- Ectopic pregnancy is common and can be life threatening.
- Clinical signs and symptoms are nonspecific and are frequently present in healthy pregnancy as well as ectopic pregnancy.
- Serum خ²-human chorionic gonadotropin levels and ultrasound are used to make early diagnosis.
- Medical or surgical treatment may be used, with similar long-term outcomes in terms of tubal function and future fertility.
Background
Definition
An ectopic pregnancy is one in which the fertilized ovum implants at any site other than the endometrial cavity. The fallopian tube is the most common site, accounting for more than 95% of ectopic pregnancies, but other implantation sites include the cervix, abdominal cavity, and ovary.
Incidence
The incidence of ectopic pregnancy in the United States has nearly tripled over the past 30 years; whether this is due to increasing recognition because of sensitive diagnostic tools or a true increase is unclear. Currently, ectopic locations are diagnosed in approximately 1.5% of clinically recognized pregnancies. Ectopic pregnancy is the most common cause of non-puerperal maternal mortality and is the leading cause of first-trimester maternal death. With an ectopic pregnancy, the risk of maternal death is 10 times that of childbirth and 50 times greater than first-trimester legal abortion.
| TABLE 7-1 Risk Factors and Relative Risk for Ectopic Pregnancy | ||||||||||||||||||||
| ||||||||||||||||||||
Etiology
A number of risk factors for ectopic pregnancy have been identified (Table 7-1). including the following conditions:
- Salpingitis. Approximately 50% of ectopic pregnancies can be attributed to a history of salpingitis. Salpingitis has been shown to increase a woman's risk for ectopic pregnancy sevenfold. Chlamydial salpingitis may pose a greater risk than gonorrheal infection.
- Prior ectopic pregnancy. In subsequent pregnancies there is a 15% to 20% risk of recurrence, in either the same or opposite tube.
- Peritubal adhesions following postabortal or puerperal infections, appendicitis, or endometriosis.
- Tubal surgery, including tubal ligation, tubal reanastomosis, prior surgery for ectopic pregnancy, and infertility tubal surgery.
- Intrauterine device. Intrauterine devices (IUDs) are highly effective at preventing intrauterine pregnancy. Thus, any pregnancy in an IUD user is more likely to be tubal.
- Progestin-only contraceptives. Users of progestin-only oral contraceptives as well as injectable progestins are at increased risk of ectopic pregnancy if pregnancy occurs, possibly because of altered tubal motility.
- History of infertility. Infertile couples have an increased proportion of ectopic pregnancies compared to the total number of pregnancies, regardless of the etiology of the infertility.
- Assisted reproductive techniques:
- Women who have conceived via assisted reproduction technologies are at increased risk of ectopic pregnancy, regardless of the etiology of their infertility. Approximately 5% of pregnancies occurring as a result of in vitro fertilization, gamete intra-Fallopian tube transfer (GIFT), gonadotropin-stimulated superovulation, and other methods of assisted reproduction result in ectopic pregnancies.
- Heterotopic pregnancy (simultaneous ectopic and intrauterine pregnancies) occur at a much higher rate in women treated with assisted reproductive technologies. Up to 2% of ectopic pregnancies in this population are heterotopic.
- Diagnosis of ectopic pregnancy is more challenging in women receiving reproductive assistance. Women treated with assisted reproductive technologies are more likely to have abdominal pain and spotting early in pregnancy. Even when confronted by a probable ectopic pregnancy, both patients and clinicians are reluctant to interfere with technologically conceived pregnancies, which may result in delay in both diagnosis and treatment.
- Developmental abnormalities of the tube, such as diverticula, accessory ostia, and hypoplasia. Women who have been exposed to diethylstilbestrol have a four to five times greater risk of ectopic pregnancy.
- Increased maternal age.
