Ectopic Pregnancy

武功密笈

小黃藏書

Ectopic Pregnancy

~ Ectopic Pregnancy ~

¹ Diagnostic Criteria in The Presence of Acute Abdomen:

Abdominal pain with or without peritoneal signs, vaginal bleeding (+ /- ), etc.

Positive for urine pregnancy test

Positive for culdocentesis

TVS shows no IUP, adnexal mass, and/or internal bleeding

　

¹ Recommended Diagnostic Approach in The Absence of Acute Abdomen:

Diagnostic Tools:

? Blood sampling for CBC, liver and renal function tests, blood group, and β-hCG

‚ TVS, which can detect IUP whenβ-hCG > 1500 IU/L (mIU/mL), with the

exception of pregnancy as result of IVF, combined intrauterine and extrauterine

pregnancy

Situations Encountered:

j If TVS shows IUP (+):

ð Under most circumstances, investigation for ectopic pregnancy can be

terminated.

Q Exception: pregnancies following IVF treatment

k If TVS shows no IUP and serum β-hCG > 1500 IU/L (mIU/mL):

~ Ectopic pregnancy is very likely, however, an early twin gestation is also likely.

ð Repeat TVS and β-hCG 3 days later:

An ectopic pregnancy is a certainly if at that juncture

the serum β-hCG is increasing yet still no IUP

is observed on TVS.

R If the precise GA is known, as it is for IVF patients or those

undergoing ovulation induction, the failure to detect a GS 24 days

or more after ovulation indicates an ectopic pregnancy.

l If TVS shows absence of IUP and adnexal mass (+ ), as well as

serum β-hCG > 1500 IU/L (mIU/mL):

ð An extrauterine pregnancy is almost certain.

m If TVS does not reveal an ectopic tubal pregnancy and

serum β-hCG < 1500 IU/L (mIU/mL):

ð Repeat TVS and β-hCG twice weekly

R β-hCG levels are usually found to double every 2 to 3 days, either in IUP until 6 to 7

weeks’ gestation, or in some early ectopic pregnancies.

R Nondoubling of β-hCG level is found in nonviable pregnancies, including ectopic and

intrauterine pregnancies that are destined to abort (miscarry).

n If repeated TVS still does not show an adnexal mass and the

serum β-hCG fails to double after 72 hours:

ð The clinician can be certain no normal intrauterine pregnancy exists and

can administer medical treatment.

　

¹ Medical Treatment: (single-dose methotrexate intramuscular injection)

± Candidates:

High compliant women with asymptomatic ectopic pregnancy, who have

serum β-hCG < 5000 IU/L (mIU/mL), tubal size < 3 cm, and no fetal

cardiac activity on U/S

± Practical, high success rates (ranging from 86% to 94% in properly selected

cases), not skill-dependent.

± Site Effects:

- Tubal rupture can still occur despite low and declining serum β-hCG levels.

- Stomatitis usually mild

- Conjunctivitis and self-limited

- Dermatitis

- Pleuritis

± Protocol for Methotrexate Treatment for Ectopic Pregnancy:

　

Pretreatment tests

· CBC, BG, liver and renal function tests, serum β-hCG, TVS

Treatment day 0

· Methotrexate (50 mg/m²) IM

· RhoGAM 300 μg IM, if needed

· Discontinue folinic acid supplements

· Advise the p’t to refrain from strenuous exercise and intercourse

Treatment day 4

· Serum β-hCG

Treatment day 7

· Serum β-hCG

· TVS

· Second dose of metnotrexate if the decline in serum β-hCG is

< 25% of day 0 level

Weekly

· Serum β-hCG until the level is < 10 mIU/mL

· TVS

Any time

· Laparoscopy if U/S reveals hemoperitoneum > 100 mL,

severe abdominal pain, or acute abdomen

¹ Surgical Treatment:

± Candidates:

Patients not suitable for medical treatment

± Conservative Surgery: (laparoscopic salpingostomy)

- Higher subsequent intrauterine pregnancy rage

- Higher recurrence rate of ectopic pregnancy

- A logical option for women wishing to preserve fertility

- Technique of laparoscopic salpigostomy:

? Vasopressin (0.2 IU/mL of physiologic saline) injection into the wall of the tube at

the area of maximal distention

‚ A 10- to 15- mm longitudinal incision on the maximally distended antemesosalpix

wall of the tube

ƒ Removal of conception product by combination of hydrodissection and gentle

blunt dissection with a suction irrigator.

(Removing it piecemeal with forceps is inadvisable and may lead to retained

trophoblastic tissue.)

„ Removal of conception product from abdominal cavity.

… Check bleeding under water

~ Light application of bipolar coagulation or ligation of vessels in the

mesosalpinx

~ Coagulation of the “placental bed” inside the tube is not recommended,

as it will lead to tubal destruction.

- Post-operative follow-up: day 1 and weekly serum β-hCG

If day 1 serum β-hCG falls 50% or more from preoperative value, there is a greater

than 85% probability that a persistent ectopic pregnancy will not occur.

± Radical Surgery: (salpingectomy)

- Indications:

Uncontrolled bleeding, ectopic pregnancy that recurs in the same tube,

a severely damaged tube, tubal pregnancy of 5 cm or more, and ectopic

pregnancy in women who have completed their family.

　

¹ Treatment for Persistent Ectopic Pregnancy:

j A single dose of methotrexate (50 mg/m²)

k TVS and serum β-hCG are measured weekly until the level is below 10 IU/L

　

¹ Place for Expectant Management:

Expectant management is done when ectopic pregnancy is suspected, but TVS

fails to reveal an ecoptic pregnany.

　

¹ Conclusion:

Early diagnosis has allowed conservative surgical and medical treatment of

ectopic pregnancy. The clinical presentation, serum β-hCG levels, and TVS

findings dictate the management of this condition. Methotrexate can be given to

women with asymptomatic ectopic pregnancy, who have high compliance, serum

β-hCG levels below 5000 IU/L, tubal size less than 3 cm, and no fetal cardiac

activity on U/S. The most practical and efficient method is a single intramuscular

injection. Those patients who do not meet the criteria for methotrexate treatment

should be treated surgically, which can be done by laparoscopy.

　

§ References:

1. Togas Tulandi, MD. New protocol for ectopic pregnancy.

Contemporary OB/GYN, October 1999, P42-55

Filename: Ectopic Pregnancy