Suspected Ectopic Pregnancy

Suspected Ectopic Pregnancy
Obstetrics & Gynecology vol. 107, No2 part 1, February, 2006 OBGY R2 BYUN JUNG MI

Suspected Ectopic Pregnancy
Abstract Incidence Risk factors Diagnostic Approach Therapeutic Approach Follow-up

Abstract Women who present with pain and bleeding in the first trimester are at risk for ectopic pregnancy, a life-threatening condition. Predisposal condition : damaged fallopian tubes from prior tubal surgery or previous pelvic infection, smoking, conception using assisted reproduction. Many women without risk factors can develop an ectopic pregnancy. A diagnostic algorithm : use of transvaginal ultrasonography, human chorionic gonadotropin (hCG) concentrations sometimes, uterine curettage Predisposal : 소인

Abstract When the initial hCG value is low, serial hCG values can be used to determine whether a gestation is potentially viable or spontaneously resolving. The minimal rise in hCG for a viable pregnancy : 53% in 2 days. The minimal decline of a spontaneous abortion : 21–35% in 2 days, depending on the initial level. A rise or fall in serial hCG values that is slower than this is suggestive of an ectopic pregnancy. Inversely :역으로

Abstract Treatment - medical management with methotrexate
(for unruptured ectopic pregnancy ) : used to safely treat an ectopic pregnancy with success rates, tubal patency rates, and future fertility that are similar to those obtained with conservative surgery. : Success rates using methotrexate - inversely rated to baseline hCG values - higher using "multidose" compared with "single-dose“ regimens. - Surgical treatment : may be conservative or definitive and should be attempted in most cases via laparoscopy.

Ectopic pregnancy Definition
: The implantation of a fertilized ovum outside the endometrial cavity, continues to be a major cause of morbidity and mortality in reproductive- age women. Prevalence : 2% of pregnancies in the United State If undiagnosed and/or untreated : accounting for about 9% of maternal pregnancy-related deaths in U.S. (result in rupture of the fallopian tube and massive intraperitoneal hemorrhage )

Incidence Between 1970 and 1992, a 6-fold increase was seen in the number of ectopic pregnancies diagnosed in the U.S. earlier, more accurate diagnosis of pregnancies. increased incidence of sexually transmitted infections earlier diagnosis of pelvic inflammatory disease resulting in tubal damage but not complete blockage rise in the number of ectopic pregnancies resulting from assisted reproductive technologies(ART) → may account for the overall increase.

Incidence Incidence of tubal pregnancy after oocyte retrieval / embryo transfer may be as high as 4.5% (by Maymon and Shulman) Incidence of heterotopic pregnancy : about 1:4000 in the general population 1:100 in in vitro fertilization (IVF) pregnancies (much higher than the originally described prevalencies of 1:30,000 in the late 1940s’) -> Due to the increasing use of ovulation induction agents that increase the chance of twinning and may cause hormonal fluctuations affecting tubal motility, and also due to the invasive nature of ART. Retrieval : 복원, 복구, 재생

Risk Factors Impede the migration of the fertilized ovum to the uterus
Damage to the fallopian tube from prior pelvic inflammatory disease History of ectopic pregnancy and previous tubal surgery, including previous tubal ligation Cigarette smoking (thought to affect tubal motility) Increasing age more than one lifetime sexual partner weakly linked to an increased risk of ectopic pregnancy. No clear association has been documented between ectopic pregnancy and oral contraceptive use, previous elective pregnancy termination, spontaneous miscarriage, or cesarean delivery. this same pathophysiologic mechanism of altered tubal integrity may be the cause of an increased number of ectopic pregnancies seen in patients with infertility of previous pelvic surgery.

Fig. 1. Possible anatomic sites in ectopic pregnancies
Fig.1. Possible anatomic sites in ectopic pregnancies. Illustration :John Yanson.Seeber. Suspected Ectopic Pregnancy. Obstet Gynecol 2006.

