Surgical Management of Ectopic Pregnancy

Author: Allahyar Jazayeri, MD, PhD, FACOG, DACOG, FSMFM, Women Specialty Care, Green Bay WI; Medical Director of Perinatal Services, Bellin Health Hospital Center
Coauthor(s): Herbert S Coussons, MD, FACOG, Private Practice in Obstetrics and Gynecology, Women's Specialty Care

Introduction

Ectopic pregnancy is defined as implantation of a fertilized egg outside the endometrial cavity. Ectopic pregnancy is estimated to occur in 2% of all pregnancies. It remains a major cause of maternal morbidity and mortality when misdiagnosed or left untreated and accounts for as much as 9% of maternal death in this country. Quantitative measurements of the beta subunit of human chorionic gonadotropin (β -hCG) and transvaginal ultrasonography have improved the accuracy of diagnosis and allow earlier detection of ectopic pregnancies. Although deaths associated with ectopic pregnancy have declined, more than three quarters of deaths in the first trimester and about 10% of all pregnancy-related deaths are associated with pregnancies outside of the womb.

History of the Procedure

Ectopic pregnancy was described by Charles Dickens in Nicholas Nickelby, in which he refers to "a disease in which death and life are so strangely blended." This is an accurate description since implanting outside the endometrial cavity results in the loss of pregnancy and the mother is also exposed to significant morbidity and potential mortality. 

In the past 30 years the ability to diagnose and treat ectopic pregnancies has significantly improved, thereby reducing the maternal risks.

Robert Lawson Tait, a British surgeon, is credited with performing the first successful laparotomy for ruptured tubal pregnancy in 1883. In 1881, Tait was consulted in the case of a patient who had been diagnosed with intraperitoneal hemorrhage secondary to a ruptured tubal pregnancy. The patient's physician suggested that Tait open the abdomen and remove the ruptured tube. Tait rejected the idea. After the woman died, Tait injected the specimen and determined that if he had operated and tied the broad ligament, he would have arrested the hemorrhage and probably would have saved the woman's life. In April of 1883, he operated on another woman and ligated the ruptured tube and broad ligament. This was the first successful surgical management of ruptured tubal pregnancy. At a time when ectopic pregnancy was associated with a greater than 60% mortality rate, Tait lost only 2 patients of the first 42 on which he operated.

By the 1920s, laparotomy and ligation of the bleeding vessels with removal of the affected tube was the standard of care and remained so until operative laparoscopy and salpingostomy replaced laparotomy and salpingectomy in the late 1970s.

In the 1980s and 1990s, medical therapy of ectopic pregnancy has been implemented and has replaced surgical treatment in many cases. Thus, in less than 3 decades, treatment has evolved from a surgical emergency to conservative medical management.

Problem

An ectopic pregnancy occurs outside of the uterus. Approximately 97.7% of all ectopic pregnancies occur in the fallopian tubes, with the rest occurring in the ovary, abdomen, or cervix.

Of tubal pregnancies, the ampulla is the most common site of implantation (80%), followed by the isthmus (11%), fimbria (4%), cornua (2%), and interstitia (3%).

Frequency

The incidence of ectopic pregnancy is reported most commonly as the number of ectopic pregnancies per 1000 conceptions. The incidence varies among populations. Over the last 40 years, the incidence has been increasing steadily.

In 1970, the reported rate in the United States was 4.5 cases per 1000 pregnancies. By 1987, this was reported as 16.8 cases per 1000 pregnancies. These statistics are based on US Centers for Disease Control and Prevention data that use hospitalizations for ectopic pregnancy to determine the total number of ectopic pregnancies. Looking at raw data, 17,800 hospitalizations for ectopic pregnancies were reported in 1970. This number rose to 88,000 in 1989 but fell to 30,000 in 1998. This raises the question of whether the number of ectopic pregnancies is declining or whether many ectopic pregnancies are now treated in ambulatory surgical centers and even using medical therapy without admission. The author and many others believe the latter is true, but truly accurate statistics are lacking. The prevalence is estimated at 1 in 40 pregnancies or approximately 25 cases per 1000 pregnancies.

Approximately 85-90% of ectopic pregnancies occur in multigravid women. In the United States, rates are nearly twice as high for women of other races compared with white women.

Etiology

Risk factors for ectopic pregnancy include tubal damage, smoking, and altered motility in the fallopian tube.

