Ectopic Pregnancy

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In ectopic pregnancy, implantation occurs in a site other than the endometrial lining o the uterine ca!ity"in the allopian tu#e, uterine interstitium, cer!i$, o!ary, or a#dominal or pel!ic ca!ity% Ectopic pregnancies cannot #e carried to term and e!entually rupture or in!olute% Early symptoms and signs include pel!ic pain, !aginal #leeding, and cer!ical motion tenderness% &yncope or hemorrhagic shock can occur with rupture% Diagnosis is #y '-human chorionic gonadotropin measurement and ultrasonography% Treatment is with laparoscopic or open surgical resection or with IM methotre$ate% Incidence o ectopic pregnancy (o!erall, )*+,, diagnosed pregnancies- increases as maternal age increases% .ther risk actors include prior pel!ic in lammatory disease (particularly due to /hlamydia trachomatis-, prior tu#al surgery, prior ectopic pregnancy (+, to )01 recurrence risk-, cigarette smoking, e$posure to diethylstil#estrol, and prior induced a#ortion% Pregnancy is less likely to occur when an intrauterine de!ice (IUD- is in place2 howe!er, a#out 01 o such pregnancies are ectopic% &imultaneous ectopic and intrauterine pregnancies occur in only +*+,,,,, to 3,,,,, pregnancies #ut may #e more common among women who ha!e undergone o!ulation induction or assisted reproducti!e techni4ues

such as in !itro ertili5ation and gamete intra allopian tu#e trans er (6I7T-2 in such cases, the reported ectopic pregnancy rate is 8 +1% The most common site o ectopic implantation is a allopian tu#e, ollowed #y the uterine interstitium (cornua-% /er!ical, cesarean section scar, o!arian, a#dominal, and pel!ic pregnancies are rare% 9upture o an ectopic pregnancy results in #leeding that can #e gradual, or rapid enough to produce hemorrhagic shock% Intraperitoneal #lood e!entually causes peritonitis% &ymptoms and &igns &ymptoms !ary% Most patients ha!e pel!ic pain, sometimes crampy, !aginal #leeding, or #oth% Menses may or may not #e delayed or missed% 9upture may #e heralded #y sudden, se!ere pain, ollowed #y syncope or #y symptoms and signs o hemorrhagic shock or peritonitis% 9apid hemorrhage is more likely in cornual ectopic pregnancies% /er!ical motion tenderness, unilateral or #ilateral adne$al tenderness, or an adne$al mass may #e present% The uterus may #e slightly enlarged (#ut less than anticipated #ased on date o last menstrual period-% Diagnosis Ectopic pregnancy is suspected in any emale o reproducti!e age with pel!ic pain, !aginal #leeding or une$plained syncope or hemorrhagic shock, regardless o se$ual, contracepti!e, and menstrual history% 7indings o physical (including pel!ic- e$amination are neither sensiti!e nor speci ic% Diagnosis re4uires measurement o the urine ' su#unit o human chorionic gonadotropin ('-h/6-, which is a#out ::1 sensiti!e or pregnancy (ectopic and otherwise-% I urine 'h/6 is negati!e and i clinical indings do not strongly suggest ectopic pregnancy, urther e!aluation is unnecessary unless symptoms recur or worsen% I urine '-h/6 is positi!e or i clinical indings strongly suggest ectopic pregnancy, 4uantitati!e serum '-h/6 and pel!ic ultrasonography are indicated% I 4uantitati!e serum '-h/6 is ; 0 mIU*m<, ectopic pregnancy is e$cluded% I ultrasonography detects an intrauterine gestational sac, ectopic pregnancy is e$tremely unlikely e$cept in women who ha!e used assisted reproducti!e technologies2 howe!er, cornual and intraa#dominal pregnancies may appear similar to intrauterine pregnancies% Ultrasonographic indings suggesting ectopic pregnancy (noted in += to 3)1- include comple$ (mi$ed solid and cysticmasses, particularly in the adne$a2 ree luid in the cul-de-sac2 and a#sence o a uterine gestational sac on trans!aginal !iews, particularly i the '-h/6 le!el is > +,,, to ),,, mIU*m<% A#sence o an intrauterine sac with a '-h/6 le!el > ),,, mIU*m< strongly suggests an ectopic pregnancy% Use o trans!aginal and color Doppler ultrasonography may impro!e detection rates%

I ectopic pregnancy appears unlikely and patients are sta#le, serum le!els o 'h/6 can #e measured serially on an outpatient #asis% ?ormally, the le!el dou#les e!ery +%@ to )%+ days up to @+ days2 in ectopic pregnancy (and in a#ortions-, le!els may #e lower than e$pected #y dates and usually do not dou#le as rapidly% I initial e!aluation or serial '-h/6 le!els suggest ectopic pregnancy, diagnostic laparoscopy may #e necessary or con irmation% Progesterone le!els may #e measured when the diagnosis is unclear2 i they are 8 0 ng*m<, a !ia#le intrauterine pregnancy is !ery unlikely% Prognosis and Treatment Untreated ectopic pregnancy is atal to the etus, #ut i treatment occurs #e ore rupture, maternal death is !ery rare% In the U&, ectopic pregnancy pro#a#ly accounts or :1 o pregnancy-related maternal deaths% Aemorrhagic shock is treated (see &hock and 7luid 9esuscitationB Prognosis and Treatment-2 such hemodynamically unsta#le patients re4uire immediate laparotomy% 7or sta#le patients, treatment is usually laparoscopic surgery2 sometimes laparotomy is re4uired% I possi#le, salpingotomy, usually using cautery or laser, is done to conser!e the tu#e, and the products o conception are e!acuated% &alpingectomy is indicated when ectopic pregnancies recur or are > 0 cm, when the tu#es are se!erely damaged, or when no uture child#earing is planned% .nly the irre!ersi#ly damaged portion o the tu#e is remo!ed, ma$imi5ing the chance that tu#al repair can restore ertility% The tu#e may or may not #e repaired simultaneously% A ter a cornual pregnancy, the tu#e and o!ary in!ol!ed can usually #e sal!aged, #ut occasionally repair is impossi#le and hysterectomy is necessary% I unruptured tu#al pregnancies are 8 3%, cm in diameter, no etal heart acti!ity is detected, and '-h/6 le!el is ; 0,,,, mIU*m< ideally #ut ; +0,,,, mIU*m< certainly, women can #e gi!en a single dose o methotre$ate &ome Trade ?ames 9AEUMAT9EC /lick or Drug Monograph 0, mg*m) IM% '-h/6 measurement and ultrasonography are repeated on a#out days @ and D% I the '-h/6 le!el does not decrease E +01, a )nd dose o methotre$ate &ome Trade ?ames 9AEUMAT9EC /lick or Drug Monograph or surgery is needed% A#out +, to 3,1 o women treated with methotre$ate &ome Trade ?ames 9AEUMAT9EC /lick or Drug Monograph e!entually re4uire a )nd dose% &uccess rates with methotre$ate &ome Trade ?ames 9AEUMAT9EC

/lick or Drug Monograph are a#out FD12 D1 o women ha!e serious complications (eg, rupture-% &urgery is indicated when methotre$ate &ome Trade ?ames 9AEUMAT9EC /lick or Drug Monograph is inappropriate (eg, '-h/6 le!el > +0,,,, mIU*m<- or ine ecti!e% <ast ull re!iew*re!ision ?o!em#er ),,0 /ontent last modi ied ?o!em#er ),,0 Back to Top

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