Pathogenesis
- In tubal pregnancies, the fertilized ovum implants in the epithelium of the tube. The trophoblast invades the tubal muscularis and the maternal blood supply, resulting in bleeding and weakening of the tubal wall. Eventually, the pregnancy either extrudes out the fimbriated end of the tube (tubal abortion) or ruptures the wall of the tube. Either of these situations can cause intra-abdominal bleeding.
- Approximately 80% of tubal pregnancies implant in the ampullary portion of the tube, and 5% implant more distally on the fimbriae.
- Isthmic pregnancies, accounting for approximately 13% of ectopic pregnancies, rupture earlier than ampullary pregnancies and may result in secondary broad ligament implantation.
- Interstitial pregnancies, although only 2% of ectopics, result in the greatest morbidity because they can grow large and can mimic an intrauterine pregnancy. When these pregnancies rupture, severe hemorrhage may ensue.
Diagnosis
- Ectopic pregnancy should be suspected any time a woman presents with bleeding and/or pain in early pregnancy. While abnormal intrauterine pregnancy is more common than ectopic pregnancy, ectopic pregnancy is more likely to be life threatening; therefore, it is critical to consider the diagnosis.
- The diagnosis of ectopic pregnancy is not always obvious; initial diagnoses are often incorrect. Women may present with catastrophic intra-abdominal hemorrhage and shock; however, more frequently they will have ill-defined abdominal pain and minimal vaginal bleeding.
- It is important to carefully evaluate all women of reproductive age with abdominal pain. Early diagnosis before rupture decreases morbidity and allows wider treatment options. More than half of women presenting with life-threatening intra-abdominal bleeding have had at least one visit to a health care provider before rupture.
Clinical Manifestations
- Women with catastrophic presentation. Women with hemoperitoneum as a result of ruptured ectopic pregnancy will present with an acute abdomen and shock. Often there is a history of vague abdominal pain followed by sudden and worsening acute pain
beginning in the lower quadrants and extending to the entire abdomen. Pelvic exam may reveal a doughy mass in the cul-de-sac caused by clotted blood. Assessment of the uterus and adnexa is usually impossible because of abdominal distention and rigidity.
- Signs and symptoms with a less catastrophic presentation:
- Abdominal pain is present in more than 95% of women with ectopic pregnancy. The pain often begins as intermittent, colicky discomfort in one lower quadrant, progressing to more constant, severe pain that generalizes throughout the lower abdomen. The degree of pain may be less than expected, even with a significant hemoperitoneum. Shoulder pain is present in 15% of women with a ruptured ectopic pregnancy as a result of blood irritating the diaphragm.
- Delayed menses is reported by 90% of women with ectopic pregnancy, varying from a few days to several weeks.
- Vaginal bleeding, often as spotting, is present in 80% to 90% of women in whom ectopic pregnancy is ultimately diagnosed. However, bleeding is present in about half of all pregnancies, even those with normal outcome. The abnormal bleeding results from low hormonal levels with resulting slough of the endometrium. Bleeding ranges from scant spotting to menstrual-like flow. Some women report passage of tissue, representing decidualized endometrium.
- Physical examination reveals abdominal tenderness, adnexal tenderness, especially unilateral, and cervical motion tenderness. Up to 10% of women present with intra-abdominal hemorrhage, in which case diffuse abdominal tenderness and rigidity, rebound tenderness, and hypovolemic shock may be present.
- Abdominal tenderness is found in 80% to 90% of women with ectopic pregnancies varying from mild to severe tenderness, guarding, and rebound tenderness.
- Adnexal tenderness on pelvic exam is present in nearly all women with ectopic pregnancies, and it may be associated with cervical motion tenderness.
- Adnexal mass or cul-de-sac mass may be palpable in 50% of women with ectopic pregnancy; however, it is contralateral to the pregnancy nearly half the time and is often a corpus luteum cyst rather than the gestation itself.
- Uterine enlargement, often less than expected relative to the last menstrual period, is present in 25% and does not rule out ectopic pregnancy.
