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Tubal ectopic pregnancy

Dr Abhilash Sandhyala and Dr Frank Gaillard et al.

A tubal ectopic pregnancy (or adnexal ectopic pregnancy) is a type a ectopic pregnancy.

Epidemiology

It is by far the most common type of ectopic : accounts for ~ 93 - 97 % of cases.

Pathology

Although the fallopian tube has many anatomical parts, as far as ectopics are concerned it can be divided into :

ampullary ectopic : most common : ~ 70 % : also considered the longest segment ⁴
isthmic ectopic : ~ 12% ⁴
fimbrial ectopic : ~ 11% ⁴

Radiographic features

Ultrasound

An adnexal mass that is separate from the ovary is the most common finding may be seen on in up to 89 - 100 % of cases ⁴.
- The presence of an adnexal mass becomes more specific for an ectopic pregnancy when it contains a yolk sac or a living embryo or when it moves independently from the ovary.
- However, an extrauterine mass may not be sonographically detected upto 35% of patients with an ectopic pregnancy
There may be evidence of a haematosalpinx (a tubal ectopic is the commonest cause for a haematoslapinx⁸).
A tubal echogenic ring may be also seen : typically a 1 - 3 cm mass consisting of a 2 - 4 mm concentric, echogenic rim of tissue surrounding a hypoechoic center) representing an echogenic ring surrounding a extra-uterine gestational sac.
Colour Doppler interrogation may show a peripheral vascularity giving a "ring of fire sign".
There may be evidence of a large haemoperitoneum or large amount of free fluid, especially in cases of rupture

Complications

tubal rupture

Treatment and prognosis

Fortunately, compared to an interstitial ectopic or cervical ectopic, the risk of uncontrollable haemorrhage is fortunately lower, nonetheless expedient diagnosis is required.

Management

Management was previously only surgical, with open and then laparoscopic salpingectomy being favored. salpingotomy (thus preserving the tube) is increasingly performed.

Medical management includes methotrextate ( a folate antagonist ) either administered systemically or by direct ultrasound guided injection. The ectopic may show a paradoxical increase in size and vascularity on subsequent imaging even with succesful methotrexate.

Increasingly 'conservative' management is being recognised as an option for those ectopics where rupture has not occurred (i.e no haemoperitoneum ) and fetal demise has already taken place.