s
visit: www.infertilitytutorials.com
Ectopic Pregnancy

General

Incidence Rates

Diagnosis

Treatment Options

Patients of Dr Eric Daiter:
their candid reviews

Click here for more video reviews

How Can I help You?

Dr Eric Daiter is an experienced infertility expert with considerable expertise in the diagnosis and treatment of ectopic pregnancy. If you have any questions about ectopic pregnancy, or you need treatment options for an ongoing ectopic pregnancy, Dr Eric Daiter would be happy to help you (in the office or on the telephone). It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).

Availability

"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."

Cost

"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."

Need help or have a question?

Name:


Phone:


Email (Will be kept private):


How can we help?:



Verify code above:

Ampullary  |   Isthmic  |   Fimbrial  |   Cornual  |   Ovarian  |   Abdominal  |   Cervical

Ampullary Ectopic Pregnancy

Case: 29 year old G1 P0 with a history of regular menstrual intervals every 30 x 3-4 days, a last menstrual period starting September 1, abnormally rising hCG titers (2100 IU/L on October 10 and 2000 IU/L on October 12), and a transvaginal ultrasound examination on October 12 revealing an "empty uterus" (9mm endometrial stripe with no identified intrauterine gestational sac) with a 2-3 cm complex cystic structure in the right adnexa that appears to be distinct from the right ovary. Patient was counseled on the likelihood of an ectopic pregnancy and strict ectopic precautions were advised.

Persistent mild to moderate pelvic pain began on October 13. Immediate active management was suggested.

(Scenario #1): A D+C on October 13 resulted in the removal of a scanty amount of tissue (from the uterine cavity) that could not be identified as placental villi (pregnancy tissue).

A concurrent laparoscopy (October 13) allowed the identification of a 3cm "blue" dilatation of the right fallopian tube in the ampullary region without evidence of rupture or intraabdominal bleeding.

Question:What treatment options of this (presumed) ampullary ectopic pregnancy should be considered?

Answer: The dilatation and blue discoloration of the fallopian tube is characteristic of, but not pathognomonic (diagnostic) of, an ectopic pregnancy.

When I initially discuss the surgical management of a probable ectopic pregnancy with a couple preoperatively, I review the possible intraoperative findings and the reasonable treatment alternatives in detail. This preoperative discussion is very important in that it allows the couple to participate in the selection of a clinically appropriate treatment alternative. Surgical treatment generally takes place immediately following diagnosis.

The most appropriate surgical treatment options of an ampullary ectopic pregnancy include salpingostomy (opening the outer layers of the fallopian tube, removing the ectopic pregnancy and allowing the fallopian tube to reclose on its own) and salpingectomy (removing the segment of the fallopian tube that contains the ectopic pregnancy).

If the ampullary ectopic pregnancy has ruptured and there is active bleeding into the pelvis, the most rapid control of bleeding is possible when one removes the portion of the tube that contains the ectopic pregnancy and its blood supply (the bleeding sites). Salpingectomy (removal of a portion of the fallopian tube) is therefore suggested whenever there is hemodynamic compromise (clinical instability) due to a significant loss of blood.

When an ampullary ectopic pregnancy has ruptured, some bleeding into the pelvis has occurred, and the patient is clinically stable then one may be able to consider a salpingostomy with the rapid removal of ectopic pregnancy tissue and coagulation of bleeding sites. If complete control of hemostasis is difficult or in question then removal of this portion of tube (salpingectomy) may become the optimal treatment plan.

If the ampullary ectopic pregnancy is unruptured, then one can consider conserving the fallopian tube via a salpingostomy. This is often possible with ampullary ectopic pregnancies since they tend to grow between the inner lumen of the fallopian tube and the outer serosa (sheath) of the tube.

Laparoscopy is contraindicated in the presence of a hemodynamically unstable patient. If laparoscopy is not contraindicated, then any of these surgical options can generally be accomplished rapidly by a surgeon (experienced in operative laparoscopy).

Following surgical treatment for an ectopic pregnancy, postoperative serial hCG titers are necessary until the hCG concentration is negative.




Case: 29 year old G1 P0 with a history of regular menstrual intervals every 30 x 3-4 days, a last menstrual period starting September 1, abnormally rising hCG titers (2100 IU/L on October 10 and 2000 IU/L on October 12), and a transvaginal ultrasound examination on October 12 revealing an "empty uterus" (9mm endometrial stripe with no identified intrauterine gestational sac) with a 2-3 cm complex cystic structure in the right adnexa that appears to be distinct from the right ovary. Patient was counseled on the likelihood of an ectopic pregnancy and strict ectopic precautions were advised.

Persistent mild to moderate pelvic pain began on October 13. Immediate active management was suggested.

(Scenario #2) A D+C on October 13 resulted in the removal of a scanty amount of tissue (from the uterine cavity) that could not be identified as placental villi (pregnancy tissue).

