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Learning Issue: Etopic pregnancy

With an ectopic pregnancy the beginning of life starts outside of the uterus. Because
most ectopic prenancies develop inside the fallopian tubes, most people refer to them
as tubal pregnancies. Ectopic pregnancies cannot develop normally, only the uterus
contains the space and nutrient rich tissues that are required to nuture a fetus. One
other location an ectopic pregnancy can occur is in the ovary itself. Because the
ovaries and fallopian tubes are so narrow, a developing pregnancy can cause a
rupture. A ruptured tube can produce severe bleeding and can be life threatening. An
ectopic pregnancy can occur anywhere in the pelvic area.

Frequency: In the US: The incidence of ectopic pregnancy in 1992

based on aggregated inpatient and outpatient data was 108,800, or
19.7 per 1000 reported pregnancies. Females taking fertility drugs
have a higher risk of ectopic pregnancy than that of females not
taking such drugs.

Symptoms to look for in an ectopic pregnancy:

 A missed period.
 Signs of early pregnancy.
 Vaginal bleeding not caused by menstruation.
 Dizziness or fainting
 Low blood pressure when bleeding is severe.

Physical examination:

• Vaginal bleeding may be mild or absent.

• Abdominal pain may be minimal or severe.
• Shoulder pain is suggestive of peritoneal free fluid (significant
• Ectopic pregnancies can be accompanied by sloughing material, which
is suggestive of a miscarriage.
• Adnexal masses may be palpable in only 60% of patients (under
• Tenesmus or syncope may occur.
• Decidual cast may be passed.
• Clinical shock may occur after rupture.
Diagnosis of ectopic pregnancy

HCG levels

Although we talk a lot about hCG levels and ultrasound studies, the clinical
impression of the gynecologist or reproductive endocrinologist is the most important
factor in making a timely diagnosis of ectopic pregnancy.

Progesterone levels and ectopics

Progesterone levels are usually not of much use in making the diagnosis of ectopic pregnancy,
but they can be another clue

Ultrasound and Ectopics

With good vaginal probe ultrasound (vag probe is best for imaging the uterus), a normal
singleton pregnancy can be seen by the time the hCG level reaches 2000 mIU/ml

Surgical treatment of ectopic pregnancy

The possible procedures for ectopic pregnancy can all be done by laparoscopy (same
day surgery) or by laparotomy (bigger incision).

Medical therapy: Methotrexate

First tubal pregnancy treated and reported was in 1985.

Methotrexate inhibits rapidly growing cells such as a pregnancy or some cancer cells.
Most side effects seen with low-dose MTX therapy have been mild and transient.
Selection criteria for methotrexate:
1. Hemodynamically stable
2. No evidence of tubal rupture or significant intra-abdominal hemorrhage
3. Tube < 3-4 cm diameter
4. No contraindications to MTX
5. Informed consent
6. Patient will be available for protracted follow-up.