Ectopic Pregnancy

Epidemiology/Risk

100

What is the most common location for ectopic pregnancy? 

Fallopian tube 90% (specifically, ampulla)

abdomen (1%), ovary (1-3%), cervix (1%), c-section scar (1-3%)

200

What percentage of total pregnancies are ectopic? 

~2% (though national surveillance data not updated since 1992)

300

What percentage of women with ectopic pregnancy have no known risk factors? 

50%

https://doi.org/10.1016/j.fertnstert.2005.12.023

400

Name the risk factors for ectopic pregnancy

Prior ectopic (10% chance of repeat)

Previous damage to fallopian tubes, factors secondary to ascending pelvic infection, prior pelvic/fallopian tube surgery, tubal factor infertility, multiple embryo transfer in IV

cigarette smoking, age > 35

500

What percentage of pregnancies that occur with an IUD in place result in ectopic pregnancy? 

up to 53% (though overall risk of ectopic lower due to lower chance of pregnancy)

https://doi.org/10.1016/j.ajog.2003.07.021

Diagnosis

100

Minimal diagnostic evaluation

transvaginal ultrasound + confirmation of pregnancy

200

signs of ruptured ectopic pregnancy

hemodynamic instability, acute abdomen (peritoneal signs)

300

At what gestational age should an intrauterine gestational sac with yolk sac be visible on transvaginal ultrasonography? 

5-6 weeks of gestation 

400

What ultrasound findings should raise suspicion for ectopic pregnancy? 

mass or a mass with a hypoechoic area that is separate from the ovary

definitive findings: a gestational sac with a yolk sac, or embryo, or both, is noted in the adnexa

500

In what case is visualization of an intrauterine pregnancy not sufficient to rule out ectopic? 

Rare instance of heterotopic pregnancy. (risk 1/4,000-1/30,000 in naturally achieved pregnancy, estimated to be as high as 1/100 in IVF)

https://doi.org/10.1093/humupd/2.6.541

https://doi.org/10.1016/j.fertnstert.2006.05.085

Medical Management

100

Medical Management for Ectopic

Methotrexate 

single-dose, two-dose and multidose protocols. 

multi has higher efficacy compared to single (92.7 vs 88.1%), but single has lower risk of adverse effects OR 0.44 (95% CI 0.31-0.63)

200

Mechanism of action of methotrexate

folate antagonist. Binds the catalytic site of dihydrofolate reductase--> interrupts synthesis of purine nucleotides & amino acids serine and methionine--> inhibition of DNA synthesis/repair 

300

Candidates for 

confirmed or high suspicion of ectopic pregnancy, hemodynamically stable, unruptured mass, no absolute contraindications

400

Absolute Contraindications for

intrauterine pregnancy

evidence of immunodeficiency 

moderate to severe anemia, thrombocytopenia, leukopenia

sensitivity to methotrexate 

Active pulmonary disease, peptic ulcer disease, hepatic disease, renal dysfunction

breastfeeding

ruptured ectopic, hemodynamically unstable, inability to follow-up

500

When was methotrexate first used to treat ectopic pregnancy? 

1982

Surgical Management

100

Typical surgical management

laparoscopic salpingectomy (removal of part/all of fallopian tube)

laparascopic salpingostomy (removal of ectopic pregnancy without removal of tube)

200

Required for

patients with hemodynamic instability, ruptured ectopic mass, signs of intraperitoneal bleeding 

any absolute contraindications to methotrexate 

failed medical management

300

When is laparotomy indicated

Patients with hemodynamic instability/large amts of intraperitoneal bleeding, patients with poor visualization by laparoscopy 

400

In what case is salpingectomy preferred

significant tubal damage

500

Which surgical procedure results in fewer future ectopic pregnancies, which in higher subsequent intrauterine pregnancy rates? 

No statistical difference in RCTs

Cohort studies - salpingostomy higher intrauterine, but higher risk of ectopic