A concurrent laparoscopy (October 13) allowed the identification of a 3cm "blue" dilatation of the right fallopian tube in the ampullary region, evidence of slow but active bleeding (rupture), and a small amount (about 100cc) of blood in the pelvis. The patient strongly desires conservation of the fallopian tube if at all appropriate.

Question: Is a salpingostomy appropriate in this situation?

Answer: When an ectopic pregnancy in the ampullary portion of the fallopian tube has ruptured, the ability to conserve the tube is less likely but may still be possible. If the outer serosa of the tube can be opened and the ectopic pregnancy removed without any (perceived) injury to the tubal lumen, then a salpingostomy may be reasonable. The bleeding sites must each be identified and controlled to establish hemostasis.

In general, I try to control all bleeding involving the fallopian tube and pelvis using a bipolar coagulation device since these devices cause much less lateral thermal damage (potential for burn injury) to surrounding tissue and the tubal lumen (as compared to monopolar coagulation devices).

If (1) the patient becomes hemodynamically unstable, (2) it is impossible to assure complete hemostasis, (3) the ectopic pregnancy grew within (and significantly damaged) the tubal lumen, or (4) the (fallopian) tubeís inner lumen is significantly damaged during the surgery to remove the pregnancy, then salpingectomy becomes medically desirable.

Occasionally a fertility seeking woman with a prior history of ectopic pregnancy(ies) will have a second or third ectopic pregnancy and also desire "what ever is possible to preserve her fertility." When an unruptured ampullary ectopic pregnancy is identified, salpingostomy is (usually) appropriate when this is the first ectopic pregnancy for the patient, the patient has had an ectopic pregnancy on the opposite side in the past (the initial ectopic pregnancy within the affected tube), or the patient has had a prior ectopic pregnancy on the same side but is not able to consider In Vitro Fertilization (for financial or other reasons) to bypass the tubes and has (previously) had the other tube removed. After 2 ectopic pregnancies on the same side, the general risk of another ectopic pregnancy is greater than 25% (1 in 4).

Following surgical treatment for an ectopic pregnancy, postoperative serial hCG titers are necessary until the hCG concentration is negative.




Case: 29 year old G1 P0 with a history of regular menstrual intervals every 30 x 3-4 days, a last menstrual period starting September 1, abnormally rising hCG titers (2100 IU/L on October 10 and 2000 IU/L on October 12), and a transvaginal ultrasound examination on October 12 revealing an "empty uterus" (9mm endometrial stripe with no identified intrauterine gestational sac) with a 2-3 cm complex cystic structure in the right adnexa that appears to be distinct from the right ovary. Patient was counseled on the likelihood of an ectopic pregnancy and strict ectopic precautions were advised.

Persistent mild to moderate pelvic pain began on October 13. Immediate active management was suggested.

(Scenario #3) A D+C on October 13 resulted in the removal of a scanty amount of tissue (from the uterine cavity) that could not be identified as placental villi (pregnancy tissue).

A concurrent laparoscopy (October 13) allowed the identification of a 3cm "blue" dilatation of the right fallopian tube in the ampullary region without evidence of tubal rupture.

Question: Is medical management appropriate in this situation?

Answer: When an unruptured ectopic pregnancy is suggested clinically, as in this case, treatment can be either medical or surgical. These treatment alternatives should be clearly discussed with the couple pre-operatively and ideally a decision will be made (by the physician and the couple) concerning the most to least desired treatment alternatives prior to surgery.

Currently, the primary benefit of medical management for an unruptured ectopic pregnancy appears to me to occur when (more extensive) abdominal surgery can be avoided.

In the clinical situation where a laparoscopy can safely be avoided entirely, then methotrexate seems to have a clear benefit.

In the clinical situation where a diagnostic laparoscopy is performed and the surgeon is unable to surgically treat the ectopic pregnancy via laparoscopy (possibly due to the surgeonís lack of laparoscopic surgical experience, availability of appropriate operative laparoscopic equipment in the OR, etc), then medical management with methotrexate may avoid the larger abdominal incision (laparotomy) that is associated with a longer postoperative recovery period and greater postoperative discomfort. General guidelines concerning patients for which medical management is appropriate have been developed. If appropriate, surgical treatment is advised regardless of the size of the incision required.

In the clinical situation where the surgeon is able to remove the ectopic pregnancy with the laparoscopy equipment that is immediately available during diagnostic laparoscopy, then the benefit of laparoscopic removal of an ectopic pregnancy seems to be the (likely) immediate resolution of a potentially dangerous situation.

There do not appear to be significant disadvantages of methotrexate management when compared to surgical treatment in terms of future fertility.

Methotrexate is contraindicated for the treatment of an ectopic pregnancy if there is a coexistent desired intrauterine pregnancy (heterotopic pregnancy), severe anemia, severe renal impairment or renal failure, an active infection, peptic ulcer disease, HIV disease, and a noncompliant patient. Methotrexate is less effective and the risk of rupture may be increased when the ectopic pregnancy is over 4 cm diameter, the hCG concentration is greater than 10,000 IU/L, or there is an active fetal heart beat.

