MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY

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MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY

• Cary L. Clarke, MD

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Definition

• Pregnancy located outside the uterus
• Most common site is in the fallopian tube
• Tubal pregnancy may be the most dangerous
• Abdominal pregnancy may be carried to term in
  some patients

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Incidence and Impact

• Occurs in 1 in 50 pregnancies
• Is becoming increasingly more common
• Is the second leading cause of maternal mortality
  overall, and primary mortality factor in first
  trimester pregnancies
• May lead to impairment or loss of fertility

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Risk Factors

• Previous ectopic pregnancy
• Tubal damage from infection or surgery
• Increased age (more common after 35)
• Smoking (?)
• Use of an Intrauterine Device

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• Assisted reproduction (GIFT, IVF, ovulation
  induction)
• Tubal ligation
• History of infertility (implying underlying
  damage)
• History of PID (C.Trachomatis especially) is a
  predictor of ectopic pregnancy risk

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Symptoms (early)

• Amenorrhea for an average of 7 weeks
• Abdominal pain (usually lateral)
• Caveat some women have no pain, and about
  one-third of women will not have adnexal
  tenderness.
• Vaginal bleeding after an interval of amenorrhea
• may include uterine cast, the pregnancy
  endometrium which is sloughed with loss of
  progesterone from corpus luteum failure

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Symptoms (later)

• Hemodynamic instability
• Peritoneal signs/acute abdomen
• Distended, silent, doughy abdomen
• Shoulder pain

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Pathophysiology

• Conceptus lodges and implants in tube
• Positive beta-HCG and symptoms of pregnancy
• Overdistension of the tube eroding the blood
  vessels supplying the corpus luteum
• Failure of the pregnancy
• Bleeding into the abdominal cavity

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Natural history

• May regress spontaneously
• Abortion out the end of the tube
• Chronic hematoma formation
• Reimplantation elsewhere (abdominal pregnancy)

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Diagnosis

• History and physical
• any woman presenting with pain and vaginal
  bleeding should be considered to have an ectopic
  pregnancy until otherwise ruled out

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• Laboratory markers
• Beta-HCG(measured in mIU/mL) --lack of doubling
  signals only impending failure, not indicative of
  locationabsolute value only helpful in
  correlation with ultrasound
• Progesterone--also only indicates impending loss,
  not location

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• Ultrasound--transvaginal is most sensitive at
  this stage of pregnancy.
• Correlation with the quantitative serum hormone
  levels is suggested to increase your sensitivity
• if intrauterine gestational sac is seen and b-HCG
  is 1,000-2,000, normal pregnancy is virtually
  certain.
• If b-HCG is lt1,000 and there is an empty uterus,
  ectopic pregnancy is very likely

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• if b-HCG is is less than 1,000 and definite
  intrauterine ring of pregnancy is seen, SAB is
  imminent. Serum progesterone may be helpful (if
  less than 5ng/mL, pregnancy is nonviable).

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Finding Ectopic risk

• No mass or free fluid
• Any free fluid
• Echogenic mass
• Moderate to large amount fluid
• Echogenic mass and fluid

• 20
• 71
• 85
• 95
• 100

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Treatment Options

• Surgery
• Tube sparing salpingotomy--used when gestational
  sac is lt2cm and in distal tube lateral incision
  made and gestational sac removed
• Tube sacrificing salpingectomy
• Expectant mangagment
• b-HCG is lt1000 and falling, there is minimal pain
  and bleeding, and patient is reliable for
  follow-up

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• Methotrexate
• Requires proper patient selection
• Spares patient from surgery and its risks
• Does not require hospitalization
• May help preserve future fertility

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Patient Selection

• Hemodynamically stable
• No medical contraindications (normal LFTs, renal
  function, CBC and Plt)
• Unruptured ectopic pregnancy
• Absence of embryonic cardiac activity
• Ectopic mass 4cm or less
• Starting b-HCG lt5,000mIU/mL
• Reliable for follow up

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Mechanism of Action

• Methotrexate is an antimetabolite which inhibits
  the reduction of folic acid to tetrahydrofolate.
  This interferes with DNA synthesis and cell
  multiplication. Ideal for disrupting
  trophoblastic tissue proliferation.

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Success Rate

• Defined as resolution of pregnancy without
  surgery
• Systemic administration carries a rate between
  85 and 95, with preservation of fertility
• Single dose regimens are essentially as
  effective, with fewer side effects
• If a second dose is required, success rate is
  around 98

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Method of administration

• May inject into the gestational sac under
  ultrasound guidance
• Single dose systemic treatment
• Methotrexate 50mg/M2 body surface area
• Usual dose range is 50-120 mg, average dose is
  80-90mg
• Injected IM

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Follow up

• b-HCG is measured on days 1,4 and 7
• If hormone levels fail to decline at least 15
  between days 4 and 7, or at least 15 each week
  thereafter, repeat methotrexate dosing.
• Average time to resolution
• for single administration, 26days
• two dose patients, 48 days

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• Failure to resolve
• if the serial quantitative analysis fails to
  reach near zero levels, patient needs further
  ultrasonographic evaluation and possible
  exploratory surgery.

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Surgical Consultation

• Cervical pregnancy
• Tubal rupture
• Broad ligament pregnancy
• Interstitial/Cornuate pregnancy (implantation at
  the segment of tube penetrating uterine wall)
• Heterotypic ectopic (concurrent ectopic and
  intrauterine pregnancies)