Differential Diagnosis
- Other pregnancy-related conditions. Threatened, incomplete, or complete spontaneous abortion, septic abortion, and hydatidiform mole may be confused with ectopic gestations. A normal early intrauterine pregnancy with a bleeding corpus luteum cyst must also be considered. The combination of clinical findings, quantitative human chorionic gonadotropin (hCG), and ultrasound can usually help distinguish these conditions.
- Nonpregnancy-related conditions. Salpingitis, appendicitis, adnexal torsion, ruptured corpus luteum in the absence of pregnancy, and urinary tract disorders such as infection and stones must be considered. Generally, negative results of a sensitive urine or serum pregnancy test can eliminate ectopic pregnancy when these diagnoses are being considered.
- Intra-abdominal hemorrhage secondary to ruptured spleen or liver may present a diagnostic challenge in the pregnant patient; however, because patients presenting in this manner need urgent surgery, such difficulties in diagnosis may not be problematic.
Evaluation
Laboratory Tests
- Pregnancy testing. Testing for b-hCG levels is of great value in evaluating a woman with suspected ectopic pregnancy, as virtually all ectopic pregnancies will be associated with detectable levels of hCG in blood or urine. These tests should be available in all facilities providing health care to women of reproductive age.
in maternal serum within a few days of implantation. The خ²-hCG level rises rapidly, initially doubling in 1 to 1.5 days. By approximately 5 weeks' gestation menstrual age (3 weeks postconception), خ²-hCG will normally double about every 48 hours.
- Ectopic pregnancies produce less خ²-hCG than normal intrauterine pregnancies at the same gestational age because of a smaller volume of functional trophoblasts. Consequently, the rate of خ²-hCG rise is slower than normal intrauterine pregnancies. The failure of serial خ²-hCG levels to double at the proper rate can be used to distinguish ectopic pregnancy from normal pregnancy.
- If the exact date of conception is known, a single hCG level can predict normal versus abnormal placentation; however, an error of even 48 hours in the date of conception can obviously lead to confusing results. Therefore, single hCG levels alone are of limited clinical usefulness.
- In early-pregnancy patients when there is suspicion of ectopic pregnancy, serial hCG levels are drawn 48 hours apart to detect subnormal doubling, which is present in 85% of women with ectopic pregnancy.
- It is important to note that abnormal intrauterine pregnancies often have abnormally slow-rising خ²-hCG values, and that up to 10% of normal pregnancies can have doubling rates as low as 53% in 48 hours. Therefore, subnormal doubling rates are suggestive but not diagnostic of an ectopic pregnancy.
- Serum progesterone. The use of serum progesterone levels is not generally helpful for distinguishing ectopic pregnancy from abnormal intrauterine pregnancy.
- Progesterone initially is made by the corpus luteum of the ovary, with a gradual transition to production by the trophoblast.
- In a woman with bleeding and/or pain, a serum progesterone level can be helpful in determining normal from abnormal early pregnancy. A level >25 ng per ml is associated with normal intrauterine pregnancy. A level <5 ng per ml is strongly associated with abnormal pregnancy outcome. However, there is no difference between the level of progesterone associated with abnormal intrauterine pregnancy and ectopic pregnancy. Intermediate levels are nondiagnostic. The majority of results in symptomatic women are in the nondiagnostic range, and an abnormal result does not distinguish the location of the abnormal pregnancy.
- For these reasons serum progesterone measurement is not widely used in the diagnosis of ectopic pregnancy.
- Other trophoblast markers. A variety of trophoblast markers have been evaluated as possible diagnostic tests for ectopic pregnancy; however, none is clinically available at this time.
- Other laboratory tests. The white blood cell count may be elevated in the range of 10,000 to 15,000. Hemoglobin and hematocrit should be tested; however, these values may be normal even with significant hemoperitoneum.
