Management of

ectopic pregnancy
By Nil Goordyal


 Contents

 Mx of acute ectopic pregnancy
 Salpingectomy
 Mx of chronic ectopic pregnancy
 Mx of unruptured ectopic pregnancy
 Expectant management
 Medical management
 Conservative surgical management
 Summary

 Management of ectopic
pregnancy

 Approach evolved to more conservative medical or
surgical treatment
 Type of treatment individualized and depends on
clinical presentation of the patient
 Divided into acute, unruptured and subacute
(chronic or old)
 Mx of acute ectopic
pregnancy

 Principle is resuscitation and laparotomy
 Antishock treatment + simultaneous preparation for
urgent laparotomy
 Antishock treatment:
1. IV ringer’s solution
2. Arrangement for blood transfusion
3. Volume replacement with colloids (hemacel)
 Indication of laparotomy: Hemodynamically unstable,
Laparoscopy CI, evidence of rupture
 Approach to laparotomy is “quick in quick out”
 Steps of laparotomy

 Infraumbilical longitudinal incision
 Grasp uterus and draw it up under vision
 Tube and ovaries of both sides quickly inspected to
find site of rupture
 Salpingectomy; excised tube sent for HPE
 Ipsilat ovary and its vascular supply preserved
 Place of subtotal hysterectomy: Interstital pregnancy


 Mx of chronic ectopic
pregnancy

 All cases admitted as emergency
 Observation, investigations and patient put up for
laparotomy
 Usually pelvic hematocele found
 Blood clots removed
 Affected tube identified and salpingectomy done
 Mx of unruptured
ectopic pregnancy

 Expectant
 Medical
 Surgical
 Conservative
 Ablative
 Expectant Mx

 Observation done hoping spontaneous resolution
 Indications:
1. Initial serum hCG level < 1000 IU/L and subsequent
falling levels
2. Gestation sac < 4cm
3. No fetal heart beat on TVS
4. No evidence of bleeding or rupture on TVS
 Medical Mx

 Indications:
• Hemodynamically stable
• Serum hCG less than 3000 IU/L
• Tubal diameter < 4cm without any fetal cardiac
activity
• No intra abdominal hemorrhage
 Commonly used drugs: methotrexate, potassium
chloride, PGF2a, hyperosmolar glucose or actinomycin
 Systemic therapy: Single dose MTX 50mg/M² IM
 Monitoring

 Measure serum B-hCG on D4 and D7
 When decline in hCG b/w D4 and D7 > or equal to
15%= patient followed up weekly with serum hCG
until hCG < 10 mIU/mL
 If decline is less than 15%, second dose of MTX
50mg/M² given on D7
 Variable dose MTX

 MTX 1mg/kg IM on D1,D3,D5,D7
 Leucovorin 0.1mg/kg IM on D2,D4,D6,D8
 Serum hCG monitored weekly until < 5.0 mIU/ml
 Conservative Surgery

 Done either laparoscopically or microsurgical
laparotomy
 Indications:
• Cases not fulfilling criteria of medical therapy
• B-hCG not decreasing despite medical therapy
• Persistent fetal cardiac activity
 Linear Salpingostomy
• Longitudinal incision on antimesenteric border
• Remove products (by fingers, scalpel handle or
suction)

• Incision line kept open to be healed later
• Hemostasis by eletrocautery or laser
 Linear salpingotomy: Incision line closed in two
layers with 7-0 interrupted vicryl sutures (not
commonly done)
 Segmental resection
• Choice in isthmic pregnancy
• End to end anastomosis can be done
 Fimbrial expression: In cases of distal ampullary
pregnancy and done digitally

 Following conservative
surgery

 Estimation of B-hCG weekly till value < 5.0 mIU/ml
 Additional monitoring by TVS
 Persistent ectopic
pregnancy

 D/t incomplete removal of trophoblast
 High after fimbrial expression
 In cases where initial serum B-hCG level > 3000 IU/L
 Prophylactic single dose MTX (1mg/kg) IM

 References

 Dutta Textbook of Obstetrics