Diagnostic Approach Symptoms : abdominal or pelvic pain and vaginal bleeding in the first trimester of pregnancy (m/c) * Nonspecific : spontaneous miscarriage, cervical irritation or trauma, and infection Physical examination hypotension and tachycardia with rebound tenderness and guarding → tubal rupture with immediate need for surgical intervention ß-hCG USG (transvaginal sonography) Evacuation of Uterine contents Progesterone

Diagnostic Approach -Steps to Diagnosis -
Transvaginal ultrasound examination Gestations >51/2 weeks should identify an intrauterine pregnancy with near 100% accuracy. Geataional sac (‘double decidual sign’ at 41/2~5weeks after the LMP) Yolk sac (at 5 weeks) Fetal pole with later cardiac motion (at 51/2~6weeks)

Diagnostic Approach - Discriminatory Cutoff-
Definition : level of ß-hCG at which a normal intrauterine pregnancy can be visualized by ultrasonography with sensitivity approaching 100% above the discriminatory cutoff of 1,500~2,500 IU/L, using transvaginal ultrasonography, a normal intrauterine pregnancy should always be visualized.

Diagnostic Approach - Discriminatory Cutoff-
Varying the discirminatory cutoff will affect the sensitivity and specificity for diagnosis low discriminatory cutoff (ß-hCG of 1.500IU/L) high discriminatory cutoff (ß-hCG of 3,000IU/L) high sensitivity for ectopic low specificity provided with extra reassurance that lack of visualization of an intrauterine pregnancy did not miss an early viable gestation increases the possibility of misclassifying a developing intrauterine pregnancy as an abnormal gestation delay the diagnosis of ectopic pregnancy, decreasing the initial sensitivity and resulting in the possibility of rupture Sensitivity : positively identifying an ectopic gestation Specificity : correctly excluding an ectopic when none exists reassurance : 안심시키기 Visualization : 가시화 In our view, it is better to set the discriminatory cutoff high, especially in a population of stable patients who maintain close medical follow-up.

Diagnostic Approach (Fig. 2. Diagnostic algorithm for ectopic pregnancy. )
Early Pregnancy with pain / bleeding Expectant management Intrauterine pregnancy Treat ectopic pregnancy Ultrasound Ectopic pregnancy Abnormal intrauterine pregnancy Non-diagnostic Expectant management vs D&C vs intravaginal misoprostol ß-hCG >discrminatory zone (no intrauterine pregnancy) < discriminatory zone No treatment Abnormal rise or fall Evaluation of uterine contents Serial ß-hCG Normal fall No chorionic villi Chorionic villi (Dx: Abnormal intrauterine pregnancy) Normal rise ⁂ Uttrasound when ß-hCG > discriminatory zone (back to top) Treat ectopic pregnancy

Diagnostic Approach - Human Chorionic Gonadotropin Above Discriminatory Cutoff-
Diagnosing an ectopic pregnancy based solely on serial ß-hCG levels that are declining abnormally below the discriminatory zone is inaccurate in up to 31% of cases. if pathological examination : not available → ß-hCG may be checked approximately 12-24hrs later if the level does not drop significantly on the day after uterine evacuation, → an extrauterine gestation is diagnosed. We use a drop of 15% as the minimal needed but normally see a much steeper drop if the pregnancy tissue has been successfully removed. To definitively confirm resolution of the pregnancy in the absence of tissue diagnosis, ß-hCG values should be followed at least weekly until undetectable, a process that may take up to several weeks. Procurement : 획득 Available :이용할수 있는 쓸모있는

Diagnostic Approach - Human Chorionic Gonadotropin Below Discriminatory Cutoff-
initial ß-hCG < the discriminatory zone → serial ß-hCG measurements are needed to document a growing (potentially viable) or a nonviable pregnancy. The minimum rise for a potentially viable pregnancy that presents with pain and/or vaginal bleeding is 53%, based on the 99th percentile confidence interval(CI) around the mean of the curve of ß-hCG rise over time → followed with serial ß-hCG levels until an intrauterine pregnancy was confirmed. Document : 증거를 제공하다. Viable : 생존 가능한 , 진짜

Diagnostic Approach - Human Chorionic Gonadotropin Below Discriminatory Cutoff-
Intervention for a ß-hCG rise of less than 66% over 2days, a practice supported by previous data, would potentially result in the interruption of many viable pregnancies. If the ß-hCG does not rise appropriately, or declines, a nonviable pregnancy has been diagnosed. A rapid decline in ß-hCG value is consistent with a miscarriage that may resolve spontaneously. If the ß-hCG does not fall 21~35% in 2days (depending on the initial value), → suspected ectopic pregnancy @ Intervention : 조정, 중재

Diagnostic Approach -Definitive Diagnosis-
More than 70% of women who have an ectopic pregnancy will have - a rise in hCG that is slower than the minimal rise for a viable pregnancy or - a decline that is slower than the minimal rate of fall in a spontaneous abortion hCG rises like an IUP in 21% of EP hCG falls like an SAB in 8% of EP