Following treatment for an ectopic pregnancy, postoperative serial hCG titers are necessary until the hCG concentration is negative.




Case: 29 year old G1 P0 with a history of regular menstrual intervals every 30 x 3-4 days, a last menstrual period starting September 1, abnormally rising hCG titers (2100 IU/L on October 10 and 2000 IU/L on October 12), and a transvaginal ultrasound examination on October 12 revealing an "empty uterus" (9mm endometrial stripe with no identified intrauterine gestational sac) with a 2-3 cm complex cystic structure in the right adnexa that appears to be distinct from the right ovary. Patient was counseled on the likelihood of an ectopic pregnancy and strict ectopic precautions were advised.

Persistent mild to moderate pelvic pain began on October 13. Immediate active management was suggested.

(Scenario #4) A D+C on October 13 resulted in the removal of a large amount of tissue (from the uterine cavity) that appears to be placental villi (pregnancy tissue).

Question: Is a laparoscopy necessary for this patient?

Answer: The amount of tissue that is retrieved from the uterine cavity can be large in either an abnormal intrauterine pregnancy (this tissue includes placental villi) or an ectopic pregnancy (this is decidual tissue without placental villi). The difference between these tissues may be (but is not always) relatively obvious to an experienced gynecologist on gross (visual) inspection. If there is a significant level of uncertainty regarding the presence of placental villi, then a pathologist can often do an immediate "frozen section" of the tissue to determine whether villi are present. If a pathologist is not available and there is uncertainty about the presence of villi in the tissue removed, then it would be prudent to consider the laparoscopy to rule out an ectopic pregnancy (that may be about to rupture).

If placental villi are obtained on D+C, then the utility of a laparoscopy is reduced. Theoretically, a heterotopic pregnancy may involve coexisting intrauterine and ectopic pregnancies. In this situation, a laparoscopy may be able to diagnose the ectopic component even if there are villi at the time of a D+C. The primary clinical situation in which the risk of a heterotopic pregnancy is increased is following controlled ovarian hyperstimulation, when FSH containing fertility medications are used to mature multiple eggs simultaneously.

Following surgical treatment for an ectopic pregnancy, postoperative serial hCG titers are necessary until the hCG concentration is negative.




Case: 29 year old G1 P0 with a history of regular menstrual intervals every 30 x 3-4 days, a last menstrual period starting September 1, abnormally rising hCG titers (2100 IU/L on October 10 and 2000 IU/L on October 12), and a transvaginal ultrasound examination on October 12 revealing an "empty uterus" (9mm endometrial stripe with no identified intrauterine gestational sac) with a 2-3 cm complex cystic structure in the right adnexa that appears to be distinct from the right ovary. Patient was counseled on the likelihood of an ectopic pregnancy and strict ectopic precautions were advised.

Persistent mild to moderate pelvic pain began on October 13. Immediate active management was suggested.

(Scenario #5) A D+C on October 13 resulted in the removal of a scanty amount of tissue (from the uterine cavity) that could not be identified as placental villi (pregnancy tissue).

A concurrent laparoscopy (October 13) allowed the identification of a 3cm "blue" dilatation of the right fallopian tube in the ampullary region without evidence of tubal rupture. Laparoscopic salpingostomy with an apparently complete removal of the ectopic pregnancy was accomplished.

Question: What postoperative management is appropriate in this situation?

Answer: Ideally, serial hCG titers should be followed until they are negative following surgical removal of an ectopic pregnancy.

Following the hCG titers until they are negative is especially important following conservative surgery (salpingostomy) for an ectopic pregnancy since there is a 5-10% chance of postoperative persistent (growing) placental tissue. This means that some of the placental tissue from the ectopic pregnancy may continue to grow within the tube after the surgery.

One reason that there is a high incidence of persistent placental tissue after conservative surgery for an ectopic pregnancy is that tremendous care is (often) taken to minimize tubal damage. In an attempt to reduce damage to the fallopian tube during conservative surgery for an ectopic pregnancy, some of the placental tissue may be left in place in order to spare the surrounding tubal tissue within the implantation site rather than completely removing the placental tissue along with some of the surrounding normal tubal tissue.

If persistent placental tissue does exist following conservative surgery for an ectopic pregnancy, the amount of placental tissue is usually very small and this is usually then treated effectively with methotrexate medical management.




Isthmic Ectopic Pregnancy

Case: 26 year old G1 P0 with a history of regular menstrual intervals every 28 x 5-6 days, a last menstrual period starting May 1, a positive urine pregnancy test on June 3, persistent moderate intensity pelvic pain predominantly on the right side starting on June 27, hCG titers on June 27 (690 IU/L) and June 28 (731 IU/L) that were lower than expected for her gestational age (and were increasing at an abnormally slow rate), and a transvaginal ultrasound examination on June 28 that revealed a normal uterine contour (with an endometrial stripe that measured 9mm without evidence of an intrauterine gestational sac), normal appearing ovaries (and adnexae), and no free fluid in the pelvis.

