IUP Signs and symptoms ofruptured ectopic Assess risk factors for ectopic pregnancy Quantitative hCG Vaginal ultrasound and hCG within 12−24 hours ≥15% decline in hCG Plateau or rising hCG hCG/USG in 48 hours Nonlaparoscopic methotrexate Laparoscopy IUP • No IUP • No mass or mass ≤3.5 cm • No IUP • Ultrasound consistent with unruptured ectopic pregnancy NonlaparoscopicMethotrexate D & C Repeat hCG in 48−72 hours • No IUP • Mass >3.5 cm IUP • No IUP • ≥50% rise in hCG Repeat hCG/USGwhen hCG is expected to be ≥2000 • No IUP plateau or rise≥50% hCG Repeat hCG in 48−72 hours Falling Completedabortion D & C Plateau or rising hCG IUP Ultrasound consistent with completed abortion Ultrasound consistent with incomplete abortion • No IUP • Mass ≤3.5 cm suspicious for ectopic• hCG rising• hCG <2000 • No IUP • Mass >3.5 cm suspicious for ectopic• hCG ≥2000 • No IUP • No mass, or mass ≤3.5 cm • hCG ≥2000 Immediate surgical treatment
Figure 20.5 Nonlaparoscopic algorithm for diagnosis of ectopic pregnancy.
D & C Uterine curettingsfloated in saline Villi present Villi present hCG increasing mass >3.5 cm hCG increasing mass ≤3.5 cm Ectopic pregnancy Nonlaparoscopicmethotrexate DecreasinghCG • Completed Ab• Ectopic-spontaneousresolution IncreasinghCG Follow-uphCG in 48 hours DecreasinghCG Laparoscopy • Incompleteabortion • Routine follow-up Villi absent Await final histology • Repeat hCG in 12–24 hours • Transvaginalultrasound Villi absent
Figure 20.5 (continued ) hCG, human chorionic gonadotropin; IUP, intrauterine pregnancy; USG, urine specific gravity; D&C, dilation and curettage.
identified, the patient is considered to have an extrauterine pregnancy and can be treated without further testing.
2.
Adnexal cardiac activity, when seen, definitively confirms the diagnosis of ectopic pregnancy.
3.
A tubal mass as small as 1 cm can be identified and characterized. Masses greater than 3.5 cm with cardiac activity or larger than 4 cm without cardiac activity should not be treated with medical therapy.
Suction curettage is used to differentiate nonviable intrauterine pregnancies from ectopic gestations (less than 50% rise in hCG level over 48 hours, an hCG level of less than 2,000 mIU/mL, and indeterminate ultrasonography findings). Performance of this procedure avoids unnecessary use of methotrexate in patients with abnormal intrauterine pregnancy that can be diagnosed only by evacuating the uterus. An unlikely potential problem with suction curettage is missing either an early nonviable intrauterine pregnancy or combined intrauterine and extrauterine pregnancies.
Treatment Ectopic pregnancy can be effectively treated medically or surgically. Traditionally, exploratory laparotomy with unilateral salpingectomy was used for diagnosis and treatment for ectopic pregnancies. With techniques available that allow for early detection, including serum quantitative hCG levels and ultrasound, more conservative treatment options are available. Minimally invasive surgical techniques and medical management with methotrexate are the commonly used treatment options for ectopic pregnancies. The treatment approach depends on the clinical circumstances, the site of the ectopic pregnancy, and the available resources.