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Although the risk of pregnancy is very low with a tubal ligation, if a pregnancy does occur, 10–50% are EP, representing a 20- to 100-fold increased risk [6]. Frequency is also higher with endometrio­sis, assisted reproductive technology (ART), and emergency contraception [7]. The pathogenesis of tubal pregnancy after natural and invitro fertiliza­tion (IVF) conception is presented in Fig.9.1.

Less than 5% of EPs occur in the ovary, cervix, or intra-abdominally, and the locations slightly dif­fer between normal conception and conception after ART (Fig.9.2) [9].

A persistent EP refers to the continuation of tro­phoblastic growth after a surgical intervention to remove an EP. After a conservative procedure to preserve the affected Fallopian tube, such as a sal-

The clinical features are complex and subject to signicant variations in character and severity. A quote from Howard A.Kelly seems timely that if

culties lies in the fact that the symptoms associ­ated with extrauterine gestation arise not directly from the presence of the growing ovum in the Fallopian tube but from certain secondary lesions, either traumatic or inammatory, which super­vene. These secondary lesions may be briey enumerated as follows [23]:

• intraperitoneal ooding from tubal abortion or

sealed,

• slowly progressive or recurrent bleeding lead-

ing to the formation of encysted collections of

When the course of the gestation becomes interrupted by any of the occurrences mentioned above, the clinical features undergo rapid trans­formation, and symptoms of extrauterine preg­nancy appear—those that result from the interruption of the pregnancy by injury to the developing ovum or its containing sac. These symptoms, regarded as secondary symptoms, are highly variable in character and intensity in cor­respondence with the nature of the lesion which has given rise to them. The most easily recog­nized is intraperitoneal ooding; the symptoms that attend to it are uniform and characteristic. With a clinical history of amenorrhea and a care­ful pelvic examination made, mistakes are rare. Perforation of a hollow viscus, such as the stom­ach, duodenum, or gall bladder, is the only condi­tion for which it is likely to be mistaken, even under the circumstances unfavorable for diagno­sis. Constant bleeding from the uterus is a sec­ondary symptom of extrauterine gestation. If no period of amenorrhea has occurred, it forms the initial symptom, and if there has been amenor­rhea, it succeeds it. Mostly, it is the earliest indi­cation of anything wrong. However, as the same thing frequently occurs from the disturbance of a uterine pregnancy, little importance is usually given to it. The bleeding is slight or moderate in degree, sometimes continuous, sometimes irreg­ular; it is usually dark, thick, and syrupy in appearance. It may continue for several weeks if the patient is not relieved by the operation. The bleeding is due to separation and discharge of the uterine decidua, sometimes complete, more often in fragments. However, in most cases, the pieces of membrane do not attract attention. The most interesting phenomenon is this attempt on the uterus to throw off its decidua when the tubal ovum has been damaged. Some reex mecha­nism is initiated, which excites uterine contrac­tion insufciently powerful to detach portions of the membrane from the uterine wall and gives rise to bleeding, which continues until the whole decidua has been expelled. It is possible that at the commencement, some blood that escapes

several hours.

Rupture of ovarian pregnancy classically occurs during the rst trimester and is preceded by pain corresponding to distension of the ovar-

For simultaneous intestinal obstruction with ectopic pregnancy, see Sect. 18.12.2. Subjective symptoms of pregnancy may also be present, such as breast tenderness and emesis gravidarum.

color of the blood through the thinned-out semi­transparent hernia.

Meyers etal., by computed tomography, rst noted that blood in the abdominal wall might be responsible for these signs [27]. They dened the anatomy of various retroperitoneal spaces and compartments, revealing a direct extension of hemorrhagic uid from the posterior parare­nal space to the lateral edge of the quadrates lumborum muscle, where a defect in the trans­versalis fascia permits access to the abdominal wall musculature. The intramuscular hemor­rhagic uid presumably reaches the subcutane­ous tissues via interruptions in muscular continuity. Cullen’s sign results from tracking blood along the round ligament to the umbili­cus. The portal of entry to the round ligament complex from the retroperitoneum is via the gastrohepatic ligament to the falciform liga­ment at the inferior-posterior liver edge [28]. The falciform ligament contributes to the con­nective tissue tube covering the round ligament (obliterated left umbilical vein) as it passes to the umbilicus.

Differential diagnosis of Cullen’s sign includes several conditions. Periumbilical cellulitis typi­cally causes blanching erythema that is warm to the touch. Sister Mary Joseph’s sign (nodule)—a metastatic spread of an intra-abdominal malig­nancy to the umbilicus—may present with thick­ening and erythema of periumbilical skin or as a palpable mass lesion around the umbilicus [33]. Subcutaneous administration of heparin may result in abdominal wall ecchymoses, which are typically distant from the umbilicus. Patients with psoriasis may develop periumbilical ery­thema with a silvery scale that bleeds on removal (Auspitz’s sign). Umbilical endometriosis is accompanied by bleeding in conjunction with the menstrual cycle. Ulceration of a recanalized umbilical vein in the setting of cirrhosis may cause periumbilical skin darkening [34].

Signs of intra-abdominal bleeding without

Cullen’s sign have various nontraumatic causes.