Ultrasound
Pelvic ultrasound is invaluable in the evaluation of suspected ectopic pregnancy. Verification of an intrauterine pregnancy by ultrasound makes ectopic pregnancy extremely unlikely. Heterotopic pregnancies (multiple gestations with embryos in both the tube and the uterus) are extremely rare, occurring in 1 to 2 per 10,000 spontaneous pregnancies, and in up to 2% of pregnancies conceived with assisted reproductive techniques.
- Using transvaginal sonography, landmarks consistent with intrauterine pregnancy can be detected as early as 4.5 to 5 weeks menstrual age (Table 7-2). Transabdominal sonography is less sensitive because detection of intrauterine pregnancy is not reliable until 6 weeks' gestation or later.
- Absence of intrauterine pregnancy on ultrasound examination is diagnostic for ectopic pregnancy if the gestational age is known for certain or if the خ²-hCG level is >2500 IU per ml (see below).
- Other ultrasonographic findings associated with ectopic pregnancy include a mass in the tube, which may be echodense or echolucent; free fluid or blood clot in the cul-de-sac; and a “pseudosac†or fluid collection within the uterine cavity. A false or pseudosac, may be seen in 10% of women with ectopic pregnancy.
- Other sonographic findings suggestive but not diagnostic of ectopic gestation include
- Mass in the adnexa. This is not specific for ectopic pregnancy because it may be a corpus luteum cyst.
- Gestational sac in adnexa. This is seen in 25% of ectopics with vaginal sonography, but false positives can occur. A gestational sac in the adnexa may be easier to detect with color Doppler ultrasound, with the trophoblast appearing as a “ring of fire†surrounding the sac.
- Fluid in cul-de-sac. This is seen on abdominal scan in 50% and on vaginal scan in 75% of ectopics. It may be associated with unruptured ectopic pregnancy.
| TABLE 7-2 Intrauterine Pregnancy Landmarks Obtained from Transvaginal Ultra-sonography and Corresponding خ²-hCG Hormone Levels | ||||||||||||||||||
| ||||||||||||||||||
Combining Human Chorionic Gonadotropin Levels and Ultrasound: The Discriminatory Zone
- By combining the hCG level with information from ultrasound scanning, a diagnosis can frequently be made (Table 7-3).
- An intrauterine pregnancy is reliably visible on ultrasound when it has reached a size associated with a خ²-hCG level of 6500 IU per ml (abdominal scan) or 2500 IU per ml (vaginal scan). This level is known as the discriminatory zone.
- Depending on the sensitivity of ultrasound equipment and the experience of the ultrasonographer, the خ²-hCG representing the discriminatory zone may be lower. It is important for clinicians to be familiar with ultrasound performance in their own institutions.
| TABLE 7-3 Diagnosis of Ectopic Pregnancy by Ultra-sonography and Human Chorionic Gonadotropin | ||||||||||||||||||
| ||||||||||||||||||
Culdocentesis
Culdocentesis refers to the insertion of a needle through the vaginal wall posterior to the cervix into the peritoneal cavity and aspiration of contents of the cul-de-sac.
- A positive result of culdocentesis is one in which nonclotting blood is obtained and is highly suggestive of an ectopic pregnancy in the presence of symptoms and a positive pregnancy test. A negative result is one in which clear serous fluid is obtained, making
an ectopic pregnancy unlikely. A nondiagnostic test is one in which either no fluid (“dry tapâ€) or a few milliliters of clotting blood are obtained. A nondiagnostic culdocentesis neither confirms nor rules out an ectopic pregnancy.
- Culdocentesis is a readily available, rapid, and low-morbidity procedure; it is also painful, and it has a high frequency of nondiagnostic results. Now that sensitive serum خ²-hCG screening and vaginal ultrasound are available, culdocentesis is rarely indicated in the diagnosis of ectopic pregnancy.