A D+C on June 28 resulted in the removal of a scanty amount of tissue from the uterine cavity without evidence of villi.

(Scenario #1) A laparoscopy was performed concurrently (June 28) and identified a 2-3 cm blue dilatation of the isthmic portion of the fallopian tube without evidence of rupture.

Question: Is salpingostomy appropriate in this situation?

Answer: The positive urine pregnancy test on June 3 confirms that the minimal gestational age at this time is about 3.5 weeks (1.5 weeks from the date of ovulation). If a less sensitive urine test (many urine pregnancy tests commercially available in the USA are sensitive to about 20-30 IU/L of hCG) were used then the gestational age would be more advanced.

Given this information, the gestational age would be at least 7 weeks on June 28. At 7 weeks gestation, the hCG titer is usually well in excess of 20,000 IU/L, it normally rises by at least 67-100% every other day, and a transvaginal ultrasound should be able to confirm an intrauterine pregnancy (by identifying an intrauterine gestational sac) that is viable (has an active fetal heart beat). In this case, the hCG was much lower than expected, the rate of rise was much slower than normal and the ultrasound could not identify an intrauterine gestational sac. In these situations, a fetal heart beat can sometimes (but certainly not always) be identified within the adnexa of the pelvis (in an ectopic location).

Given the history of pain and the findings as described above, the decision was made to proceed to active management for a possible ectopic pregnancy, starting with a D+C. When no placental tissue (villi) was found on evacuation of the uterine cavity, the decision was to proceed with laparoscopy.

At laparoscopy, an unruptured isthmic ectopic pregnancy was identified.

At this point, the serosa of the tube overlying the ectopic pregnancy can be opened. If the ectopic pregnancy can be removed from the isthmic portion of the fallopian tube without (apparent) damage to the inner lining of the tube, then conservative management can be considered. If the inner lining has been damaged significantly by either the ectopic pregnancy or the surgery, then future function is very unlikely and a tubal fistula (opening to the pelvis) can form unless a segmental resection is performed.




Case: 26 year old G1 P0 with a history of regular menstrual intervals every 28 x 5-6 days, a last menstrual period starting May 1, a positive urine pregnancy test on June 3, persistent moderate intensity pelvic pain predominantly on the right side starting on June 27, hCG titers on June 27 (690 IU/L) and June 28 (731 IU/L) that were lower than expected for her gestational age and were increasing (at an abnormally slow rate), and a transvaginal ultrasound examination on June 28 that revealed a normal uterine contour (with an endometrial stripe that measured 9mm without evidence of an intrauterine gestational sac), normal appearing ovaries (and adnexae), and no free fluid in the pelvis.

A D+C on June 28 resulted in the removal of a scanty amount of tissue from the uterine cavity without evidence of villi.

(Scenario #2) A laparoscopy was performed concurrently (June 28) and identified a 5 cm blue dilatation that looked like a hematoma under the isthmic portion of the fallopian tube within the broad ligament.

Question: What surgery is appropriate in this situation?

Answer: If the ectopic pregnancy ruptures from the tube into the underlying broad ligament it can develop an ample blood supply from the major vessels that are contained in this ligament. In one such case, I remember that the lumen of the isthmic portion of the fallopian tube was destroyed and the ectopic pregnancy seemed to be predominantly contained between the two leaves of the broad ligament.

Care must be exercised when approaching any ectopic pregnancy since the blood supply to these pregnancies can be tremendous. In this case, a segmental resection (removal) of the fallopian tube is most appropriate if the inner lumen has been destroyed with meticulous (slow) removal of the pregnancy while maintaining continuous hemostasis.

In the event that the broad ligament can be opened and the ectopic pregnancy removed without simultaneously removing a portion of the fallopian tube, then the tube can be spared if the lumen does not appear to have been damaged.

In any case in which the surgery involves the broad ligament the surgeon must always try to confirm the location of the other important anatomic structures contained within this ligament (eg., the ureter).




Case: 26 year old G1 P0 with a history of regular menstrual intervals every 28 x 5-6 days, a last menstrual period starting May 1, a positive urine pregnancy test on June 3, persistent moderate intensity pelvic pain predominantly on the right side starting on June 27, hCG titers on June 27 (690 IU/L) and June 28 (731 IU/L) that were lower than expected for her gestational age and were increasing (at an abnormally slow rate), and a transvaginal ultrasound examination on June 28 that revealed a normal uterine contour (with an endometrial stripe that measured 9mm without evidence of an intrauterine gestational sac), normal appearing ovaries (and adnexae), and no free fluid in the pelvis.

A D+C on June 28 resulted in the removal of a scanty amount of tissue from the uterine cavity without evidence of villi.