Diagnostic Approach -Progesterone-
Debated. Progesterone levels are higher in intrauterine pregnancies : no well-established upper cutoff to use to discriminate

Diagnostic Approach -Novel Diagnostic Methods-
develop a serum-based test that relies on placental or pregnancy-specific markers * elevated levels of vascular endothelial growth factor (VEGF) have been noted 11days after embryo transfer during IVF cycles in ectopic gestations, but with rather low predictive values. Pregnancy-associated plasma protein A (PAPP-A) Pregnancy-specific B1-glycoprotein human placental lactogen (hPL) hCG anonplacental markers - glycodelin, VEGF and progesterone

Diagnostic Approach -Novel Diagnostic Methods-
One study : VEGF + PAPP-A + progesterone → discriminate ectopic pregnancy from intrauterine pregnancy : sensitivity : 97.7% / specificity : 92.4% (although this discriminative power was lower for early gestations. ) Other markers- not appear useful in the clinical setting at this point- : creatinine kinase, fetal fibronectin, leukemia inhibitory factor, smooth muscle heavy-chain myosin and CA125.

Therapeutic Approach minimally invasive surgery or medical therapy
→These treatment modalities have been shown to have success rates comparable to the gold-standard treatment of laparotomy with salpingectomy, but with the potential benefit of fallopian tube conservation. Laparotomy : therapy for hemodynamically unstable patients with high suspicion of tubal rupture.

Therapeutic Approach -Methotrexate-
Class of drugs called folic acid antagonists History Initially used for treating leukemia, it gained wide use in gynecology for the treatment and cure of choriocarcinoma First introduced as a novel therapy for ectopic pregnancy in 1982. Action mechanism ; by inactivating the enzyme dihydrofolate reductase (DHFR), leading to depletion of the cofactors required for DNA and RNA synthesis. Goal of medical management with MTX : to selectively kill the cytotrophoblasts, the rapidly dividing cells at the fallopian tube implantation site. → The body will then spontaneously resorb the remaining products of conception and blood clot that constitute the ectopic pregnancy. Safe and effective means of treating ectopic pregnancy without the risks associated with surgery. Since 1948 It and its active metabolites compete for the folate binding site of the enzyme dihydrofolate reductase. Folic acid must be reduced to tetrahydrofolic acid by this enzyme for DNA synthesis and cellular replication to occur. Competitive inhibition of the enzyme leads to blockage of tetrahydrofolate synthesis, depletion of nucleotide precursors and inhibition of DNA, RNA and protein synthesis. Methotrexate also inhibits thymidylate synthase and the transport of reduced folates into the cell. MTX is cell cycle phase-specific (S phase) Depletion :소모, 고갈

Therapeutic Approach -Methotrexate-
Leucovorin( folic acid ) : used as a “rescue” medication - allows for higher MTX dose administration by preventing some of the otherwise prohibitive adverse effects. Administration : oral, intramuscular, intrathecal, or by continuous infusion In ectopic pregnancy : IM is preferred, although there have been reports of success with the oral route. It may be used as primary treatment of (Indication) persistent ectopic pregnanacy after salpingostomy prophylaxis for suspected persistent products of conception after conservative surgery in cases of unusually located ectopic pregnancies. Rescue : 구조

Therapeutic Approach -Methotrexate Dosing Regimens-
<Protocol > Multidose regimen - MTX : 1mg/kg per day, IM, on days 1,3,5, and 7 - leucovorin : 0.1mg/kg , IM, on days 2,4,6 and 8 Treatment Day Lab Test Intervention Pretreatment ß-hCG, CBC with differential, LFTx, Cr, type, and screen Rule-out SAB Rho GAM if Rh(-) 1 ß-hCG MTX 1.0mg/kg 2 LEU 0.1mg/kg 3 MTX 1.0mg/kg if <15% decline day 1 to day 3. If ß-hCG >15%, stop treatment and start surveillance* 4 5 MTX 1.0mg/kg if <15% decline day 3 to day 5. 6 7 MTX 1.0mg/kg if <15% decline day 5 to day 7. 8 * Surveillance : ß-hCG should be checked every 7days until ß-hCG,<5

