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Ectopic pregnancy

Last updated: September 10, 2021

Summarytoggle arrow icon

Ectopic pregnancy occurs when an embryo attaches outside the uterus, most commonly in the fallopian tubes. It is frequently associated with pelvic inflammatory disease (PID), which may lead to stenosis of the fallopian tubes. This prevents the fertilized egg from passing through to the uterus, instead causing it to attach to the tube itself. In addition to signs of pregnancy, symptoms include abdominal pain and vaginal bleeding. The first diagnostic step is to confirm the pregnancy with a β-hCG test, which should be followed by a transvaginal ultrasound to determine the location of the pregnancy and the fetal heartbeat. Uncomplicated ectopic pregnancies often resolve spontaneously and are usually difficult to diagnose. Patients are typically hemodynamically stable with low, declining hCG concentrations (< 5000 IU/L). Complicated cases may involve tubal abortion or rupture, which can lead to intraabdominal bleeding and shock. Whereas uncomplicated cases are treated conservatively (e.g., methotrexate or expectant management), complicated ectopic pregnancy requires surgical removal. In cases of abdominal pain in women of reproductive age, it is therefore important to rule out ruptured ectopic pregnancy.

Localization [4]

Risk factors [5][6][7][8]

Anatomic alteration of the fallopian tubes

Nonanatomical risk factors

General symptoms [13][14][15]

Right lower quadrant pain may indicate appendicitis. Cervical motion tenderness may be a sign of PID.

Tubal rupture [13][14][15]

The following recommendations are consistent with the 2018 American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on tubal ectopic pregnancy and the 2017 American College of Emergency Physicians (ACEP) Clinical Policy on the initial evaluation and management of patients with early pregnancy presenting to the emergency department. [1][17]

Approach [1][17][18]

Consider ectopic pregnancy in all women of childbearing age presenting with general symptoms of ectopic pregnancy or with known risk factors (e.g., anatomical alteration of the fallopian tubes).

Every woman of reproductive age with abdominal pain should undergo a pregnancy test, regardless of contraception use.

Up to 20% of patients with ectopic pregnancy can be hemodynamically unstable and require immediate therapy. Do not delay stabilization and definitive treatment to confirm the diagnosis! [19]

Laboratory studies [1][18][20]

Serum β-hCG level

Additional studies

Imaging [18][22]

Transvaginal ultrasound (TVUS)

Can be performed as a formal ultrasound or POCUS. [23]

Transabdominal ultrasound (TAUS)

  • Can be used to exclude differential diagnoses (e.g., acute appendicitis)
  • Provides a general picture of the pelvic anatomy and upper abdomen but is less sensitive than TVUS in detecting extrauterine pregnancy
  • POCUS can be performed using the transabdominal approach to rapidly rule in IUP if present.

Exploratory laparoscopy [1]

Do not delay laparoscopy in unstable patients with suspected ectopic pregnancy!

Endometrial biopsy [25]

The following recommendations are consistent with the 2018 ACOG practice bulletin on tubal ectopic pregnancy. [1]

Approach

  • Unstable patients: See “Management of ruptured ectopic pregnancy.”
    • Begin acute stabilization.
    • Obtain an immediate OB/GYN consult for emergency surgery.
  • Stable patients: Determine whether medical, surgical, or expectant management is appropriate.
    • Consider clinical, laboratory, and radiological findings.
    • Share decision-making with patients in consultation with OB/GYN.
  • All patients: Provide adequate supportive care.
  • Patients suited to medical or expectant management at home
    • Provide education on red flag symptoms indicating rupture, e.g., severe worsening pain, shoulder tip pain, dizziness, or heavy bleeding.
    • Arrange appropriate follow-up prior to discharge.

Supportive care

Provide for all patients regardless of management approach.

Do not forget anti-D immunoglobulin in all Rh-negative patients with bleeding!

Medical therapy (methotrexate) [1][18]

Methotrexate (MTX) is the treatment of choice.

Methotrexate regimens for medical treatment of ectopic pregnancy [1]
Single-dose regimen Two-dose regimen Multiple-dose regimen
Characteristics
  • Lower risk of adverse effects than other regimens
  • More effective than single-dose regimen for patients with high initial β-hCG
  • More adverse effects than other regimens
  • Higher success rate than other available regimens
Methotrexate administration
β-hCG monitoring
Response to β-hCG monitoring results
  • Decrease > 15% from day 4 to day 7: Measure β-hCG weekly until negative.
  • Decrease < 15% from day 4 to day 7: Repeat MTX dose.
  • No decrease after 2 doses: Consider surgical management.
  • Decrease > 15% from day 4 to day 7: Measure β-hCG weekly until negative.
  • Decrease < 15% from day 4 to day 7: Repeat MTX dose on day 7 and measure β-hCG on day 11.
  • This may be repeated until the patient has received 4 doses.
  • No decrease after 4 doses: Consider surgical management.
  • Decrease > 15% in 2 consecutive measurements: Discontinue MTX and measure β-hCG weekly until negative.
  • No β-hCG decrease after 4 doses: Consider surgical management.
Follow up

Methotrexate therapy is contraindicated in ruptured ectopic pregnancy!

Nonurgent surgical management [1][18]

See “Management of ruptured ectopic pregnancy” for emergency surgical indications and preferred approach.

  • Indications for nonurgent surgery
    • Contraindications for MTX
    • Unsuccessful medical treatment
    • A concurrent surgical procedure (e.g., bilateral tubal blockage) is necessary.
    • The patient has indicated a preference for surgical treatment.
  • Approach: Laparoscopy (preferred)
  • Procedure: salpingostomy, i.e., removal of ectopic pregnancy without removing the affected fallopian tube (tube‑conserving operation)

Expectant management [1]

Asymptomatic patients with very low β-hCG levels may experience spontaneous resolution of ectopic pregnancy without medical or surgical treatment. Consider this approach in select patients after consultation with OB/GYN. [1]

  • Indications
    • Minimal symptoms
    • No evidence of ectopic mass on TVUS
    • Confirmed plateauing or decreasing serial β-hCG levels
  • Considerations during expectant management
    • Provide extensive counseling on the risks of complications in addition to general counseling (see “Approach”).
    • Arrange close surveillance and serial β-hCG measurement (e.g., every 2–7 days).
  • Conversion to medical or surgical therapy
    • Increasing symptoms, e.g., pain, signs of ruptured ectopic pregnancy
    • Insufficient decrease, persistent plateau, or increase in β-hCG levels

Follow the ABCDE approach for patients with obvious signs of rupture and those at high risk of impending rupture.

Rapid assessment

Suspect ruptured ectopic pregnancy in patients in their first trimester with any of the following:

Obtain emergency OB/GYN consult without delay if ruptured ectopic pregnancy is likely!

Acute stabilization

Surgical management

Nonruptured ectopic pregnancy [1]

Ruptured or impending rupture of ectopic pregnancy [1]

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