(Scenario #3) A laparoscopy was performed concurrently (June 28) and was not able to identify any abnormality in the fallopian tubes or the presence of an ectopic pregnancy.

Question: What management is appropriate in this situation?

Answer: The dates of this pregnancy strongly suggest that there is either an abnormal intrauterine pregnancy or an ectopic pregnancy.

The positive urine pregnancy test on June 3 marks the minimal gestational age at this time to be 3.5 weeks (1.5 weeks from the date of ovulation). On June 28, the gestational age would be at least 7 weeks. At 7 weeks gestation, the hCG titer is usually well in excess of 20,000 IU/L, it rises by at least 67-100% every other day, and a transvaginal ultrasound should be able to confirm an intrauterine pregnancy (by identifying an intrauterine gestational sac) that is viable (has an active fetal heart beat). In this case, the hCG was much lower than expected, the rate of rise was much slower than normal and the ultrasound could not identify a gestational sac.

Therefore, given the supplemental history of pelvic pain, the management plan was (appropriately) to actively rule out an ectopic pregnancy that might rupture imminently.

In this situation, the uterine cavity was evacuated and a concurrent laparoscopy could not identify the pregnancy in an ectopic location. Therefore, an ectopic pregnancy "about to rupture" has been essentially ruled out.

In this situation, I would usually follow the hCG titers for the next few days and if they drop normally then I would follow them to negative. This may occur if the pregnancy tissue was evacuated from the uterine cavity (without being noticed) during the D+C. If the hCG titers continue to rise or do not drop normally, then I would suggest methotrexate medical management. The methotrexate will enter the circulation and affect living tissues that are rapidly growing (like the pregnancy). Therefore, the exact location of the pregnancy does not need to be determined by the physician.

I discourage opening the patient (with the larger laparotomy incision) in order to "palpate the tissues" in an attempt to locate the possible ectopic pregnancy. This results in more extensive surgery and a good chance of tissue trauma during the search. In my experience, surgeons who do "go looking" for a small ectopic pregnancy often fail to find it. They also may start removing tissues (like the fallopian tubes) in the process in order to look for the ectopic.

A single injection of methotrexate is almost always effective in cases like this, with minimal side effects.




Fimbrial Ectopic Pregnancy

Case: 33 year old G1 P0 with a history of irregular menstrual intervals every 24-35 x 3-5 days, a last menstrual period starting August 1, the progressive increase in left greater than right pelvic pain with menses over the past 2 years that is now severe in intensity, with the sudden onset (at 4:30 AM) of persistent severe right greater than left pelvic pain on September 22 that awoke the woman from sleep and was associated with nausea and vomiting x 2.

In the local Emergency Room, a serum pregnancy test was positive (September 22) with an hCG concentration of 3,500 IU/L. A transvaginal ultrasound was performed immediately and the uterine cavity was normal in appearance without evidence of a gestational sac, the right adnexa contained a 3-4 cm complex cystic structure that looked like it was adjacent to the right ovary, and there was a small amount of free fluid in the cul de sac behind the uterus.

Surgical consent was obtained after discussing the risks and benefits of active management to rule out (and treat) a rupturing ectopic pregnancy.

(Scenario #1) Laparoscopy revealed a 3-4 cm blood clot that apparently contained some intermixed tissue extruding from the end of the right fallopian tube. There was about 100cc of fresh appearing blood with an additional 100cc of blood clot in the pelvis behind the uterus.

Following aspiration of the blood from the pelvis, gentle irrigation of the distal end of the fallopian tube containing the ectopic pregnancy revealed active bleeding. The ectopic pregnancy spontaneously avulsed from the tube into the pelvis and at this point the fimbriated end of the tube began to bleed profusely.

Question: What surgical management is appropriate in this case?

Answer: Establishing hemostasis in a timely manner is critical.

Coagulation devices are usually readily available in the operating room, and include monopolar and bipolar cautery instruments. There is much greater potential for lateral thermal damage (burn injury) when monopolar instruments are used as compared to bipolar instruments.

If the surgeonís initial assessment of the bleeding is that it can be controlled while preserving the delicate fimbriae of the fallopian tube, then gentle bipolar coagulation (using a micro rather than a standard bipolar coagulation instrument if available) is optimal. At the point in time when the bleeding becomes too extensive to be controlled while simultaneously conserving the fallopian tube, then the bleeding should be controlled at the expense of the tube (completely cauterizing the blood supply to the tube in this area often requires sacrificing the tube).




Case: 33 year old G1 P0 with a history of irregular menstrual intervals every 24-35 x 3-5 days, a last menstrual period starting August 1, the progressive increase in left greater than right pelvic pain with menses over the past 2 years that is now severe in intensity, with the sudden onset (at 4:30 AM) of persistent severe right greater than left pelvic pain on September 22 that awoke the woman from sleep and was associated with nausea and vomiting x 2.

