Female Reproductive System ORGAN SYSTEMS

Extrauterine (ectopic) pregnancy

Implantation of a fertilized oocyte outside the uterine cavity.

Implantation of a fertilized oocyte outside the uterine cavity.

  • Tubal ectopic (M/C): Ampulla (70%) > Isthmus (12%) > Infundibulum (11%) > Interstitial & cornual (least common, 2-3%)
  • M/C non-tubal site: Ovary
  • Least common site: Cervical ectopic/ectopic in cesarean scar
Sites of ectopic pregnancies
Sites of ectopic pregnancies | Tay, J. I., Moore, J., & Walker, J. J. (2000). Ectopic pregnancy. The Western Journal of Medicine, 173(2), 131–134.


Extrauterine pregnancy is of multifactorial origin. Up to half of all women with an extrauterine pregnancy have no recognized risk factors for it.

  • Prior tubal surgery (biggest risk factor)
  • Prior ectopic pregnancy
  • History of infertility
  • PID (M/C cause): Salpingitis >> oophoritis, endometritis
    • M/C organism: Chlamydia
  • Ruptured appendix
  • Smoking
  • Contraceptive methods: IUDs, PIPs, tubal sterilization
  • Salpingitis isthmica nodosa (SIN): Inflammatory condition of the fallopian tubes strongly associated with infertility and an increased risk of ectopic pregnancy


Most commonly diagnosed in the 6th through 9th week of gestation.  and commonly present with pain and vaginal bleeding between 6 and 10 weeks’ gestation.

Ectopic pregnancy

Intact tubal pregnancy:

Intact fallopian tube and embryo, perhaps with discernible cardiac function
  • Usually asymptomatic

Classical triad: 30% cases

May indicate extrauterine pregnancy but can also arise in an intact intrauterine pregnancy or as a consequence of early miscarriage
  1. Aching pelvic pain
  2. Mild vaginal spotting
  3. Secondary amenorrhea

Other features:

  • Endometrial sloughing: Endometrial growth not maintained d/t fall in β-hCG & progesterone
  • Decidual cast: Entire decidua expelled at once

Ruptured ectopic pregnancy:

Pelvic pain with severe hemorrhagic shock
  • Hemorrhagic shock/hemodynamic instability (dyspnea, hypotension, tachycardia)
  • Syncope
  • Danforth sign: Shoulder pain on inspiration, due to irritation of the diaphragm by a hemoperitoneum in ruptured ectopic pregnancy
  • Abdominal guarding or an acute abdomen


40% of ectopic pregnancies go undiagnosed on initial presentation.

Diagnostic criteria:

  • Paalman & McElin criteria (cervical ectopic clinical criteria)
  • Rubin criteria (cervical ectopic histological criteria)
  • Studdiford criteria (abdominal ectopic)
  • Spiegelberg criteria (ovarian ectopic)

Transvaginal ultrasonography (TVS):

Investigation of choice
  • Empty uterus (1st sign on USG)
  • Tubal ring sign or bagel/blob sign: Echogenic ring surrounding an unruptured ectopic pregnancy
  • Pseudogestational sac: Small fluid collection, centrally located within endometrial cavity and surrounded by thick decidual reaction
  • Complex adnexal mass

Serum β-Human chorionic gonadotrophin (β-hCG):

Performed if TVS inconclusive
  • Critical titre (levels at which gestational sac should be visible on USG):
    • TVS: 1500 IU/l
    • TAS: 6500 IU/l
  • Repeat test done after 48hr if β-HCG < 1500 IU/l:
    • β-HCG ↑ (x2): Normal pregnancy
    • β-HCG ↓ : Abortion
    • β-HCG ↑ (< x2): Ectopic pregnancy
Mean (SE) serum concentrations of human chorionic gonadotrophin in normal pregnancy
Mean (SE) serum concentrations of human chorionic gonadotrophin in normal pregnancy | Braunstein GD, Rasor J, Adler D, Danzer H, Wade ME. Serum human chorionic gonadotrophin levels throughout normal pregnancy. Am J Obstet Gynecol. 1976;126:678–681.


Procedure to obtain free fluid from the cul de sac of women indicated in suspected ruptured ectopic pregnancy and acute salpingitis or pelvic inflammatory disease (PID).
  • Non-clotting blood: Hemoperitoneum (suspect ectopic pregnancy)
  • Clotting blood: Vein/artery aspirated (remove needle, re-insert to aspirate again)
Culdocentesis: Diagnostic puncture of the cul-de-sac
Diagnostic puncture of the cul-de-sac | Cutting Off The. (2020) MCPC – Culdocentesis and colpotomy – Health Education To Villages. Retrieved October 18, 2020, from

Differential diagnosis:

  • Appendicitis (M/C mistaken for)
  • Cystic/solid adnexal tumors causing peritoneal irritation (esp by torsion or rupture)
  • Adnexal infection (e.g., PID, UTI, tubo-ovarian abscess)
  • Ovarian hyperstimulation syndrome with ascites


Expectant management:

Some ectopic pregnancies resolve spontaneously, and expectant management is possible in selected cases.
  • Not preferred

Medical management:

Treatment of choice before rupture in haemodynamically stable patients with hCG <5000 IU/l, rising hCG level within 48 hours and a gestational sac <4 cm
  • DOC: Methotrexate (folic acid antagonist) (IM/direct local injection)
    • Close follow up with serial measurements of serum concentrations of hCG required. 3 courses can be attempted before surgical intervention.
  • Other drugs: Potassium chloride, actinomycin, hyperosmolar glucose, PGF2-α

Surgical management:

Indicated in rupture, hemodynamic instability, symptoms (eg., pain), diagnostic laparoscopy or suspected heterotopic pregnancy
  • Radical procedure (salpingectomy)
  • Conservative procedure (salpingostomy)
  • Anti-D (300 µg): Alloimmunization after surgical management of ectopic pregancy
Algorithm for tubal ectopic
Algorithm for the individualized surgical treatment of tubal pregnancy (TP), | Wallwiener D, Pollmann D, Gauwerky J, Sohn C, Bastert G. Operative treatment of tubal pregnancy. In: Bastert G, Wallwiener, editors. Lasers in gynecology. Berlin, Heidelberg: Springer; 1992.
Tubal ectopic pregnancy at laparoscopy.
(A) Left tubal ectopic pregnancy at laparoscopy. (B) Tubal ectopic pregnancy has been removed by salpingectomy. | Sivalingam, V. N., Duncan, W. C., Kirk, E., Shephard, L. A., & Horne, A. W. (2011). Diagnosis and management of ectopic pregnancy. The journal of family planning and reproductive health care, 37(4), 231–240. doi:10.1136/jfprhc-2011-0073

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