Diagnostic Dilation and Curettage
- When an abnormal pregnancy is diagnosed by hormone levels and ultrasound, but the location of the pregnancy is uncertain, diagnostic dilation and curettage (D&C) is a cost effective way to distinguish intrauterine pregnancy failure from ectopic pregnancy.
- If chorionic villi are identified on gross or histologic examination, ectopic pregnancy is virtually ruled out. If no products of conception are present, the patient has either an ectopic pregnancy or a completed spontaneous abortion.
- Some authorities suggest that diagnostic D&C should always precede medical management, but this is controversial.
Treatment
Catastrophic Presentation
Ectopic pregnancies frequently present as life-threatening emergencies. The patient presenting in shock with an acute abdomen should be stabilized and taken to surgery immediately.
- Fluid resuscitation must be carried out immediately. Two large-bore peripheral intravenous lines should be started, and balanced salt solution should be infused rapidly. A Foley catheter should be placed to monitor urine output. In the absence of complicating medical conditions, central venous monitoring is generally not needed.
- Laboratory tests needed are minimal. Blood should be drawn for hematocrit and cross-matched for 4 U of red cells. An hCG level should be obtained, but it is not necessary to wait for the results.
- Surgical approach. The patient should be taken to surgery as quickly as possible. In some women with massive hemorrhage and severe shock, it may be necessary to proceed to surgery while the patient is being stabilized. Either a low midline vertical incision or a transverse suprapubic incision can be used. After the abdomen has been entered, rapid palpation of the uterus and both adnexae will usually localize the pregnancy. Upward traction on the uterus coupled with digital pressure on the involved tube will stop the bleeding so that fluid resuscitation, including transfusion if needed, can be completed. Only then should the hemoperitoneum be cleared and the involved adnexa stabilized in the operative field. The tube should be clamped across the mesosalpinx, the tube excised, and the mesosalpinx suture ligated. There is no need to remove the ipsilateral ovary. Hysterectomy is not indicated unless the ectopic pregnancy is interstitial or cornual, and the uterine rupture is so severe that it cannot be repaired.
Less Acute Presentation
In the hemodynamically stable patient with an ectopic pregnancy, there are three possible strategies for management: expectant, surgical, and medical.
- Expectant management:
- Many ectopic pregnancies will end in tubal abortion, with cessation of trophoblast growth, separation of the products of conception from the tubal wall, and spontaneous resolution.
- The risk associated with expectant management is intraperitoneal hemorrhage, which cannot be predicted. Even women with low and falling خ²-hCG levels may have significant bleeding. For this reason, expectant management is rarely used.
- Patients who are Rh-negative should receive Rho(D) immunoglobulin (RhoGAM), even though the risk of sensitization is low.
- Surgical management:
- Procedure selection. The first choice for surgical management is operative laparoscopy with either salpingostomy or salpingectomy. Laparotomy is reserved for specific indications.
- Laparoscopic salpingostomy is the procedure of choice in most circumstances.
- Salpingectomy is selected if future fertility is not desired (e.g., ectopic pregnancy after tubal ligation) or if rupture has destroyed the tube. Some authorities argue that salpingectomy is the treatment of choice if the contralateral tube is normal; others reserve salpingectomy only for situations where the tube cannot be salvaged (significant bleeding which cannot be controlled, rupture of the tube, or severely damaged tube).
- Laparotomy should be performed if laparoscopy is unsatisfactory because of extensive adhesions, if the patient becomes unstable, or if there are medical limitations to laparoscopy. Laparotomy is usually performed via a small Pfannenstiel incision.
- In the stable patient, a short waiting time to assemble personnel and equipment and to ensure safety (e.g., allowing time for gastric emptying) may be appropriate. Dilation and curettage is performed only if the pregnancy is undesired or the cervix is widely dilated. If the pregnancy is intrauterine, villi can be identified by floating the uterine contents in saline and searching for characteristic bubble like structures joined by strands of tissue. Frozen section can also be used to search for villi; however, there are high rates of false-positive and false-negative results with frozen sections, and they may be difficult to obtain in a timely manner.