  • Tubal damage can be the result of infections such as pelvic inflammatory disease or salpingitis or can also result from abdominal surgery or tubal ligation.
  • Smoking is a risk factor in about one third of ectopic pregnancies and may contribute to decreased tubal motility by damage to the ciliated cells in the fallopian tubes.
  • Altered tubal motility can also occur as the result of hormonal contraception. Both progesterone only contraception and progesterone intrauterine devices (IUDs) have been associated with increased risk of an ectopic pregnancy. 

One third of ectopic pregnancies occur in women with no known risk factors.

Pathophysiology

Delay or prevention of passage of the fertilized ovum (blastocyst) to the uterine cavity by the factors mentioned or by factors inherent in the embryo result in premature implantation.

Presentation

The typical triad includes bleeding and abdominal pain and a positive pregnancy test result. The clinical presentation can therefore be confusing, since symptoms overlap with miscarriage. A third of women have no clinical signs and 9% have no symptoms of ectopic pregnancy. As a result, almost half of cases are not diagnosed at the first prenatal visit.

The signs of ectopic pregnancy on examination include lower abdominal tenderness with or without rebound and pelvic tenderness usually much worse on the affected side. Abdominal rigidity, involuntary guarding, and severe tenderness as well as evidence of hypovolemic shock, such as orthostatic blood pressure changes and tachycardia, should alert the clinician to a surgical emergency; this may occur in up to 20% of cases.

On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary.

Indications

Indications for surgery in ectopic pregnancy include women with the following criteria:

  • Not suitable candidate for medical therapy
  • Failed medical therapy
  • Heterotopic pregnancy with a viable intrauterine pregnancy
  • Hemodynamically unstable and need immediate treatment

Relevant Anatomy

The illustration below shows the anatomy of an ectopic pregnancy and the frequency distribution for this phenomenon

Sites of ectopic pregnancies.

Sites of ectopic pregnancies.


Contraindications

The only contraindication to surgical management is a patient with a medically treatable ectopic pregnancy and other medical conditions that would make the risk of surgery unacceptable.

Workup

Laboratory Studies

  • Human chorionic gonadotropin (quantitative)
    • The quantitative level of β-hCG found in ectopic pregnancy varies. Serum β-hCG levels correlate with the size and gestational age in normal embryonic growth. In a normal pregnancy, the β-hCG level doubles every 48-72 hours until it reaches 10,000-20,000 mIU/mL. With ectopic pregnancies, β-hCG levels usually increase less.
    • The discriminatory zone of β-hCG is the level above which a normal intrauterine pregnancy (IUP) is reliably visualized. Once β-hCG has reached a level of 700-1000 mIU/mL, a gestational sac should be seen within the uterus on transvaginal ultrasonographic images. Once it has reached 6000 mIU/mL, a gestational sac should be visualized within the uterus on abdominal scan images.
    • The lack of an IUP when the β-hCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion.
  • Measure serial hemoglobin or hematocrit levels to quantify blood loss.
  • Blood type, Rh type, and antibody screen should be done in all pregnant patients with bleeding to identify patients in need of Rhogam and to ensure availability of blood products in case of excessive blood loss.

Imaging Studies

  • Endovaginal ultrasonography to exclude an IUP can be performed in the outpatient clinic or emergency department. Transvaginal ultrasonography has been reported to have sensitivity of 90%, specificity of 99.8%, with positive and negative predictive values of 93% and 99.8% respectively.1
    • Definite IUP: A gestational sac with a sonolucent center (>5 mm in diameter) is surrounded by a thick, concentric, echogenic ring located within the endometrium and contains a fetal pole, yolk sac, or both (see following image).

    • An endovaginal ultrasound revealing an approximat...

