Diagnostic clues to ectopic pregnancy.

Lin EP, Bhatt S, Dogra VS.

Department of Imaging Sciences, University of Rochester School of Medicine,

Rochester, NY 14642, USA.

Abstract

Ectopic pregnancy accounts for approximately 2% of all pregnancies and is the most
common cause of pregnancy-related mortality in the first trimester. Initial evaluation
consists of hormonal assays and pelvic ultrasonography (US). A history of pelvic pain
along with an abnormal beta human chorionic gonadotropin level should trigger an
evaluation for an ectopic pregnancy. The fallopian tube is the most common location
for an ectopic pregnancy. An adnexal mass that is separate from the ovary and the
tubal ring sign are the most common findings of a tubal pregnancy. Other types of
ectopic pregnancy include interstitial, cornual, ovarian, cervical, scar, intraabdominal,
and heterotopic pregnancy. Interstitial pregnancy occurs when the gestational sac
implants in the myometrial segment of the fallopian tube. Cornual pregnancy refers to
the implantation of a blastocyst within the cornua of a bicornuate or septate uterus. An
ovarian pregnancy occurs when an ovum is fertilized and is retained within the ovary.
Cervical pregnancy results from an implantation within the endocervical canal. In a
scar pregnancy, implantation takes place within the scar of a prior cesarean section. In
an intraabdominal pregnancy, implantation occurs within the intraperitoneal cavity.
Heterotopic pregnancy occurs when an intrauterine and an extrauterine pregnancy
occur simultaneously. A spectrum of intra- and extrauterine findings may be seen on
US images. Although many of the US findings are nonspecific by themselves, when
several of them are seen, the specificity of US in depicting an ectopic pregnancy
substantially improves.

(c) RSNA, 2008.

PMID: 18936028 [PubMed - indexed for MEDLINE]Free Article

Unruptured ectopic pregnancy:

diagnosis and treatment. State of art.]
[Article in Portuguese]

Elito Junior J, Montenegro NA, Soares Rda C, Camano L.

Departamento de Obstetrícia, Universidade Federal de São Paulo, São Paulo, SP,

Brazil. elitojjr@hotmail.com

Abstract
It is advisable to do the non-invasive diagnosis of ectopic pregnancy precociously,
before there is the tube rupture, combining for that the transvaginal ultrasonography
with the dosage of the b-fraction of the chorionic gonadotrophin. A range of treatment
options may be used. Either a surgical intervention or a clinical treatment may be
taken into consideration. Laparotomy is indicated in cases of hemodynamic
instability. Laparoscopy is the preferential route for the treatment of tube pregnancy.
Salpingectomy should be performed in patients having the desired number of
children, while salpingostomy should be indicated in patients willing to have more
children, when the b-hCG titers are under 5,000 mUI/mL and the surgical conditions
are favorable. The use of methotrexate (MTX) is a consecrated clinical procedure and
should be indicated as the first option of treatment. The main criteria for MTX
indication are hemodynamic stability, b-hCG <5,000 mUI/mL, anexial mass <3,5 cm,
and no alive embryo. It is preferable a single intramuscular dose of 50 mg/m(2),
because it is easier, more practical and with less side effects. Protocol with multiple
doses should be restricted for the cases with atypical localization (interstitial, cervical,
caesarean section scar and ovarian) with values of b-hCG >5,000 mUI/mL and no
alive embryo. Indication for local treatment with an injection of MTX (1 mg/kg)
guided by transvaginal ultrasonography should occur in cases of alive embryos, but
with an atypical localization. An expectant conduct should be indicated in cases of
decrease in the b-hCG titers within 48 hours before the treatment, and when the initial
titers are under 1,500 mUI/mL. There are controversies between salpingectomy and
salpingostomy, concerning the reproductive future. Till we reach an agreement in the
literature, the advice to patients who are looking forward to a future gestation, is to
choose either surgical or clinical conservative conducts.

Current evidence on surgery, systemic

methotrexate and expectant
management in the treatment of tubal
ectopic pregnancy: a systematic
review and meta-analysis.
Mol F, Mol BW, Ankum WM, van der Veen F, Hajenius PJ.

Department of Obstetrics and Gynaecology, Academic Medical Centre, PO Box

22700, 1100 DE Amsterdam, The Netherlands. f.mol@amc.nl

Comment in:

• Hum Reprod Update. 2009 Mar-Apr;15(2):261-2.

Abstract

BACKGROUND: To evaluate the effectiveness of surgery, medical treatment and

expectant management of tubal ectopic pregnancy (EP) in terms of treatment success
(i.e. complete elimination of trophoblast tissue), financial costs and future fertility.
METHODS: We searched for randomized controlled trials which described treatment
interventions that have been widely adopted in clinical practice. A systemic literature
search identified 15 trials.

RESULTS: Laparoscopic salpingostomy was significantly less successful than the

open surgical approach (relative risk, RR 0.9, 95% CI 0.82-0.99) due to a higher
persistent trophoblast rate, but was significantly less costly. A prophylactic single shot
methotrexate (MTX), given intramuscularly (i.m.) immediately post-operatively,
significantly reduced persistent trophoblast after laparoscopic salpingostomy (RR
0.89, 95% CI 0.82-0.98, number needed to treat of 10). With systemic MTX in a fixed
multiple dose i.m. regimen the likelihood of treatment success was higher than with
laparoscopic salpingostomy (RR 1.15, 95% CI 0.93-1.43), but the difference was not
significant. Systemic MTX in a fixed multiple dose i.m. regimen was only cost-
effective if serum human chorionic gonadotrophin (hCG) concentrations were <3000
IU/l. If serum hCG concentrations were <1500 IU/l, then the single-dose MTX i.m.
regimen-if necessary with additional MTX injections-was also cost-effective.
Expectant management could not be evaluated yet. Subsequent fertility did not differ
between the interventions studied.

CONCLUSIONS: This meta-analysis shows that laparoscopic surgery is the most

cost-effective treatment for tubal EP. Systemic MTX is a good alternative in selected
patients with low serum hCG concentrations.

PMID: 18522946 [PubMed - indexed for MEDLINE]Free Article