In the local Emergency Room, a serum pregnancy test was positive (September 22) with an hCG concentration of 3,500 IU/L. A transvaginal ultrasound was performed immediately and the uterine cavity was normal in appearance without evidence of a gestational sac, the right adnexa contained a 3-4 cm complex cystic structure that looked like it was adjacent to the right ovary, and there was a small amount of free fluid in the cul de sac behind the uterus.

Surgical consent was obtained after discussing the risks and benefits of active management to rule out (and treat) a rupturing ectopic pregnancy.

(Scenario #2) Laparoscopy revealed a 3-4 cm blood clot that apparently contained some intermixed tissue extruding from the end of the right fallopian tube. There was about 100cc of fresh appearing blood with an additional 100cc of blood clot in the pelvis behind the uterus.

Question: What surgical management is appropriate for this patient?

Answer: The pelvis should be irrigated with either Normal Saline Solution or Ringerís Lactate solution (2 isotonic solutions that are readily available in most operating rooms) and the blood and clots aspirated from the pelvis. Active bleeding from the end of the fallopian tube at the site of tissue collection can then be assessed.

On occasion, the mere movement or manipulation of the fallopian tube to gain visualization will dislodge the ectopic pregnancy if it is in the process of being "aborted" from the tube into the pelvis. On other occasions, irrigating the end of the tube gently with an isotonic solution to identify bleeding sites may also dislodge an ectopic pregnancy.

If the ectopic pregnancy "falls off" of the end of the tube without significant pulling or squeezing, then I examine the fimbriated end of the tube carefully to identify whether there is any further bleeding. If the ectopic pregnancy tissue has been entirely extruded from the tube, the amount of residual bleeding is often insignificant.

If the tube is not bleeding, the ectopic pregnancy that aborted from the tube is removed from the pelvis and the pelvis is "cleaned up" so as to remove any blood. The case is then concluded.

If the tube is bleeding, hemostasis must be assured prior to concluding the surgery. Gentle bipolar coagulation specifically to small bleeding sites that are identified is often all that is needed. Care (when possible) should be taken to limit coagulation around the delicate fimbriae at the end of the fallopian tube.

If the ectopic pregnancy does not spontaneously fall from the tube, then the outer serosa of the distal fallopian tube is opened and the ectopic is carefully removed. This is similar to conservative surgery (salpingostomy) for an ampullary ectopic pregnancy.

If a surgeon tries to pull the ectopic from the distal end of the tube, or squeeze the ectopic from the distal end of the tube, it is possible to cause significant (and often avoidable) trauma to the tube. The ectopic tissue that is removed may be attached firmly to the surrounding tubal tissue and pulling the tissue roughly to avoid opening the serosa may "rip" the tube and cause significant bleeding.




Cornual Ectopic Pregnancy

Case: 24 year old G1 P0 with a history of regular menstrual intervals every 27-29 x 4 days, a last menstrual period starting January 1, a positive urine pregnancy test on February 5, normally rising hCG titers (290 IU/L on February 6 and 610 IU/L on February 8), and a routine obstetrical ultrasound on March 11 (10 weeks gestation by dates) revealing a right cornual ectopic pregnancy. There has been no pain or vaginal bleeding. The embryo has a crown rump length (size) of 36 mm (consistent with 10 weeks gestation) and an active fetal heart beat.

Question: What management is appropriate in this situation?

Answer: Cornual ectopic pregnancies can be challenging to diagnose with an ultrasound. If there is any question about the diagnosis when speaking with the radiologist who performed the procedure, I would suggest a second radiologic opinion or confirmation with an MRI.

In an asymptomatic woman (woman without symptoms) who is diagnosed with a cornual ectopic pregnancy, I immediately review the clinical situation with the couple. It is important to identify that these cornual ectopic pregnancies (1) can not safely develop to full term, (2) are extremely difficult to remove surgically, and (3) are dangerous to treat medically.

Surgical management requires maintaining constant meticulous hemostasis. The blood supply to the cornual (interstitial) portion of the fallopian tube can be enormous and care must be taken to devascularize the pregnancy during removal. A partial or complete hysterectomy may be necessary if adequate hemostasis cannot otherwise be controlled.

Medical management has been attempted with cornual ectopic pregnancies. Once the pregnancy has reached this size and level of development, single dose methotrexate has reduced efficacy. It may be necessary to use one of the longer (multiple dose) methotrexate protocols (using leucovorum rescue on alternate days). These patients must be followed very closely during medical management, to assure that if profuse bleeding occurs that it is rapidly identified and treated. Hospitalization during treatment may be ideal.




Case: 24 year old G1 P0 with a history of regular menstrual intervals every 27-29 x 4 days, a last menstrual period starting January 1, a positive urine pregnancy test on February 5, normally rising hCG titers (290 IU/L on February 6 and 610 IU/L on February 8), and a routine obstetrical ultrasound on March 11 (10 weeks gestation by dates) revealing a right cornual ectopic pregnancy. There has been no pain or vaginal bleeding. The embryo has a crown rump length (size) of 36 mm (consistent with 10 weeks gestation) and an active fetal heart beat.