      An endovaginal ultrasound revealing an approximate 6-week intrauterine pregnancy. A yolk sac (ys), gestational sac (gs), and fetal pole (fp) are note

    • Probable abnormal IUP: The gestational sac is larger than 10 mm in diameter without a fetal pole or with a definite fetal pole but without cardiac activity. This frequently has an irregular or crenelated border.
    • Definite ectopic pregnancy: A thick, brightly echogenic, ringlike structure is located outside the uterus, with a gestational sac containing an obvious fetal pole, yolk sac, or both. This is an unusual finding.
    • No definite IUP (empty uterus): An empty uterus on endovaginal ultrasound images in patients with a serum β -hCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proven otherwise. An empty uterus also may represent a recent abortion.
    • Other ultrasonographic findings: These include an adnexal mass (usually a corpus luteum, occasionally hematoma), free cul-de-sac fluid, and/or severe adnexal tenderness with probe palpation. Patients with no definite IUP and the above-mentioned findings may be at high risk for an ectopic pregnancy.
  • An appreciation for the sonographic spectrum of ultrasound findings in ectopic pregnancy may allow physicians to recognize an early ectopic pregnancy. The spectrum of sonographic findings in ectopic pregnancy includes the following:
    • Tubal ring: An echogenic ringlike structure found outside of the uterus represents an early ectopic pregnancy (see following image).

    • An endovaginal ultrasound image demonstrating an ...

      An endovaginal ultrasound image demonstrating an early ectopic pregnancy. An echogenic ring (tubal ring) found outside of the uterus can be seen in this view.

    • Extrauterine mass: The presence of a tender adnexal mass on ultrasound images suggests an ectopic pregnancy. One study suggested that the presence of any adnexal mass other than a simple cyst was the most significant ultrasound finding for the diagnosis of ectopic pregnancy.
    • Interstitial ectopic pregnancy: An interstitial ectopic pregnancy implants at the highly vascular region of the uterus near the insertion of the fallopian tube. These types can grow larger than those within the fallopian tube because the endometrial tissue is more expandable. Because of the increased size and partial endometrial implantation, these advanced ectopic pregnancies can be misdiagnosed as IUPs. An aid in the diagnosis of an interstitial ectopic pregnancy is the eccentric location of the gestational sac. Evaluating the amount of uterine myometrium surrounding the gestational sac and echogenic decidual layer is important. This is termed the myometrial mantle. At least 5 mm of myometrium should be present. The presence of less than 5 mm suggests the diagnosis. Another sonographic finding is the interstitial line sign.
    • Heterotopic pregnancy: This is a combined IUP and ectopic pregnancy. It may occur in approximately 1 in 30,000 pregnancies and is more common in patients taking fertility agents.
    • Extrauterine empty gestational sac: The presence of an extrauterine mass with a thick, brightly echogenic band (ring) also may represent an ectopic pregnancy (see following image).

    • An endovaginal ultrasound revealing a complex mas...

      An endovaginal ultrasound revealing a complex mass outside of the uterus, with a small yolk sac present within. The mass is more echogenic compared to the uterus above and represents an ectopic pregnancy.

    • Hemosalpinx: Fallopian tubes may fill with blood or free fluid.
    • Ruptured ectopic pregnancy: Findings on ultrasonographic images include free fluid or clotted blood in the cul-de-sac or in the intraperitoneal gutters, such as in the Morrison pouch.

Other Tests

Progesterone has been used by some in assessment of an ectopic pregnancy. While a value of 25 ng/mL is associated with normal pregnancies in 98% of cases, a value of less than 5 ng/mL identifies a nonviable pregnancy without regard to location of the pregnancy. Unfortunately, most women with an ectopic pregnancy will fall somewhere in between these 2 values, limiting the clinical usefulness of progesterone in diagnosing an ectopic pregnancy.

Other serum markers have been studied as potential biochemical markers for an ectopic pregnancy. These markers that are usually either early pregnancy proteins or markers for inflammation and damage in smooth muscles have not been sufficiently sensitive to be useful. 

Diagnostic Procedures

  • Culdocentesis can be performed to help diagnose blood in the cul-de-sac. No clotting blood is diagnostic of chronic hemorrhage in the abdomen and may suggest a ruptured ectopic pregnancy.
  • Products of conception passed through the cervix in an inevitable abortion can be used to confirm the diagnosis of an intrauterine pregnancy if fetal or placental tissue can be identified.

Treatment

Medical Therapy

The greatest advance in the management of ectopic pregnancy since Tait's endeavors has been the development of medical management that became available in the mid 1980s. Initial protocols required long-term hospitalization and multiple doses of methotrexate and were associated with significant side effects. Modification and refinements of the protocols for medical therapy of ectopic pregnancy have allowed single-dose outpatient therapy.

