Ectopic Pregnancy Treatment

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.