<Protocol > Multidose regimen Patients are given up to 4 doses (1MTX, 1leucovorin) until the ß-hCG decreases by at least 15% on 2 consecutive days 2nd course after one week may be given if there is an increase or plateau in 2 consecutive ß-hCG values

<Protocol > Single-dose regimen - MTX : 50mg/m2 , IM , not use leucovorin rescue. Treatment Day Lab Test Intervention Pretreatment ß-hCG, CBC with differential, LFTx, Cr, type, and screen Rule-out SAB Rho GAM if Rh(-) ß-hCG MTX 50mg/m2 IM 4 7 MTX 50mg/m2 if <15% decline day 4 to day 7. If ß-hCG >15%, stop treatment and start surveillance* Surveillance : 감시, 관리 Surveillance : ß-hCG should be checked every 7days until ß-hCG <5 2nd dose may be administered after 1week if ß-hCG values do not decline by at least 15% between days 4 and 7 after treatment Using the “single-dose” protocol, approximately 20% of women require more than one treatment cycle.

Regardless of the MTX regimen used, patients need to be followed weekly with surveillance ß-hCG after their treatment until ß-hCG is undetectable in serum. → only way to confirm complete resolution of the ectopic pregnancy → It is important to be aware that ectopic pregnancies may cause tubal rupture even when the ß-hCG levels are on their way down. Specifically, in situations where the ß-hCG increased at least 66% over 48 hours before MTX administration → the tubal rupture risk : as high as 20%. This may also be the case in situations where MTX has already been administered for treatment.

Therapeutic Approach -Effectiveness of Methotrexate-
based on 12 studies with at least 20 patients each, the authors concluded that MTX treatment has been shown to be successful in 78~96% of selected patients, → posttreatment hysterosalpingogram-documented tubal patency : 78%, 65% : subsequent pregnancy succeeded 13% : incidence of recurrent ectopic pregnancy. - Reviewed by Pisarska et al

Therapeutic Approach -Single Dose Versus Multidose-
Recent meta-analysis : Barnhart et al (data from 26 articles that met their search criteria, reviewing cases of women diagnosed with ectopic pregnancy who were treated with MTX) - overall success rate for the use of methotrexate : 89% - considering each regimen separately, the success rate of “multidose” therapy : 92.7% with a 95 CI of 89~96% for “single-dose” : 88.1% with a 95% of 86~90%, a statistically significant difference. Importantly, when the frequency of failure was compared, controlling for initial hCG value and the presence of embryonic cardiac activity, the failure rate with single-dose therapy was almost 5 times greater (95%CI)

New protocol 2 doses of MTX (on day 1 and day 4) without leucovorin rescue using the follow-up of the single-dose protocol may more optimally balance convenience and efficacy. Ultimately, the success of any medical management regimen should be compared with the conservative surgical approach of laparoscopic salpingostomy, whose failure rate ranges from 3% to 20%. Optimally :최선의 Ultimately :결국, 마침내

Absolute Contraindications to Medical Therapy With Methotrexate Breastfeeding Overt or laboratory evidence of immunodeficiency Alcoholism, alcoholic liver disease, or other chronic liver disease Preexisting blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia Known sensitivity to methotrexate Active pulmonary disease Peptic ulcer disease Hepatic, renal, or hematologic dysfunction Relative contraindications Gestational sac 3.5cm or greater Embryonic cardiac motion Adapted from American Colleage of Obstetricians and Gynecologists Medical Management of Tubla Pregnancy. ACOG Practice Bulletin 3. Washington, DC ; ACOG ; 1998.

Premedicational preparation CBC, LFT, and S/E especially Scr Chest X-ray : if, Hx of pulmonary disease(+) discontinue folic acid supplements and prenatal vitamins. ★ When using the multidose protocol, the above laboratory studies should be repeated 1 week after the last dose of MTX. the risk of interstitial pneumonitis reported in patients with underlying lung disease)

Therapeutic Approach -Predictors of Success-
Initial serum ß-hCG level (most predictive) progesterone level, size and volume of the gestational mass, presence or absence of cardiac activity, presence or absence of free peritoneal blood

Therapeutic Approach -Predictors of Success-
Treatment failure 65% of cases : ß-hCG level > 4,000 IU/L 7.5% : ß-hCG < IU/L Tawfiq et al Median pretreatment serum ß-hCG level was lower in women in whom treatment was successful compared with women with treatment failures (773 vs mIU/mL) –Potter et al Recent review of 350 women treated with single-dose MTX for ectopic pregnancy found that the only factor that contributed significantly to the failure rate was ß-hCG level before treatment * >5,000 mIU/mL: the failure rate rose to about 13% - No absolute level at which medical management is contraindicated. We currently use the multidose protocol or the new “2-dose protocol” to treat women with a hCG above 1,000mIU/mL

