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Ectopic pregnancy or (EP) is a very risky condition which the fertilized egg burrow and grows in any location other than the inner lining of the uterus.
In rare cases, an ectopic pregnancy may occur at the same time as an intrauterine pregnancy. So many health specialist and gynecologist said that ectopic pregnancy is very dangerous, they also call it eccysis.
For Ectopic pregnancy detection in early gestation was achieved mainly only for the enhanced diagnostic capability. When the embryo is growing to the lining of the fallopian tube and burrows into the tubal lining, is called a typical ectopic pregnancy . It’s like about half of many ectopic pregnancies will resolve without treatment if it’s left untreated.
For the normal pregnancy, the fertilized egg enters the uterus and burrow into the uterine wall which has enough room to accommodate the divide and growing of the embryo. I made this WEBSITE to be able to share and provide women some of the most useful and helpful knowledge concerning all about pregnancy, healthy diet plans, Nutrition, morning sickness remedies, signs and symptoms, pregnancy problems and so many things that may guide you right before you plan a pregnancy through your labor.
Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the United States, accounting for 9% of all pregnancy-related deaths.
Ectopic pregnancy was first described in the 11th century, and, until the middle of the 18th century, it was usually fatal. In the beginning of the 20th century, great improvements in anesthesia, antibiotics, and blood transfusion contributed to the decrease in the maternal mortality rate. Ectopic pregnancy is derived from the Greek word ektopos, meaning out of place, and it refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, cornual region of the uterus, and the abdominal cavity.
Since 1970, the frequency of ectopic pregnancy has increased 6-fold, and it now occurs in 2% of all pregnancies.
After one ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy.
Prior tubal surgery has been demonstrated to increase the risk of developing ectopic pregnancy. Conception after previous tubal ligation increases a women's risk of developing ectopic pregnancies. Ovulation induction with clomiphene citrate or injectable gonadotropin therapy has been linked with a 4-fold increase in the risk of ectopic pregnancy in a case-control study. One study has demonstrated that infertility patients with luteal phase defects have a statistically higher ectopic pregnancy rate than patients whose infertility is caused by anovulation. The presence of an inert copper-containing or progesterone intrauterine device (IUD) traditionally has been thought to be a risk factor for ectopic pregnancy. Salpingitis isthmica nodosum is defined as the microscopic presence of tubal epithelium in the myosalpinx or beneath the tubal serosa. Other risk factors associated with increased incidence of ectopic pregnancy include previous diethylstilbestrol (DES) exposure, a T-shaped uterus, prior abdominal surgery, failure with progestin-only contraception, and ruptured appendix.
Remember, however, that only 40-50% of patients with an ectopic pregnancy present with vaginal bleeding, 50% have a palpable adnexal mass, and 75% may have abdominal tenderness. Within the last 2 decades, a more conservative surgical approach to unruptured ectopic pregnancy using minimally invasive surgery has been advocated to preserve tubal function (see Surgical Therapy ). Candidates for successful expectant management are asymptomatic and have no evidence of rupture or hemodynamic instability. Surgical treatment in cases in which the pregnancy is located on the cervix, ovary, or in the interstitial or the cornual portion of the tube is often associated with increased risk of hemorrhage, often resulting in hysterectomy or oophorectomy. In cases involving uncontrolled bleeding and hemodynamic instability, conservative treatment methods are avoided in favor of radical surgery.
Patients with early normal intrauterine pregnancies often present with signs and symptoms similar to those encountered in patients with ectopic pregnancies and other gynecological or gastrointestinal conditions. In order to reduce the morbidity and mortality associated with ectopic pregnancy, a high index of suspicion is necessary to make a prompt and early diagnosis.
Furthermore, even though ectopic pregnancies have been established to have lower mean serum bhCG levels than healthy pregnancies, no single serum bhCG level is diagnostic of an ectopic pregnancy.
The major disadvantage in relying on serial titers to distinguish between normal and abnormal pregnancies is the potential for delay in reaching the diagnosis. A single serum progesterone level is another tool that is useful in differentiating abnormal gestations from healthy intrauterine pregnancies.
Several other serum and urine markers are currently under investigation to help distinguish normal and abnormal pregnancies. At present, use each of these markers only as a research tool until substantial clinical evidence proves their role in clinical medicine.
Transvaginal US, with its greater resolution, can be used to visualize an intrauterine pregnancy by 24 days postovulation, or 38 days after last menstrual period, which is about 1 week earlier than transabdominal US.
A pseudosac is a collection of fluid within the endometrial cavity created by bleeding from the decidualized endometrium often associated with an extrauterine pregnancy and should not be mistaken for a normal early intrauterine pregnancy.
The yolk sac is the first visible structure within the gestational sac, and it resembles a distinct circular structure with a bright echogenic rim and a sonolucent center. In the absence of reliable menstrual and ovulatory history, a discriminatory zone of bhCG levels validates the US findings.
