Ectopic Pregnancy

Ectopic Pregnancy | Tubal Pregnancy

Definition of ectopic Pregnancy with the fertilized embryo implanted on any tissue other than the uterine lining 95% of ectopics are in the tube, 1.5% abdominal, 0.5% ovarian and 0.03% are in the cervix Related Pages Pregnancy after ectopic Tubal infertility In vitro fertilization, IVF IVF cost IVF money back plans IVF success rates Tubal surgery Come here for IVF Risk factors for ectopic pregnancy Previous ectopic pregnancy is a major risk factor for having another tubal pregnancy Details on pregnancy after ectopic pregnancy In vitro fertilization, IVF will be the best option for having a baby for many women with a history of tubal damage and 1 or more ectopic pregnancies. IVF pregnancies have a greatly reduced risk of another ectopic. Our IVF success rates Pelvic inflammatory disease, PID The rate of ectopic pregnancy in women with previous known PID is about 10 times higher than in women with no previous history of PID. A published study of 745 women with one or more episodes of PID that attempted to get pregnant showed that 16% were infertile from blocked tubes. For those that got pregnant, 6.4% had ectopics. Pelvic inflammatory disease is usually caused by invasion of gonorrhea or chlamydia from the cervix up to the uterus and tubes The infection in these tissues causes an intense inflammatory response. Bacteria, white blood cells and other fluids (pus) fill the tubes as the body fights infection. Eventually, the body wins and the bacteria are destroyed. However, during the healing process the delicate inner lining of the tubes is permanently scarred. The end of the tube by the ovaries may become partially or completely blocked, and scar tissue often forms on the outside of the tubes and ovaries. All of these factors can impact ovarian or tubal function and the chances for successful pregnancy in the future. If pelvic inflammatory disease is treated early and aggressively with IV antibiotics, the tubal damage can be minimized, and fertility can be maintained. Other risk factors for ectopic pregnancies Pregnancy after tubal ligation After non-laparoscopic tubal ligation about 12% of pregnancies are ectopic After laparoscopic tubal coagulation about 50% of pregnancies are ectopic Previous tubal surgery See table with ectopic rates by surgical procedure on the tubal infertility page Ovulation induction or ovarian stimulation Risk of ectopic is somewhat increased In vitro fertilization About 2% of IVF pregnancies are ectopic It is higher in women with a history of damaged tubes or previous ectopic pregnancy Progestin only contraceptives Progesterone-bearing IUD's and ectopics: About 16% of pregnancies are ectopics. Ultrasound images of ectopic pregnancies Ultrasound showing uterus and tubal pregnancy Same image as left Uterus outlined red, uterine lining green Tubal ectopic pregnancy yellow Fluid in uterus at blue circle is a "pseudosac" Looks like early pregnancy sac, but is not

Same case as above Detailed close-up of tubal pregnancy Same picture as left Tubal ectopic pregnancy sac circled in red 4.5 mm fetal pole (between cursors) in green Pregnancy yolk sac blue --> Ultrasound showing uterus and tubal pregnancy Same image as left Uterus outlined red, uterine lining green Tubal ectopic pregnancy yellow Fluid in uterus at blue circle is a "pseudosac" Looks like early pregnancy sac, but is not Same case as above Detailed close-up of tubal pregnancy Same picture as left Tubal ectopic pregnancy sac circled in red 4.5 mm fetal pole (between cursors) in green Pregnancy yolk sac blue Normal pregnancy ultrasound at 6 weeks Laparoscopy pictures of ectopic pregnancies Diagnosis of ectopic pregnancy

Although much is made of blood hCG levels and ultrasound studies, the clinical impression of the gynecologist or reproductive endocrinologist is the most important factor in making a timely diagnosis of ectopic pregnancy. Peak HCG level % of ectopics 1000 45% 1000-3000 21% 3000-5000 15% 5000-10,000 10% 10,000 9% Trend of hCG titers with ectopic pregnancies Trend of HCG levels % of cases Falling 57% Abnormally rising 36% Normally rising 7% Reference for the above tables: Daus et al, Journal of Reproductive Medicine, February, 1989, p.162

General rules often used for hCG levels: See tables with normal values for HCG levels in early pregnancy (single and twins) The hCG level should rise at least 66% in 48 hours, and at least double in 72 hours Plateauing hCG levels with either a half-life of or = 7 days or a doubling time of or = 7 days have the highest predictive value for ectopic pregnancy of any hCG pattern

An important point is that the lower limit in these "formulas" for hCG doubling times, etc., is usually the 15th percentile for symptomatic but viable pregnancies. Therefore, we must be careful to give pregnancies with slow hCG rise every chance possible - they may turn out to be normal.