While methotrexate has remained the most effective and popular drug used in medical therapy for an ectopic pregnancy, other protocols have been used, such as potassium chloride, hyperosmolar glucose, RU 486, and prostaglandins, and these have been administered orally, systemically, and locally into the ectopic pregnancy directly. These therapies remain experimental at present since experience in using them and the efficacy of such treatments as well as advantages over standard methotrexate protocol has not been established. Therefore, the focus of this article is on the use of methotrexate therapy.

In certain carefully selected patients, intramuscular methotrexate can be both safe and effective therapy.

To determine acceptable candidates for methotrexate therapy, first establish the diagnosis by one of the following criteria:

  • Abnormal doubling rate of the β-hCG level and sonographic identification of a gestational sac outside of the uterus
  • Abnormal doubling rate of the β-hCG level, an empty uterus, and menstrual aspiration with no chorionic villi

Once the diagnosis is established, the following criteria should also be met:

  1. Hemodynamically stable
  2. Reliable, compliant patient who will return for follow-up care
  3. Ectopic pregnancy smaller than 4 cm in diameter or smaller than 3.5 cm with cardiac activity
  4. Absence of fetal cardiac activity on ultrasonographic findings
  5. No evidence of tubal rupture
  6. β-hCG level less than 5000 mIU/mL

Criteria 1 and 2 must be met by every patient. Criteria 3-6 are relative contraindications to medical therapy but are not absolute. The best predictor of success of medical therapy is the initial hCG level. Based on efficacy studies done by Lipscomb et al, success exceeded 90% for single-dose methotrexate when hCG levels were less than 5000 mIU/mL and dropped to about 80% when levels were 5-10,000 mIU/mL, and success was less than 70% with an initial hCG level of greater than 15,000 mIU/mL.2  

The protocol for single-dose methotrexate is as follows:

Day 0

hCG, ultrasonography, and +/- D&C

Day 1 

hCG, SGOT/SGPT BUN, creatinine

Evidence of hepatic or renal compromise is a contraindication to methotrexate therapy. Blood type, Rh status, and antibody screening are also performed, and all Rh-negative patients are given Rh immunoglobulin.

Methotrexate (50 mg/m2 ) is administered by intramuscular injection. Advise patients not to take vitamins with folic acid until complete resolution of the ectopic pregnancy. They should also refrain from alcohol consumption and intercourse for the same period.

Day 4

The patient returns for measurement of the β-hCG level. The level may be higher than the pretreatment level. The day-4 hCG level is the baseline level against which subsequent levels are measured.

Day 7

Draw β-hCG and AST levels, and perform a CBC count. If the β-hCG level has dropped 15% or more since day 4, obtain weekly hCG levels until they have reached the negative level for the lab. If the weekly levels plateau or increase, a second course of methotrexate may be administered.

If the β-hCG level has not dropped at least 15% from the day-4 level, administer a second intramuscular dose of methotrexate (50 mg/m2 ) on day 7 and observe the patient similarly. If no drop has occurred by day 14, surgical therapy is indicated.

If the patient develops increasing abdominal pain after methotrexate therapy, repeat a transvaginal scan to evaluate for possible rupture.

Using this protocol, Stovall et al achieved a 96% success rate with a single injection of methotrexate.3

Medications

Drug Category: Antineoplastics — Inhibit cell proliferation by destroying rapidly dividing cells.

Drug Name
-Methotrexate (Folex, Rheumatrex)-Acts as a folate antagonist.

Adult Dose- Ectopic pregnancy: 50 mg/m2 IM on day 1; 50 mg/m2 IM on day 7 if β-hCG level has not dropped at least 15% from day-4 level

Pediatric Dose -Not indicated

Contraindications -Documented hypersensitivity; caution in pregnancy; caution in lactating patients; caution in those with history of alcohol abuse; caution in patients with liver dysfunction or infection; caution if patient has impaired liver or renal function or bone marrow depression

Interactions -Combined with acitretin, may increase risk of hepatotoxicity; combined with aspirin, may increase methotrexate levels; combined with COX-2 inhibitors, may increase methotrexate levels and risk of toxicity; combined with leflunomide, may increase risk of hepatotoxicity; NSAIDS, penicillins, probenecid, and salicylates may increase levels and risk of toxicity

Pregnancy -X-Contraindicated; benefit does not outweigh risk

Precautions -Caution in those with history of alcohol abuse; caution in patients with liver dysfunction or infection; caution if patient has impaired liver or renal function or bone marrow depression