- If the clinical presentation is highly suggestive of ectopic pregnancy, laparoscopy should be performed rather than relying on uterine examination unless products of conception are unequivocally seen. When the pregnancy is desired, no instruments should be passed through the cervix until the diagnosis of ectopic pregnancy is verified laparoscopically. After insertion of the laparoscope, peritoneal blood is aspirated with a large-bore aspirator. The pelvis is visualized, with lysis of adhesions if necessary to obtain a clear view. Both tubes should be carefully examined. The ectopic pregnancy usually appears as a fusiform, hemorrhagic swelling within the tube. Sometimes, tubal abortion has already taken place with the pregnancy partially or completely extruded from the fimbriated end of the tube, and the products of conception may be within the blood and clot that has been aspirated. Salpingotomy is performed by making a 2- to 3-cm incision in the antimesenteric aspect of the tube, directly over the proximal portion of the pregnancy mass, using needlepoint cautery. Hemostasis can be enhanced by injection of a dilute solution of vasopressin into the tube or the mesosalpinx. The pregnancy mass is then gently removed, using traction and fluid dissection between the mass and the tube wall. The trophoblastic site is cauterized for hemostasis using fine point cautery. There is no need to suture the salpingostomy site. If bleeding cannot be controlled, laparoscopic salpingectomy should be performed using cauterization and incision of the mesosalpinx, laparoscopic stapling devices, or endoscopic ligatures.
- After conservative surgery (when the tube is not removed), weekly خ²-hCG levels should be obtained until they are less than 10 IU per ml. Approximately 5% to 10% of women treated with salpingostomy will have persistent trophoblastic activity in the tube, which may result in tubal rupture and/or intra-abdominal hemorrhage. The risk of persistence is increased with larger pregnancies and higher baseline خ²-hCG levels. If there is concern about the completeness of removal of the pregnancy, postoperative prophylactic methotrexate using the single-dose regimen significantly decreases the rate of persistence. Early detection of trophoblastic persistence is facilitated by persistently elevated or rising خ²-hCG levels.
- Medical management:
that preferentially inhibits rapidly replicating cells such as trophoblast. In properly selected patients, methotrexate is 75% to 85% effective in resolving ectopic pregnancy, with the remaining women requiring surgery.
- Criteria for medical management include hemodynamic stability, gestational sac <3.5 cm in diameter, خ²-hCG at diagnosis <5000 IU, no ultrasound fetal cardiac activity, minimal hemoperitoneum, no underlying liver or renal disease, no blood dyscrasia, not breast-feeding, and ability to have regular followup. A D&C should be performed to rule out a nonviable intrauterine pregnancy because medical treatment is ineffective at emptying the uterus.
- Pretreatment complete blood count and platelet count, خ²-hCG level, and liver and renal function tests should be obtained.
- Methotrexate is given in a single dose of 50 mg/m2 of body surface area. Two regimens have been widely studied for treatment of ectopic pregnancy: single-dose and multidose regimens (Table 7-4). The multidose regimen has a lower failure rate; however, the risk of complications including diarrhea, abnormal liver function, and stomatitis is greater with the multidose regimen. The single-dose regimen is slightly less successful, requiring a second dose in up to 20% of women; however, there is a lower incidence of side effects. The failure rate of either regimen increases when a live embryo, a high initial خ²-hCG level, or a large adnexal mass is present.