(Scenario #2) The patient is hospitalized and a multiple dose methotrexate protocol is initiated after she signs an informed consent and has completed an appropriate pre-treatment medical evaluation.

One week after initiation of methotrexate treatment, the patient develops the sudden onset of severe pelvic pain. An ultrasound identifies a new finding, the presence of several hundred mL of free fluid within the cul de sac.

Question: What management is appropriate in this situation?

Answer: Cornual ectopic pregnancies have the ability to bleed profusely since they have an abundant blood supply.

Whenever there is significant evidence of a ruptured cornual ectopic pregnancy immediate surgical intervention is appropriate.




Ovarian Ectopic Pregnancy

Case: 28 year old G1 P0 with a history of regular menstrual intervals every 30 x 6 days, a last menstrual period starting on November 1, a positive pregnancy test on December 8, intermittent pelvic discomfort on the right greater than left side stated to be moderate in intensity and shortlived from about December 6 to December 13, sudden onset of severe pelvic pain and vaginal spotting on December 22, an hCG concentration of 52,000 IU/L (December 22), and an ultrasound (December 22) revealing a normal appearing uterine contour (with a 15mm endometrial thickness = stripe) without evidence of an intrauterine gestational sac as well as a fetal heart beat adjacent to (or within) the right ovary (that is contained in a complex cystic structure in the right adnexa) and no free fluid in the cul de sac.

Laparoscopy (on December 22) revealed a 4-5 cm complex right adnexal mass that apparently included (all or most of) the right ovary and the ectopic pregnancy, and was densely adherent to the distal right fallopian tube. There was no free blood within the pelvis. After carefully lysing the right adnexal adhesions the right fallopian tube was separated from the remaining right adnexal mass yet the right ovary was not able to be fully removed from the ectopic pregnancy.

The decision was to remove the tissue that clearly contained the embryo. The surgical dissection was difficult and some normal appearing ovarian tissue was (apparently) sacrificed so as to include wide tissue margins (of the pregnancy). Extensive coagulation of the bleeding sites was required to establish and maintain hemostasis.

Question: What diagnosis and management is appropriate in this situation?

Answer: When the ectopic pregnancy is contained within an ovary this is usually classified as an ovarian pregnancy. There are various specific criteria that have been proposed historically that can be used to further clarify this diagnosis (if desired).

Regardless of the classification of this pregnancy, the ectopic pregnancy must be treated.

Surgical removal of the ectopic pregnancy tissue was not possible without removing some of the surrounding ovarian tissue. On some similar occasions, an entire ovary may need to be sacrificed (removed) in order to both remove the pregnancy and maintain hemostasis. I always try (very hard) to preserve as much ovary as possible (while maintaining hemostasis).

Following hCG concentrations postoperatively (until negative) is important since remaining pregnancy cells may be able to grow postoperatively. If this does occur, adjuvant therapy with methotrexate to destroy any remaining pregnancy tissue is generally effective.




Abdominal Ectopic Pregnancy

Case: 30 year old G1 P0 with a history of irregular menstrual intervals every 4-6 weeks, a last menstrual period starting July 1, a positive pregnancy test in the beginning of August (uncertain of dates), intermittent pain on the right side of the pelvis that has been occasionally severe in intensity (especially in mid to late August), and vaginal bleeding with constant pelvic pain starting September 3 x 2 days.

An ultrasound (September 4) reveals an "empty uterus" (endometrial stripe measures 12 mm without evidence of an intrauterine gestational sac) with a 4-5 cm thick walled cystic structure within the abdomen containing a fetus (with a crown rump length of 26mm, which is consistent with dates, and an active fetal heart beat).

A laparoscopy is performed for an ectopic pregnancy and identifies an irregular "pseudosac" (thick walled cystic structure that is translucent containing a fetus) outside the uterus apparently attached to (the mesenteric vessels of) the bowel.

Question: What management is appropriate in this situation at this point in time?

Answer: Abdominal ectopic pregnancies are generally thought to have been expelled from the reproductive organs and have developed an adequate blood supply from one of the other abdominal organs (most often the bowel). Abdominal ectopic pregnancies are sometimes able to go to term prior to their diagnosis if they can develop an adequate source of nutrients.

Surgical removal of an abdominal ectopic pregnancy is extremely dangerous, since the blood supply that has been achieved is often extensive and may be derived from many different vessels. If removal is contemplated, this should ideally be done in the presence of an experienced general (or vascular) surgeon or gynecologic oncologist (since bowel surgery is often coincidentally involved) with several units of blood immediately available. Most gynecologists would recommend leaving the placental site in place regardless of whether the fetal component is removed.

If part (or all) of the abdominal pregnancy is left in place, medical management with methotrexate is generally initiated. Most often, a multiple dose methotrexate protocol is needed due to the larger size of these ectopic pregnancies.