Medical Versus Surgical Therapy

A study published by Hoover in 2010 reviewed trends in diagnosis and treatment of ectopic pregnancies in the United States from 2002-2007. Based on this report, over that period of time surgical management has decreased from approximately 90% to 65% while methotrexate therapy has increased from 10% to 35%. In this study, the authors reported that more than 60% of surgical cases were done laparoscopically and about 5% of surgical cases required medical therapy. In the medical treatment group, 15% were categorized as failure and required surgery.4

Surgical Therapy

Surgical therapy may be either open laparotomy or via the laparoscopic route. Ideally, all ectopic pregnancies requiring surgery should be treated laparoscopically. Risk factors for converting laparoscopy to laparotomy should be considered and include multiple prior surgeries, pelvic adhesions, skill of the surgeon and surgical staff, availability of the equipment, and condition of the patient.

A meta-analysis of medical versus surgical therapy for ectopic pregnancy was published in Human Reproduction Update 2008 and The Cochrane Collaboration. Results of this study indicated that laparoscopic surgery for ectopic pregnancy was the most cost-effective approach. Medical therapy using methotrexate was also cost effective for beta-hCG levels less than 3000 mIU/mL. Both approaches were found effective in appropriately selected patients with adequate follow-up.5 ,6

Preoperative Details

Obtain large-bore venous access and start fluid resuscitation; make sure blood is available. Do not delay the operation. The patient has an active bleeding site, and it must be stopped as soon as possible.

Place a Foley catheter prior to starting the procedure.

Either a Hulka tenaculum or a Harris-Kronner uterine manipulator/injector (ie, HUMI) device inserted into the uterus may be helpful in manipulating the tube during surgery.

Intraoperative Details

Regardless of the route of approach, salpingectomy is indicated in the following situations:

  • The ectopic pregnancy has ruptured.
  • Future fertility is not desired.
  • This is a sterilization failure.
  • It is a previously reconstructed tube.
  • Sterilization is requested.
  • Hemorrhage continues after salpingotomy.
  • The ectopic pregnancy is in the blind-ending distal segment after a previous partial salpingectomy.
  • This is a chronic tubal pregnancy.

In the absence of any of the above indications for salpingectomy, salpingotomy may be performed.

If the ectopic pregnancy is at the fimbria, then fimbrial evacuation is feasible, in the absence of indications for salpingectomy.

Partial salpingectomy may be indicated if the pregnancy is in the mid portion of the tube, none of the indications for salpingectomy is present, and the patient may be a candidate for later tubal reanastomosis.

Laparoscopy

  • Salpingectomy technique
    • Desiccate the tube between the uterus and the ectopic pregnancy using bipolar cautery.
    • Compress and desiccate the tuboovarian artery, while preserving the uteroovarian artery and ligament.
    • Cut along the desiccated path, closer to the specimen, leaving a pedicle for hemostasis.
    • Repeat until the tube is free and can be removed.
  • Salpingotomy technique
    • Infiltrate the mesosalpinx with vasopressin (20 IU in 50 mL of isotonic sodium chloride solution [ie, normal saline or NS]; some authors use only 10 IU in 50 mL of NS). Avoid intravascular injection because it is contraindicated in patients with ischemic heart disease. It frequently causes hypertension.
    • With the knife or needle electrode, make a 1- to 2-cm incision on the antimesenteric side of the tube.
    • Insert the aquadissector deep into the incision.
    • Fluid from the aquadissector, under pressure, dissects and dislodges the ectopic pregnancy and clots.
    • Irrigate the bed well.
    • If trophoblastic tissue remains, the use of vasopressin may lead to anoxia and death of the trophoblasts, preventing postoperative growth.
    • Further dissection may damage the tube and is not usually performed.
    • The products of conception are then removed through the 12-mm sleeve.
    • If needed, products of conception can be reduced to smaller pieces using biopsy forceps or the aquadissector.
    • Bleeding may be controlled by applying pressure with grasping forceps for 5 minutes.
    • Arterial bleeding may require pinpoint bipolar desiccation.
    • Diffuse venous bleeding is best controlled with monopolar current. A spark or arc is created using a current of 25-50 W through an electrode in noncontact mode.
    • Uncontrollable bleeding may require the application of an endo loop to provide compression for 10 minutes. The ligature is then released.
    • If bleeding continues, suture of the mesosalpingeal vessels may be attempted.
  • Fimbrial evacuation technique
    • Grasp the fimbria and rotate it to allow insertion of the aquadissector.
    • Fluid under pressure dissects and dislodges the ectopic pregnancy and clots.
    • Remove the products of conception.
  • Partial salpingectomy technique
    • Perform bipolar desiccation across the tube on both sides of the ectopic pregnancy.
    • Divide the tube at the sites of desiccation.
    • The mesosalpinx under the ectopic pregnancy can then be either desiccated or ligated with an endo loop.
    • Remove the products of conception.