The effectiveness of using US with discriminatory zone of bhCG levels has been well established in the literature. If the patient's serum bhCG levels were below the discriminatory zone, serial bhCG titers were performed every 2 days. The value of US is highlighted further in its ability to demonstrate free fluid in the cul-de-sac. Color-flow Doppler US has been demonstrated to improve the diagnostic sensitivity and specificity of transvaginal US, especially in cases where a gestational sac is questionable or absent.
The addition of color-flow Doppler US may expedite earlier diagnosis and eliminate delays caused by using levels of bhCG for diagnosis. This method of diagnostic dilatation and curettage may only be used, of course, in cases where continuation of a pregnancy is not desired even if it were an intrauterine gestation.
In a patient undergoing a dilatation and curettage for the diagnosis of ectopic pregnancy, obtaining consent for a diagnostic, and possibly operative, laparoscopy is also necessary in case the diagnosis of ectopic pregnancy is made; this spares the patient exposure to an additional operative procedure. While dilatation and curettage is easy and effective, it can provide false reassurance in cases of heterotropic pregnancies where multiple gestations are present, with at least one being intrauterine and one being extrauterine. Culdocentesis is another rapid and inexpensive method of evaluation for ruptured ectopic pregnancy. Laparoscopy remains the criterion standard for diagnosis; however, its routine use on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Methotrexate is an antimetabolite chemotherapeutic agent that binds to the enzyme dihydrofolate reductase, which is involved in the synthesis of purine nucleotides. Adverse effects associated with the use of methotrexate can be divided into drug adverse effects and treatment effects. In determining whether a patient is a candidate for medical therapy, a number of factors must be considered. A number of accepted protocols with injected methotrexate exist for the treatment of ectopic pregnancy. Prior to injection of methotrexate, the patient must be counseled extensively on the risks, benefits, adverse effects, and the possibility of failure of medical therapy, which would result in tubal rupture necessitating surgery.
Most patients experience at least one episode of increased abdominal pain, which usually occurs 2-3 days after the injection. Advise patients to avoid alcoholic beverages, vitamins containing folic acid, nonsteroidal anti-inflammatory drugs, and sexual intercourse until advised otherwise. Before initiating therapy, draw blood to determine baseline laboratory values for renal, hepatic, and bone marrow function, as well as a baseline bhCG level. Failure of medical treatment is defined when bhCG levels increase, plateau, or fail to decrease adequately by 15% from days 4-7 postinjection. Treatment with methotrexate is an especially attractive option when the pregnancy is located on the cervix, ovary, or in the interstitial or the cornual portion of the tube. Successful medical treatment using methotrexate has been reported in the literature with good subsequent reproductive outcomes.
The use of oral methotrexate currently is under investigation, and, while preliminary reports show promising results, efficacy remains to be established. With advances in the ability to make earlier diagnosis and improvements in microsurgical techniques, conservative surgery has replaced the standard laparotomy with salpingectomy of the past.
Linear salpingostomy along the antimesenteric border to remove the products of conception is the procedure of choice for unruptured ectopic pregnancies in the ampullary portion of the tube. Next, using a microelectrode, scissors, harmonic scalpel, or laser, a 1- to 2-cm linear incision is made along the antimesenteric side of the tube along the thinnest segment of the gestation. At this time, the pregnancy usually protrudes out of the incision and may slip out of the tube. Laparoscopic picture of an ampullary ectopic pregnancy protruding out after a linear salpingostomy was performed. Occasionally, it must be teased out using forceps (see image below) or aqua-dissection, which uses pressurized irrigation to help dislodge the pregnancy.
Coagulation of oozing areas may be necessary and can be accomplished using microbipolar forceps. Some ampullary pregnancies can be teased out and expressed through the fimbrial end (milking of the tube) by using digital expression, suction, or aqua-dissection. In some cases, resection of the tubal segment containing the gestation or a total salpingectomy is preferred over salpingostomy. Total salpingectomy can be achieved by progressively coagulating and cutting the mesosalpinx, starting from the fimbriated end and advancing toward the proximal isthmic portion of the tube. In a patient who has completed childbearing and no longer desires fertility, in a patient with a history of an ectopic pregnancy in the same tube, or in a patient with severely damaged tubes, total salpingectomy is the procedure of choice. Throughout the procedure, take care to minimize blood loss and reduce the potential for retained trophoblastic tissue, which can reimplant and persist. Note the condition of the contralateral tube, the presence of adhesions, or other pathologic processes because this helps in the postoperative counseling of the patient with regard to future fertility potential. After surgical excision of the ectopic gestation, weekly monitoring of quantitative bhCG levels is necessary until the level is zero to ensure that treatment is complete. After tubal-sparing surgical removal of an ectopic pregnancy, a fall in bhCG levels of less than 20% every 72 hours represents incomplete treatment. The increased incidence of ectopic pregnancy is partially attributed to improved ability in making earlier diagnosis.
Approximately one fourth of women presenting with ectopic pregnancies have declining bhCG levels, and 70% of this group experience successful outcomes with close observation, as long as the gestation is 4 cm or less in greatest dimension.