- Followup after methotrexate includes measurement of خ²-hCG on day 4 and day 7 after the single dose. The day 4 level is usually increased over baseline due to lysis of trophoblast. The day 7 level should be at least 15% less than the day 4 level, or the dose may be repeated. Levels of خ²-hCG should be followed weekly until it is <10 IU per ml. Transient increase in abdominal pain is common in the days to weeks after methotrexate administration. This is thought to be caused by separation of the trophoblast from the tubal wall with varying amounts of intraperitoneal bleeding. Most separation pain can be managed on an outpatient basis; however, significant pain may require hospitalization and observation to rule out rupture and intraperitoneal hemorrhage. Surgical intervention is rarely required but may be needed to manage severe pain or hemorrhage.
| TABLE 7-4 Methotrexate for Ectopic Pregnancy | ||||||||||||||||||
| ||||||||||||||||||
Unusual Locations
- Nontubal ectopic pregnancy. More than 95% of ectopic pregnancies occur in the fallopian tube, usually in the distal half. However, pregnancies can implant in a wide variety of sites, including the ovary, intramyometrial portion of the tube or uterine cornua, lower uterine segment or cervix, prior cesarean section scar, and peritoneal cavity. These
pregnancies are usually diagnosed later than tubal pregnancies, in part because they tend to grow larger and progress further in gestation before causing symptoms. Catastrophic rupture with hemorrhage and shock is significantly more likely to occur in these nontubal pregnancies. A thorough patient evaluation and comprehensive transvaginal ultrasound examination are necessary to diagnose these unusual pregnancies. Treatment is individualized, and a combination of medical and surgical therapy is often appropriate.
- Abdominal pregnancy accounts for approximately 0.003% of all pregnancies. It arises either from primary implantation in the abdominal cavity or secondary implantation after tubal abortion. Women with abdominal pregnancy may present with abdominal pain, unusual fetal lie, or unusually prominent fetal parts. If partial placental separation has occurred, the patient may present in shock with intra-abdominal hemorrhage. Diagnosis may be difficult to make with ultrasound; CT scanning or magnetic resonance imaging may be required. Once the diagnosis is established, the patient should be stabilized with fluids, blood typed and crossmatched, and a laparotomy performed. The fetus should be removed, the umbilical cord tied as close a possible to the placenta, and the placenta left in situ. Any attempt to separate the placenta from abdominal organs or the abdominal wall may result in severe blood loss and should therefore be avoided.
- Cervical pregnancy arises from implantation in the cervical epithelium instead of the endometrium. The patient usually presents with heavy vaginal bleeding and a cervical mass. The cervix may be effaced and dilated. It is sometimes difficult to distinguish a cervical implantation from an incomplete abortion with products of conception passing through the cervix. Ultrasound may help distinguish a small uterine fundus above the pregnancy mass. The patient should be stabilized, crossmatched for blood, and taken to the operating room. The pregnancy is removed with suction curettage, but bleeding from the implantation site is often very heavy. Paracervical injection with dilute vasopressin may aid with hemostasis. Hysterectomy may be necessary if hemorrhage is severe.
- Ovarian pregnancy implants within the ovarian stroma. Ovarian pregnancies are rare, and the diagnosis is seldom made preoperatively. Management is cystectomy with repair of the ovary or oophorectomy if cystectomy cannot be accomplished.
Long-Term Prognosis
- Women who have had one ectopic pregnancy are at significant risk for future infertility and for recurrent ectopic pregnancies. Regardless of treatment modality, patency of the affected tube can be demonstrated by hysterosalpingogram in approximately 75% of women.
- Women who have had an ectopic pregnancy should be educated about the symptoms associated with ectopic pregnancy and should be counseled to seek care immediately upon diagnosis of a subsequent pregnancy, regardless of symptoms. خ²-hCG levels should be monitored and an early ultrasound should be performed.
Patient Education
- Women with known risk factors for ectopic pregnancy should be informed of the risks and symptoms before trying to become pregnant.
- When a women has a suspected or diagnosed ectopic pregnancy, she should receive detailed counseling about the medical and surgical management options.
- Patients who select medical management with methotrexate must be informed of the need for close, regular followup with monitoring of خ²-hCG levels.
ليست هناك تعليقات:
إرسال تعليق