Laparotomy

  • Salpingectomy technique
    • Clamp the tube between the uterus and the ectopic pregnancy using a Pean or similar clamp. Cut the pedicle free and ligate the pedicle with a suture ligature. (See following image.)

      • Salpingectomy technique. Shown here, the pedicle ...

        Salpingectomy technique. Shown here, the pedicle is cut free and ligated with a suture ligature.

    • Clamp, cut, and ligate the tuboovarian artery, while preserving the uteroovarian artery and ligament.
    • Continue to clamp, cut, and ligate the mesosalpinx until the tube is free and can be removed.
  • Salpingotomy technique
    • Infiltrate the mesosalpinx with vasopressin (20 IU in 50 mL NS). Avoid intravascular injection because it is contraindicated in patients with ischemic heart disease. It frequently causes hypertension.
    • With the knife or needle electrode, make a 1- to 2-cm incision on the antimesenteric side of the tube. (See following images).

      • Salpingotomy technique. A 1- to 2-cm incision is ...

        Salpingotomy technique. A 1- to 2-cm incision is made on the antimesenteric side of the tube using a needle electrode.


      • Salpingotomy technique. A 1- to 2-cm incision is ...

        Salpingotomy technique. A 1- to 2-cm incision is made on the antimesenteric side of the tube using a knife.

    • Insert the aquadissector, or a syringe filled with saline, deep into the incision.
    • Fluid from the aquadissector, or syringe, under pressure, dissects and dislodges the ectopic pregnancy and clots.
    • Irrigate the bed well.
    • If trophoblastic tissue remains, the prior injection of vasopressin may lead to anoxia and death of the trophoblasts, preventing postoperative growth.
    • Further dissection may damage the tube and is not usually performed.
    • Bleeding may be controlled by applying pressure with blunt tissue forceps for 5 minutes.
    • Arterial bleeding may require pinpoint bipolar desiccation.
    • Diffuse venous bleeding is best controlled with monopolar current. A spark or arc is created using a current of 25-50 W through an electrode in noncontact mode.
    • Uncontrollable bleeding may require application of a suture ligature to provide compression for 10 minutes. The ligature is then released.
    • If bleeding continues, suture of the mesosalpingeal vessels may be attempted.
    • The tubal incision is left open and not repaired.
  • Fimbrial evacuation technique
    • Grasp the fimbria and insert the aquadissector or a syringe filled with saline.
    • Fluid under pressure dissects and dislodges the ectopic pregnancy and clots.
    • Remove the products of conception.
  • Partial salpingectomy technique
    • Place a clamp through an avascular area in the mesosalpinx under the ectopic pregnancy. This creates a space through which 2 free ties are placed.
    • Tie the free ties around the tube on each side of the ectopic pregnancy.
    • Cut free and remove the isolated portion of the tube containing the ectopic pregnancy.

Postoperative Details

Most patients with an ectopic pregnancy are able to leave the hospital as soon as they have left the recovery room.

In patients who were in shock or had to receive blood transfusions, the postoperative observation should be longer and should include observation that the kidneys are functioning normally and the patient has regained normal hemodynamics.

Follow-up

All patients who have not had the entire ectopic pregnancy removed by salpingectomy need to have their weekly hCG levels observed until these levels return to nonpregnant values. If, during this time span the hCG level either plateaus or rises, treat the patient with methotrexate.

Patients should all be on some form of effective contraception until such time as their hCG levels have returned to nonpregnant levels.

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center . Also, see eMedicine's patient education article Ectopic Pregnancy .