Case: 25 year old G1 P0 with a history of regular menstrual intervals every 30-32 x 5 days, a last menstrual period starting January 1, a positive pregnancy test on February 4, an elective termination of pregnancy procedure performed on February 17 (for an undesired pregnancy), sudden onset of pelvic pain on March 18, a positive pregnancy test with a hCG concentration of 83,000 IU/L on March 18, an ultrasound revealing an empty uterus (endometrial stripe 15 mm without evidence of a gestational sac) with a thin walled cystic structure immediately adjacent to the fundus of the uterus that contains a fetus (crown rump length 46 mm, consistent with dates, with an active fetal heart beat).

A laparoscopy is performed for an ectopic pregnancy and identifies what appears to be a predominantly transparent gestational sac that contains an active fetus, which is attached directly to the fundus of the uterus without any obvious placental tissue. The fetal umbilical cord extends directly from the fetal sac into the uterus ("through the uterine wall").

Question: What management is appropriate in this situation?

Answer: It would appear that at the time of the D+C for the termination of pregnancy a uterine perforation occurred (that was not recognized) and the embryo (with part of the gestational sac that surrounded it) was pushed (or was expelled) into the abdomen. The placental bed was not disrupted enough to cause a fetal demise so the embryo continued to develop, outside the body of the uterus, fed by the umbilical cord that extended through the wall of the uterus to the placenta.

In this situation, the fetus was not desired and would not be expected to be able to grow to term. Therefore, removal of the fetus and sac was accomplished abdominally while a D+C was able to evacuate the uterine cavity. If there had been significant bleeding from the previous perforation site, then this defect in the wall of the uterus would also have been repaired.




Cervical Ectopic Pregnancy

Case: 19 year old G1 P0 with a history of regular menstrual intervals every 29-31 x 3 days, a last menstrual period starting on December 1, a positive pregnancy test on January 7, and the desire for an elective termination of pregnancy. On February 5, during a routine preoperative assessment at the (family planning) clinic, a speculum examination of the cervix reveals a widely distended cervix (distending completely out to the lateral vaginal wall) containing what appears to be an abundant amount of tissue containing placental villi. The patient was referred to the local academic hospital emergency room for further evaluation.

At the local hospital, an ultrasound (February 6) identified a normal appearing uterine cavity and fundus with a dramatically distended uterine cervical region containing a gestational sac with a fetus measuring (crown rump length) 33 mm (c/w dates) and an active fetal heart beat. MRI was ordered and confirmed the presence of a viable pregnancy growing within the uterine cervix.

Question: What management is appropriate in this situation?

Answer: Cervical ectopic pregnancies are extraordinarily dangerous due to their potential for massive bleeding.

This young woman has not had her children yet and is interested in future fertility. Extensive counseling of the patient prior to deciding on a management plan is clearly optimal given the significant risks involved.

Many cervical pregnancies apparently bleed early on as they remodel their blood supply within the cervix (there is a continual process of expanding the vascular supply to the pregnancy via "neovascularization") and the pregnant woman often sees this bleeding since the cervix extends into the vaginal vault (and the blood can immediately flow out through the vagina). Therefore, cervical pregnancies are often diagnosed prior to developing to this (extensive) point.

Management of cervical ectopic pregnancies is very controversial since these pregnancies are (thankfully) quite rare. Consequently, no one really has much experience with cervical pregnancies. The literature from across the world describes many surgical and medical treatments that have "worked" in isolated cases, and this relatively small amount of information forms the basis of most recommendations.

Surgical management of this cervical ectopic pregnancy (due to its large size) carries an extremely high risk of requiring a hysterectomy to control bleeding. The advantage of a "gentle D+C" to see whether the pregnancy can be removed easily is that the results are immediate. The risks of surgery include (but are not limited to) massive bleeding that requires a concurrent hysterectomy (to control bleeding), damage to one or both of the ureters (tubes that pass immediately lateral to the cervix and connect the kidneys within the abdomen to the bladder on top of the lower uterus), and infection (with the raw open bleeding postoperative cervix exposed to the extensive normal bacterial flora of the vagina).

Medical management of this cervical ectopic pregnancy with a multiple dose methotrexate regimen may be effective, although the size of the pregnancy that has developed makes methotrexate less likely to be fully effective. One possible benefit of methotrexate is that it may be able to "shrink" the size of the pregnancy prior to surgery (if required) and this may reduce the surgical risks. The patient will ideally be monitored very closely during treatment, with immediate surgical intervention available. A significant potential disadvantage of methotrexate prior to a possible surgery is that the multiple dosage regimens are occasionally complicated by bone marrow suppression, with a reduction in blood count, platelets and white blood cells. This complication of methotrexate management is (fortunately) uncommon with most protocols used to treat ectopic pregnancy.



Bookmark This Site  |   Read More Tutorials

The NJ Center for Fertility and Reproductive Medicine