Therapeutic Approach -Post-Methotrexate Follow-up-
abdominal pain 6-7 days after receiving the medication (33% ~ 60% of patients ) result from tubal abortion or hematoma formation with distention of the fallopian tube. can be treated conservatively with pain medications and close follow-up and do not require surgical intervention. if there is evidence of tubal rupture with bleeding, as evidenced by declining hemoglobin levels or ultrasound visualization. → Surgery the ß-hCG level may plateau, or even rise, before it begins to fall. → explained by the fact that, although MTX arrests mitosis in the cytotrophoblasts, the syncytiotrophoblast continues to increase and produces hormone. Near the end of the first week, the blastocyst implants in the posterior wall of the uterus in the presence of high hormone levels; the blastocyst attaches at the embryonic pole (inner cell mass) so the embryo will eventually be attached dorsally. Occasionally, the blastocyst will implant on another spot in the uterus, potentially causing problems (see placenta previa). The trophoblast layer undergoes mitosis upon contact with the uterine wall and differentiates into the cytotrophoblast ("cellular" layer) and the syncytiotrophoblast ("multinucleated" layer).

ultrasound examination : may show an increase in the ectopic size and possibly an increase in vascularity before resolution. increases in ectopic size were not associated with failure of treatment. -Atri et al → not necessary to follow patients with serial ultrasound examinations once they have received MTX treatment → ultrasound findings would not alter management unless a new tubal rupture is seen.

Signs of Treatment Failure and/or Tubal Rupture Significantly worsening abdominal pain, regardless of change in ß-hCG level Hemodynamic instability Levels of ß-hCG that do not decline by at least 15% between day 4 and day 7 postinjection Increasing or plateauing ß-hCG levels after the first week of treatment Adapted from American Colleage of Obstetricians and Gynecologists Medical Management of Tubla Pregnancy. ACOG Practice Bulletin 3. Washington, DC ; ACOG ; 1998.

Therapeutic Approach -Methotrexate for Extratubal Ectopics-
Used for ectopic pregnancies located outside the fallopian tube (cervical, interstitial, ovarian, or abdominal gestations) : first-line treatment d/t the difficulty and risk of surgical resection MTX use for cervical ectopic : one review included 36 women treated with systemic MTX, local injection of MTX or potassium chloride(KCl) or a combination of these therapies → 80~90% success rate. Interstitial pregnancy : 83%

Therapeutic Approach -Complications of Methotrexate-
Folic acid analogue : affects rapidly dividing cells ( esp. those of the gastrointestinal tract and the bone marrow ) Major adverse effects impaired liver function stomatitis gastritis-enteritis bone marrow suppression

Multidose regimen(100) : sotmatits(2), elevated liver transaminases (3) - spontaneously resolved --reported by Stovall et al Single-dose regimen(120) : nausea and vomiting (1) -- reported by Barnhart et al Prevalence of adverse effects of about 30~40% using the “single-dose” and “multidose” regimens finding no difference between the two once they adjusted for ß-hCG values (table3.) their meta-analysis Adapted from Barnhart KT, Gosman G, Ashby R, Sammel M. the medical management of ectopic pregnancy ; a meta-analysis comparing “single dose’ and ‘multidose’ regimens. Obstet Gynecol 2003;101:778-84

Adverse Effects associated with Methotrexate Treatment Drug Adverse Effects Nausea Vomiting Stomatitis Gastric Distress Dizziness Severe neutropena (rare) Reversible alopecia(rare) Pneuminitis Treatment Effect Increase in abdominal pain Increase in ß-hCG levels during first 1-3days of treatment Vaginal bleeding or spotting Adapted from Amnerican College of Obstetricians and Gynecologists. Medical Management of Tubal Pregnancy. ACOG Practice Bulletin 3. Washington, DC;ACOG;1998.

Therapeutic Approach -Surgical Resection-
Laparotomy : reserved for cases of extensive intraperitoneal bleeding with intravascular compromise due to active bleeding, where hypovolemic shock must be prevented. Open surgical approach : may be preferable include - extensive pelvic adhesions : adequate visualization of the ectopic is impossible - extra-tubal, intra-abdominal ectopic gestations where risk of injury to other pelvic structures is high.

