A. Expectant Management
Because many ectopic pregnancies resolve spontaneously, it may be reasonable to manage an asymptomatic, compliant patient expectantly if β-hCG titers are low (< 200 mIU/mL) or decreasing, and the risk of rupture is low.
B. Surgical Treatment
The extent of surgery depends on the degree of damage to the uterus and adnexae. Preservation of the ovary should be attempted if feasible. Conservative surgery (ie, preservation of the fallopian tube) may be indicated in the hemodynamically stable patient with an ampullary pregnancy who wishes to preserve fertility.
A linear salpingostomy may be performed with a small (< 3 cm), intact ampullary pregnancy. The linear incision is allowed to heal by secondary intention. A linear salpingotomy involves closure of the incision and may be recommended in similar situations. Subsequent reproductive performance is comparable, with intrauterine pregnancy rates of 40-90%, but recurrent ectopic rates may be higher, up to 16%.
If the physician is competent in operative laparoscopy, both of these procedures can be performed through the laparoscope, assuming the pregnancy is < 3 cm, unruptured, and easily accessible. With both salpingostomy and salpingotomy, a β-hCG titer should be obtained weekly after surgery to ensure adequate removal of trophoblast and rule out a persistent ectopic. In stable patients, laparoscopy is preferred over laparotomy because of the associated reduction in morbidity and cost.
“Milking” the pregnancy out of the distal end of the tube is often tempting, but this has been associated with persistent trophoblast and need for reexploration, as well as increased risks of recurrent ectopic pregnancy.
With an isthmic ectopic pregnancy, segmental resection with subsequent anastomosis (usually at a later date) is typically recommended. As opposed to ampullary ectopics, the muscularis is well-developed, forcing the pregnancy to grow in the lumen. More conservative treatment such as salpingostomy or salpingotomy would likely cause scarring and compromise of the lumen. Furthermore, a tubal fistula may result if the tube were allowed to heal by secondary intention.
With fimbrial pregnancy, products of conception are often visible at the most distal end of the tube, which may be “plucked out.” As with ampullary ectopics, “milking” should be avoided.
Interstitial pregnancies require at least a cornual wedge resection, with uterine reconstruction and sometimes salpingectomy on the affected side. If there has been extensive tissue damage or if the patient is unstable, a hysterectomy may be needed.
Cervical ectopics may be associated with massive hemorrhage and may mandate hysterectomy. Attempts at medical management with methotrexate should be considered. Ovarian pregnancy requires oophorectomy and sometimes salpingectomy on the affected side. Abdominal pregnancy involves delivery of the fetus (sometimes at term) with ligation of the umbilical cord close to the placenta. The placenta is usually left in place to avoid hemorrhage following removal.
C. Emergency Treatment
Immediate surgery is indicated when the diagnosis of ectopic pregnancy with hemorrhage is made. Blood products should be available as transfusion is often necessary. There is no place for conservative therapy in a hemodynamically unstable patient.
D. Medical Management
Methotrexate (MTX), a folinic acid antagonist, has been shown to destroy proliferating trophoblast and may be effective in the medical management of small, unruptured ectopic pregnancies in asymptomatic women. Exclusion criteria include a noncompliant patient, peptic ulcer disease, immunodeficiency, pulmonary disease, liver disease, renal disease, blood dyscrasias, hemodynamic instability, free fluid in the cul-de-sac plus pelvic pain, or known sensitivity to MTX. Relative contraindications include an adnexal mass ≥ 3.5 cm or an extrauterine gestation with fetal heart motion, because of the higher failure rate. In select cases, approximately 90% of ectopics resolve, taking on average just under 1 month. Protocols vary from single to multiple injections, typically given systemically. The dose of MTX depends on the patient’s body surface area, and nomograms are available for determining the correct dose. Follow-up β-hCG levels, along with a complete blood count, serum creatinine, and serum aspartate transaminase are obtained, for comparison with baseline values. β-hCG levels should decrease by at least 15% 4-7 days after MTX administration. Failure of MTX therapy is suggested by a persistent rise or plateau in β-hCG titer, worsening pain in conjunction with a hemoperitoneum on ultrasound, and/or hemodynamic instability, and demands either another dose of MTX or surgery. Available studies comparing MTX to traditional surgical management report similar subsequent tubal patency and fertility rates. Arguments against its use include its toxicity, namely marrow suppression, dermatitis, and stomatitis, as well as potential for treatment failure and tubal rupture.
Chronic ectopics, with decreasing but persistent β-hCG titers, pose a management dilemma. Some will resolve on their own, while others will require surgery. Unfortunately, at present it is impossible to predict which patients will fail expectant management.
Rho (D) immune globulin should be given to any Rh-negative mother with the diagnosis of ectopic pregnancy, as sensitization can occur just as with intrauterine pregnancy.
Revision date: June 21, 2011
Last revised: by Andrew G. Epstein, M.D.