Complications

While not exactly a complication, cervical pregnancy should be discussed. Cervical pregnancy is an ectopic pregnancy that has implanted in the cervix. This can cause severe hemorrhage if it starts to separate from the cervix. Few muscle fibers are in the cervix; thus, no constriction occurs around the hypertrophied blood vessels that developed for the pregnancy. With no pressure on the vessels, profuse hemorrhage can occur.

In recent years, ultrasound diagnosis has improved to the point that the diagnosis is made much more frequently in asymptomatic patients. This leads to many more management options.

Previously, the only treatment was surgical in nature, with curettage of the implantation site. This frequently led to such profuse hemorrhage that surgeons recommended opening the patient's abdomen and placing ligatures around the uterine arteries or hypogastric arteries prior to starting the curettage. Hysterectomy was frequently the result.

Currently, the recommended treatment is either hysterectomy for those who do not desire fertility or methotrexate for those who desire fertility. Because patients who receive methotrexate occasionally develop severe hemorrhage, observe these patients closely for 1-2 weeks after therapy. An interventional radiologist should be available for arterial embolization if severe hemorrhage occurs as the pregnancy separates from the cervix.

Medical pitfalls

Certain diagnostic pitfalls can occur for the physician sonographer in the diagnosis of ectopic pregnancy.

  • Low β-hCG levels: Consider β-hCG levels carefully in conjunction with ultrasound findings. Low β-hCG levels may be misleading. Kaplan et al found that 29% of ectopic pregnancies in women with β-hCG levels less than 1000 IU/L were ruptured.7 Indeterminate sonographic findings in pregnant patients should prompt further workup despite β-hCG levels.
  • Location of gestational sac: An ectopic pregnancy may be mistaken for a hemorrhagic corpus luteum cyst or bowel. Advanced ectopic pregnancies are misdiagnosed as an IUP when the gestational sac and contents have a normal appearance but the sonographer overlooks the extrauterine position of the sac. Using a systematic approach with longitudinal and transverse image planes of the uterus and adnexa is mandatory. The ultrasound examination is not complete when an IUP is identified.
  • Pseudogestational sac: A pseudogestational sac can be confused with a gestational sac or with embryonic demise. An ectopic pregnancy may stimulate the endometrium, causing a fluid collection within the endometrium.
  • Hemorrhage and hypovolemic shock
  • Infection
  • Loss of reproductive organs following surgery
  • Infertility
  • Urinary and/or intestinal fistulas following complicated surgery
  • Disseminated intravascular coagulation

Outcome and Prognosis

The prognosis for patients with an ectopic pregnancy is good for those with an early diagnosis.

Fertility may be conserved in those patients diagnosed with an ectopic pregnancy. The earlier the diagnosis is made and treatment administered, the higher the likelihood of subsequent fertility.

Thirty years ago, when the diagnosis was seldom made prior to rupture, the likelihood of a subsequent healthy term pregnancy was only approximately 35%. Currently, that number is closer to 85%. The difference is in the earlier diagnosis and treatment before the ectopic pregnancy can grow large enough to severely damage the tube.

Another factor in the improved fertility rate may be related to fewer salpingectomies and more salpingostomies. In a retrospective cohort study of 651 women who underwent an operation for their first ectopic pregnancy, Bangsgaard et al reported a fertility rate of 88% after conservative surgery (salpingostomy) versus only 66% after radical surgery (salpingectomy).8 They also found no difference in recurrence rates for ectopic pregnancy in the 2 groups. However, 8% of the group that underwent conservative treatment had persistent ectopic pregnancies. These were all treated with either methotrexate or repeat surgery. This shows the need to monitor all conservatively treated patients with serial β-hCG measurements until values return to negative.

Future and Controversies

Few well-designed studies have been done for the prevention, management, and treatment of ectopic pregnancy. Randomized controlled trials to assess the benefits and harms of the 3 different management strategies (expectant management, medical management, and surgery) are a priority. All such studies should include long-term outcomes of fertility, repeat ectopic pregnancy, health-related quality of life, treatment preferences, and the cost-effectiveness of each treatment option.

Biochemical markers for diagnosis of ectopic pregnancies have been studied but none have been found to be specific enough to be used clinically. The ideal marker should be specific for tubal damage or endometrial implantation. Leukemia inhibitory factor and smooth muscle heavy chain myosin do not appear to have the specificity needed to be used clinically. Three-dimensional ultrasonography has not been found to be superior to transvaginal sonography for the diagnosis of an ectopic pregnancy.

References

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