Ectopic Pregnancy

• An ectopic pregnancy, also called a "tubal pregnancy," is any pregnancy in which the fertilized egg implants on any tissue other than the endometrial lining of the uterus (womb).
• 95% of ectopic pregnancies occur in the fallopian tube, while 1.5% occur in the abdomen, 0.5% in an ovary, and 0.03% in the cervix.
• An ectopic pregnancy should be considered a medical emergency.  The death rate from ectopic pregnancies is about 1 per 2000 ectopics in this country. This means that 40 to 50 women die each year from ectopic pregnancy in the U.S.
• There has been a large drop in the death rate from ectopic pregnancy since 1970.

Risk Factors

• Pelvic inflammatory disease (PID) -- The rate of ectopic pregnancy in women with previous known PID is increased 6 to 10 times higher than in women with no previous history of PID.
• Previous ectopic pregnancy
• Progesterone-bearing IUD's -- 16% of pregnancies in women using progesterone-containing IUD's were ectopics.
• Tubal ligation (sterilization) -- After non-laparoscopic tubal ligation, about 12% of pregnancies are ectopic; after laparoscopic tubal coagulation, about 51% of pregnancies are ectopic.
• Previous tubal surgery
• Fertility treatment with ovulation induction or ovarian stimulation
• In vitro fertilization (IVF) -- About 2 to 5% of clinical pregnancies resulting from IVF are ectopic. The figure is higher for women with a history of previous ectopic pregnancy or tubal infertility.
• Some studies have suggested that tubal pregnancies are more likely in African American women.
• Douching -- There are still no definitive answers to the question of whether douching increases the risk of ectopic pregnancy. One study showed an increased association between the length of time a woman douched and her likelihood of ectopic pregnancy in African American women. Women who douched once or more per month for 5 years had a 4-times increased risk of ectopics compared with women who never douched.  Women who douched once per month or more for 10 years had a 6-fold increased risk compared with women who never douched (Kendrick JS et al:  American Journal of Obstetrics and Gynecology, May 1997, 176(5):991-997).

 Diagnosis

• The clinical impression of the gynecologist or reproductive endocrinologist is the most important factor in making a timely diagnosis of ectopic pregnancy.
• Blood HCG levels and vaginal ultrasound are also very helpful in making the diagnosis. By 5.5 to 6 weeks of pregnancy (1.5 to 2 weeks after a missed period), all normal pregnancies should be seen by vaginal ultrasound.
• 20 to 30% of ectopics have no detectable sonographic abnormality.
• The usual finding for ectopic on ultrasound is a mass on one side, some fluid in the pelvis, and no normal pregnancy structures in the uterus.
• Conclusive diagnosis of ectopic by ultrasound can only be made if fetus or fetal cardiac motion is seen outside the uterus. This is only seen in about 20% of ectopics with vaginal probe ultrasound.
• Sac in uterus: A "pseudosac" is seen in 10 to 20% of ectopics. This is a sac in the uterus that is not a pregnancy but can look like one initially. We need to see a yolk sac, a fetal pole, or cardiac motion to be sure it is a normal pregnancy.

Treatment

• The possible treatment procedures for ectopic pregnancy can all be done by laparoscopy (same day surgery) or by laparotomy (bigger incision). Usually, if the tube is not ruptured it is done by laparoscopy. Cases of rupture with significant hemorrhage into the abdomen are almost always done by laparotomy because it can be done more safely and quickly.
• Procedures:
• Salpingotomy (or -ostomy): Making an incision on the tube and removing the pregnancy.
• Salpingectomy: Cutting the tube out.
• Segmental resection: Cutting out the affected portion of the tube.
• Fimbrial expression: "Milking" the pregnancy out the end of the tube.
• In general, the procedure of choice will be salpingectomy if future fertility is of no concern, if the tube is ruptured, if there is significant anatomic distortion, or if there is overt hemorrhage.
  
  
• There is no evidence that suturing the incision on the tube closed or leaving it open is better.

Persistent Ectopic Pregnancy

• If the tube is saved at surgery, there is a risk that some of the pregnancy may remain in the tube. This tissue can persist and resume growing. A mass can form with subsequent rupture and hemorrhage. Case reports of patients who developed symptoms after conservative surgery have generally been at least 10 days after surgery.  If a persistent ectopic is diagnosed, methotrexate therapy is usually the treatment of choice.

Medical Therapy

• The first tubal pregnancy treated with methotrexate was reported in 1985.
• Methotrexate is a chemotherapeutic agent, which inhibits rapidly growing cells such as a pregnancy and some cancer cells.
• Most side effects seen with low-dose MTX therapy have been mild and transient.
• Selection criteria for methotrexate:
  
  
1. Patient must be hemodynamically stable (blood circulation is stable).
2. No evidence of tubal rupture or significant intra-abdominal hemorrhage
3. Tube must be less than 3 to 4 cm diameter.
4. No contraindications to MTX.
5. Informed consent must be obtained.
6. Patient will be available for protracted follow-up.
   
   
• Good results with very few side effects are seen with use of a single IM dose of 50 mg/square meter.
• Resolution of the ectopic has been reported in about 70 to 95% of cases treated. This depends somewhat on selection criteria for the study.
• Tubal patency rates by hysterosalpingogram have been 70 to 85% on the same side as the ectopic.
• Repeat ectopic and pregnancy rates are comparable to those after conservative surgery.

Future Fertility

• Conservative surgery for small, unruptured ectopics restores tubal patency in over 80% of cases.
• In general, the ratio of intrauterine to recurrent ectopic pregnancies is about 6:1 but it rises to about 10:1 if the other tube appears normal.
• After one ectopic and a tubal sparing surgery:
• --The subsequent delivery rate is about 55 to 60%.
• --The recurrent ectopic rate is about 15% (about 20% of pregnancies are ectopics).
• --The infertility rate is about 25-30%.
  
  
• If the other tube is absent or blocked:
• --The subsequent delivery rate is about 45 to 50%.
• --The recurrent ectopic rate is about 20% (about 30% of pregnancies are ectopics).
• --The infertility rate is about 30 to 35%.
  
  
• After 2 or more ectopics and conservative surgery:
• --The subsequent delivery rate is about 30%.
• --The recurrent ectopic rate is about 20 to 30% (about 50% of pregnancies are ectopics).
• --The infertility rate is about 40 to 50%.
  
  
• As a woman has more ectopics, the chances for a delivery without treatment decrease.
• After a tubal-saving procedure, ectopic pregnancy is equally likely to recur in the operated tube as in the other tube.
• Overall, delivery rates are very similar after salpingostomy or salpingectomy if there is no history of infertility and the other tube appears normal.
• If the other tube appears diseased and the woman has a history of infertility, salpingostomy gives a higher delivery rate (76% vs. 44% in one study) and also a higher risk of recurrent ectopic than would salpingectomy.

It is very important to talk to your doctor about the issues surrounding future reproductive desires before surgery (if possible). You should be aware of the risks of infertility, recurrent ectopic, and persistent ectopic pregnancy if a tubal-saving procedure is done.

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Created: 9/15/2002  -  Donnica Moore, M.D.