

• Hemorrhage and hypovolemic shock
• Infection
• Loss of reproductive organs after complicated surgery
Infertility
• Urinary and/or intestinal fistulas after complicated surgery
• Need for blood transfusions with its hazards
• Disseminated intravascular coagulation

Expected Course / Prognosis

With early diagnosis and treatment, rupture unlikely to occur

Miscellaneous

Associated Conditions

N/A

Age-Related Factors

Pediatric: N/A
Geriatric: N/A

Pregnancy

N/A

Synonyms

• Extrauterine pregnancy
• Tubal pregnancy
• Ovarian pregnancy
• Abdominal pregnancy
• Cervical pregnancy
• Intraligamentary pregnancy

International Classification of Diseases

633.90 Unspecified ectopic pregnancy without intrauterine pregnancy

See Also

Abortion, spontaneous

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