Ectopic Pregnancy

David Blair Toub, M.D.

Dept. of Obstetrics and Gynecology
Pennsylvania Hospital

Overview
Increasing ( 1:66
Pregnancies)
Mortality Decreasing With Better Detection
Surgical and Medical Treatment Available
Recurrence Rate ~ 15%
Incidence

Risk Factors
Previous

Ectopic Pregnancy

PID
Tubal

Surgery
Infertility
???IUD Use (Probably Not)
IVF
Kartegeners Syndrome (zebra)

Sites
Ampulla

(95%)
Isthmus (8%)
Cornua (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)

Symptoms
Amenorrhea
Abdominal

Pain
Vaginal Bleeding
Syncope
Pelvic Mass

Evaluation and Diagnosis

History

and Physical Exam

CBC, T+S
Serial Quantitative -hCG (BSU)
Ultrasound
Progesterone Level?
Culdocentesis
Laparoscopy

Serial BSUs
-hCG

Levels Double Every 48 Hrs

< 66% Rise / 48 Hrs Consistent With Ectopic
Single Determination Not Helpful
Best If Done Within Same Laboratory
Never Rules Out Ectopic

Ultrasound
May

or May Not Be Helpful

Discriminatory Zone:
TV: 1500-2000 mIU/ml
TA: 6500 mIU/ml
+IUP: Generally Excludes Ectopic

Culdocentesis
Highly

Specific if Interpreted
Correctly: Presence of Free-Flowing,
NON-Clotting Blood
Negative Tap Inconclusive
May Obviate U/S
Most Helpful in Emergent Situations
to Confirm Diagnosis, But Remains
Controversial

Progesterone Levels
>

15 ng/ml a/w IUP

< 15: SAb or Ectopic
May Take Several Days for Result
Clinical Use Not Yet Widespread

Treatment
Observation
Laparoscopy
Laparotomy
MTX
Hyperosmolar

Glucose

Observation
Many

Tubal Pregnancies Abort

Israeli Study: Majority of Untreated
Ectopics Resolve
Not Yet Acceptable Standard of
Care in US

Laparoscopy
Allows

Diagnosis and Treatment

Salpingostomy
Salpingectomy (Total / Partial)
Cornual Resection
Minimally Invasive, Unlike Laparotomy
Few Contraindications: Unstable
Patient (Possibly)

MTX
Toxic

to Trophoblast Cells
Minimal Side Effects
May Preserve Fertility in Cases of
Cervical Pregnancy
Requires Compliant Patient, Time
Pain Not Uncommon
BSU May Rise Initially

Persistent Trophoblast
Most

Often A/W Salpingostomy

Laparoscopic ~ 3%
Minilap <1%
Most Easily Treated With MTX

Outcomes
15%

Repeat Ectopic Rate

2 Ectopics:
33% Pregnancy Rate
25% Ectopic
No Benefit To Removing Ovary
Along With Tube

Summary
Ectopic

Pregnancy is a Common,
Treatable Problem
Sensitive BSU Assays Allow Early
Detection
Surgical and Medical Options Exist
Ruptured Ectopics Should be
Unusual with Compliant Patients and
Appropriate Medical Care