Department of Obstetrics and Gynecology,

the Second Affiliated Hospital Chongqing Medical

University

Definition
Any gestation in which implantation

occurs at a location other than the

uterine cavity.
Incidence: approximately 1~2% of

conceptions
Accounts for 10% of pregnancy-

related maternal deaths

Category
tubal pregnancy (95% of ectopic

pregnancy)
ovarian pregnancy
abdominal pregnancy
broad ligament pregnancy
cervical pregnancy
cesarean scar pregnancy

Tubal pregnancy

Tubal Pregnancy
Sites:
ampulla portion
most common

isthmic portion
fimbrial portion
Interstitial portion
rare

Etiology
chronic salpingitis
previous tubal pregnancy or tubal surgery
abnormalities or Dysfunction
assisted reproductive technique (ART)
failure of contraception

Pathology
no complete decidua
narrow lumen and thin muscle
fertilized ovum burrows into the thin tubal
muscle
fertilized ovum grows and distends the tube

Pathology
Outcomes of tubal pregnancy
Tubal abortion
Rupture of tubal pregnancy
Obsolete ectopic pregnancy
Secondary abdominal pregnancy

Pathology
Uterus changes
uterus enlargement and soften
decidualization of endometrium
The decidua will shed after the death of the
embryo, and may be passed in fragments
or intact as a decidua cast
No villi or trophoblastic cell

Uterus change
long after embryo death
proliferative phase
Arias -Stella (A-S) reaction
alive villi
secretory phase

Clinical manifestations
amenorrhea
abdominal pain
vaginal bleeding
Syncope and shock
abdominal mass

Signs
General examination
when the internal bleeding is rapid and
severe:
acute anemia, pallor
rapid and feeble pulse
low blood pressure

Abdominal examination
pressure pain & rebound tenderness
adnexal mass
sometimes ambulant sonant positive

Pelvic examination
vaginal bleeding
cervix: tenderness especially on lifiting or

moving the cervix

the most important sign of tubal pregnancy

uterus: soft and slightly enlarged

adnexa: fullness or an indefinite tender

mass, size varies

Diagnosis
history & symptoms
signs
pelvic examination
special examination

Special examination
hCG test
Progesterone test
Ultrasonography
Culdocentesis
Diagnositic curettage

Differential Diagnosis
threatened or incomplete abortion
ultrasonography
rupture of corpus luteum
acute appendicitis
acute pelvic inflammatory disease
ovarian torsion
hCG negative

Treatment
Medical treatment
Surgical treatment

Medical treatment
Indications:
no contraindication

of medical treatment
no rupture of tubal
pregnancy
diameter of
gestational sac
cm
Blood hCG<2000U/L
no obvious internal
bleeding

Contraindictions:
Unstable general

condition
Rupture or tubal
pregnancy
diameter of
gestational sac >
cm or >3.5cm with
heart beat

Medical treatment

MTX (methotrexate)
suppress the proliferation of trophoblast
damage the villi
lead to the death, abscission and absorption of the
embryo
Treatment plan
0.4mg/(kg.d) i.m. *5 days
50mg/m2 1 time
Measure

hCG on 4th and 7th day, repeat when hCG

decrease <15% till hCG<51U/L
Local treatment: injection into gestational sac

Medical treatment
With close monitor
CG+Ultras
onograph
y

After 14 days of treatment

the value of blood hCG should be negative for 3 tests

Abdominal pain relieved or disappear

Vaginal bleeding less or none

re less or no abdominal pain

less or no vaginal bleeding

Surgical treatment

indications:
unstable vital signs or with signs of internal
bleeding
unclear diagnosis
advanced ectopic pregnancy
hCG>3000IU/L or continuing increase, with

embryo heart beat, massive adnexal mass

not compliant patient

contraindication of medical management
failure of medical management

Surgical treatment
conservative surgery
patients with future conception requirement
persistent ectopic pregnancy
After conservative surgery, leftover trophoblast

cells keep grow and invade.

Hemorrhage, abdominal pain
increased hCG or hCG decrease <50% 1 day
after surgery or hCG value>10% of pre-surgery
value after 12 days
MTX or second surgery

Surgical treatment
radical surgery (salpingectomy)
No future conception requirement
Internal bleeding with shock

Laparoscopy
Most common treatment
gold standard for diagnosis of ectopic

pregnancy

Than
k you