Progesterone levels and ectopics Progesterone levels are usually not much help in making the diagnosis of ectopic pregnancy, but they can be another clue A progesterone level of less than 15 ng/ml is seen in 81% of ectopics, 93% of abnormal intrauterine pregnancies, and 11% of normal intrauterine pregnancies Less than 2% of ectopics and less than 4% of abnormal intrauterine pregnancies will have a progesterone level greater than or equal to 25 ng/ml Therefore, a single progesterone value less than 15 is probably an abnormal pregnancy A single value over 25 is probably a normal pregnancy - unless the woman had ovarian stimulation with fertility medications in which case this number might not be valid.

Ultrasound and Ectopics With good vaginal probe ultrasound (vag probe is best for imaging the uterus), a normal singleton pregnancy can be seen by the time the hCG level reaches 2000 mIU/ml By 5 to 6 weeks of pregnancy (1 to 2 weeks after the missed period) all normal pregnancies in the uterus should be seen by vaginal ultrasound 20-30% of ectopics have no detectable abnormality on ultrasound The usual finding for ectopic is a mass on one side, some fluid in the pelvis, and no normal pregnancy structures in the uterus Conclusive diagnosis of ectopic by ultrasound can only be made if a fetus or fetal cardiac motion is seen outside the uterus This is only seen in about 20% of ectopics with vaginal ultrasound

Pseudo sac with tubal pregnancy A "pseudosac" is seen in 10-20% of ectopics. This is a sac in the uterus that is not a pregnancy but can look like one very early on. We need to see a yolk sac, fetal pole or cardiac motion to know it is a gestational sac.

Surgical treatment of ectopic pregnancy The possible procedures for ectopic pregnancy can all be done by laparoscopy (same day surgery) or by laparotomy (bigger incision). If the tube is not ruptured it is usually done by laparoscopy Cases of rupture with significant bleeding into the abdomen are usually done by laparotomy since it can be done faster.

Surgical procedures: Salpingotomy (or -ostomy): Making an incision on the tube and removing the pregnancy Salpingectomy: Cutting the tube out Segmental resection: Cutting out the affected portion of the tube Fimbrial expression: "Milking" the pregnancy out the end of the tube In general, the procedure of choice is salpingectomy if future fertility is of no concern, if the tube is ruptured, or if there is significant distortion of the anatomy.

If the tube is saved at surgery, there is some risk that some of the pregnancy remains in the tube. This tissue can persist and resume growing. A mass can form with subsequent rupture and hemorrhage Case reports of patients who developed symptoms after conservative surgery have generally been at least 10 days after surgery

How common is persistent ectopic? After laparotomy: 3-5% of cases After laparoscopy: 3-20% of cases (most reports at 5-10%) Best approach is to follow the woman with weekly hCG levels until negative If a persistent ectopic is diagnosed, methotrexate is usually the best treatment

Medical therapy: Methotrexate First tubal pregnancy treated with methotrexate and reported was in 1985 Methotrexate inhibits rapidly growing cells such as a pregnancy or some cancer cells Most side effects seen with low-dose methotrexate therapy have been very mild

Selection criteria for methotrexate Hemodynamically stable (normal pulse rate and blood pressure) No evidence of tubal rupture or significant intra-abdominal hemorrhage Mass in tube is less than 3-4 cm diameter No contraindications to methotrexate Patient will be available for protracted follow-up Informed consent from the patient Good results with very few side effects are seen with use of a single intra-muscular dose of 50 mg/square meter Resolution of the ectopic has been reported in about 70-95% of cases treated. This depends somewhat on selection criteria for the study. Tubes are later found to be open on the same side as the ectopic by a "dye test" or hysterosalpingogram in 70-85% of cases Pregnancy rates and repeat ectopics are comparable to those after conservative surgery

Decision making at the time of surgery for ectopic pregnancy After a tubal-saving procedure, ectopic pregnancy is equally likely to recur in the operated tube as in the other tube Overall, delivery rates are very similar after salpingostomy or salpingectomy if there is no history of infertility and the other tube appears normal However, if the other tube appears diseased and she has a history of infertility, salpingostomy gives a higher delivery rate (76% vs. 44% in one study) and also a higher risk of recurrent ectopic as compared to removing the tube It is important for the doctor to discuss future pregnancy concerns before surgery (if possible). The woman should be aware of the risks of future infertility, recurrent ectopic and persistent ectopic if her tube is saved.

Heterotopic pregnancy: Combined intra- and extra-uterine (ectopic) pregnancy Old (1940's) literature says the rate is 1/30,000 pregnancies Current heterotopic pregnancy rate is about 1/4000 pregnancies Rate is increased with the use of ovarian stimulation With IVF, the heterotopic rate is about 1/100 clinical pregnancies

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