Therapeutic Approach -Surgical Resection-
Laparoscopic approach decreased surgical blood loss, a decrease in the amount of analgesic used, and shorter postoperative hospital stay. (compared with laparotomy) safe, effective and less costly

Therapeutic Approach -salpingostomy versus salpingectomy-
Removal of the ectopic pregnancy can be accomplished by resection of the involved fallopian tube with the implanted trophoblastic tissue (salpingectomy) by dissection and removal of only the ectopic pregnancy with tubal conservation (salpingostomy)

<Reproductive outcomes after salpingostomy and salpngectomy> Yao and Tulandi reviewed the data from 9 studies The follow-up period in these studies ranged from 3months to15years. subsequent intrauterine pregnancy rate was similar in patients who had been treated with salpingostomy and those treated with salpingectomy : 50% the rate of a subsequent ectopic : higher in the salpingostomy group (15% vs 10%)

Other studies a higher intrauterine pregnancy rate in women after salpngostomy (almost double that of salpingectomy), a 2-fold risk of recurrent ectopic after 3years of follow-up (after salpngostomy) Another recent study a high rate of successful pregnancy after salpingostomy(88%) compared with salpingectomy (66%) with an equal recurrent ectopic rate of about 16% after at least 18months of follow-up and, in some cases, up to 8years posttreatment .

The concern with conservative treatment via salpingostomy is that of the persistence of trophoblast tissue due to incomplete removal from the fallopian tube. → complicating about 5~20% of cases treated with tubal conservation, It has been reported as being higher in those patients treated with laparoscopy than with laparotomy. → very important to document a complete resolution of the ectopic pregnancy by monitoring the ß-hCG values until they return to zero. Levels that fail to drop, or ones that plateau, indicate a likely persistent ectopic pregnancy that should be treated. Very early gestations, ectopic pregnancies less than 2cm in size, and those with high starting ß-hCG levels are at increased risk of persistence. Some clinicians elect to give the MTX immediately after salpingostomy as a prophylactic measure against persistent tissue, especially in cases where incomplete resection is more probable.

In cases of tubal conservation is not indicated if tubal bleeding is encountered that reqiures extensive coagulation to achieve hemostasis, then future tubal function would likely be compromised, and salpingectomy may be the appropriate intervention. Recurrent ectopic pregnancy in a previously incised tube should also be treated with salpingectomy. Likewise : ~같이, 마찬가지로.

Therapeutic Approach -Complications of Surgery-
Usual operative risk factors as well as those associated with anesthesia. Postop adhesion formation, after laparotomy than laparoscopy : Postoperative adhesion formation may be reduced by minimizing desiccation and manipulation of pelvic and abdominal structures during surgery, as well as by using barrier agents such as oxidized regernated cellulose(Interceed; Johnson and Johnso Mediacal, New Brunswick, NJ)

Follow-up -Reproductive Outcome-
Risk of recurrent ectopic pregnancy after MTX treatment & that after salpingostomy : similar ( about 10%) Tubal patency after MTX treatment is best assessed with hysterosalpingography (HSG) <Stovall summarized the results of his group’ studies. > Although we do not know the pretreatment tubal patency rates, 58 women of 100 study participants who had received multidose MTX for an ectopic pregnancy underwent HSG and of these, 84.5% had tubal patency and 89.7% had at least one patent tube. After single-dose MTX therapy, 62 patients underwent HSG, with 82.3% showing ipsilateral tubal patency

Hafenius et al found Ipsilateral tubal patency was equal in the groups of patients treated with MTX and salpingostomy. much lower overall patency rates, 62% in the MTX group and 66% in the salpingostomy group, compared with previous reports. Reproductive outcome after a previously treated ectopic pregnancy appears to be similar, whether the treatment method had been MTX or conservative surgery. Intrauterine pregnancy rates seen to be comparable in both of these groups, with a possible slightly lower risk of recurrent ectopic seen in the medically treated group.

Woman who have had a previous ectopic pregnancy should be followed closely during their subsequent pregnancy to ensure its proper site of implantation. However, even among a population of women at increased risk for ectopic, screening them with transvaginal ultrasonography and performing ß-hCG testing when they are asymptomatic does not appear to have much benefit in decreasing morbidity.

Suspected Ectopic Pregnancy

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