Remember that no cutoff value below which expectant management is uniformly safe has been established. Complications of ectopic pregnancy can be secondary to misdiagnosis, late diagnosis, or treatment approach. Any time a surgical approach is chosen as the treatment of choice, consider the complications attributable to the surgery, whether it is laparotomy or laparoscopy. The evidence in the literature reporting on the treatment of ectopic pregnancy with subsequent reproductive outcome is limited mostly to observational data and a few randomized trials comparing the various treatment options. Data in the literature have failed to demonstrate substantial and consistent benefit of either salpingostomy or salpingectomy in improving future reproductive outcome. Dubuisson et al, reporting on 10 years of surgical experience in Paris, concluded that, for selected patients who desired future fertility, using salpingectomy, which is simpler and avoids the risk of persistent ectopic pregnancy, is possible and can result in a comparable fertility rate to tubal conservation surgery.9 Future fertility rates were no different with either surgical approach when the contralateral tube was either normal or scarred but patent. Future fertility rates are similar in patients who were treated surgically by laparoscopy or laparotomy. The modern pelvic surgeon has been led to believe that the treatment of choice for unruptured ectopic pregnancy is salpingostomy, sparing the affected fallopian tube and thereby improving future reproductive outcome. The success rates after methotrexate are comparable with laparoscopic salpingostomy, assuming the selection criteria mentioned above are observed. As the ability to diagnose ectopic pregnancy improves, physicians will be able to intervene sooner, preventing life-threatening sequelae and extensive tubal damage, which could preserve future fertility. The vast majority of ectopic pregnancies are so-called tubal pregnancies and occur in the Fallopian tube (98%); however, they can occur in other locations, such as the ovary, cervix, and abdominal cavity.
Before the 19th century, the mortality rate (the death rate) from ectopic pregnancies exceeded 50%. It is a pregnancy complication in which the embryo implants outside the uterus or uterine cavity. In some other countries with poor prenatal care, even after all of these succeeded diagnostics and notable detection techniques for ectopic pregnancy yet remains a source of serious maternal mortality and maternal morbidity all over the world. It’s bout 1% of pregnancies are in the ectopic location not occurring inside of the womb with in implantation , and the rest of the 98% occurs in the Fallopian tubes. Make sure you are getting the most important pregnancy information you need and you can trust. It is the result of a flaw in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in death of the fetus.
In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well. John Bard reported the first successful surgical intervention to treat an ectopic pregnancy in New York City in 1759.


In the early half of the 20th century, 200-400 deaths per 10,000 cases were attributed to ectopic pregnancy. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. An estimated 108,800 ectopic pregnancies in 1992 resulted in 58,200 hospitalizations with an estimated cost of $1.1 billion. In theory, anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation. Patients with chlamydial infection have a range of clinical presentations, from asymptomatic cervicitis to salpingitis and florid pelvic inflammatory disease (PID). Overall, a patient with prior ectopic pregnancy has a 50-80% chance of having a subsequent intrauterine gestation, and a 10-25% chance of a future tubal pregnancy. Thirty-five to 50% of patients who conceive after a tubal ligation are reported to experience an ectopic pregnancy.
This finding suggests that multiple eggs and high hormone levels may be significant factors. The risk of ectopic pregnancy and heterotopic pregnancy (ie, pregnancies occurring simultaneously in different body sites) dramatically increases when a patient has used assisted reproductive techniques to conceive, such as in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT).
However, only the progesterone IUD has a rate of ectopic pregnancy higher than that for women not using any form of contraception . A 3- to 4-fold increase in the risk for developing an ectopic pregnancy exists compared to women aged 15-24 years. The next most common sites are the isthmic segment of the tube (12%), the fimbria (5%), and the cornual and interstitial region of the tube (2%). Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture. The most common of these are appendicitis , salpingitis , ruptured corpus luteum cyst or ovarian follicle, spontaneous abortion or threatened abortion , ovarian torsion , and urinary tract disease . Furthermore, they should portray objective evidence of resolution, such as declining bhCG levels. The availability of various biochemical, ultrasonographic, and surgical modalities can aid the health care provider today in establishing a definitive diagnosis and differentiating among various conditions. As mentioned earlier, neither risk factors nor signs and symptoms of ectopic pregnancy are sensitive or specific enough to establish a definitive diagnosis. In short, serial serum bhCG levels are necessary to differentiate between normal and abnormal pregnancies and to monitor resolution of ectopic pregnancy once therapy has been initiated.
Furthermore, while serial bhCG titers may be used to differentiate between a normal and an abnormal gestation, the test does little to indicate the location of the pregnancy. Serum progesterone levels are not gestational age–dependent, they remain relatively constant during the first trimester of normal and abnormal pregnancies, they do not return to the reference range if initially abnormal, and they do not correlate with bhCG levels. These include serum estradiol, inhibin, pregnancy-associated plasma protein A, pregnanediol glucuronide, placental proteins, creatinine kinase, and a quadruple screen of serum progesterone, bhCG, estriol, and alfa-fetoprotein. The gestational sac, which is a sonographic term and not an anatomic term, is the first structure that is recognizable on transvaginal US.
The true gestational sac is located eccentrically within the uterus beneath the endometrial surface, whereas the pseudosac fills the endometrial cavity. It can first be recognized 3 weeks postconception, about 5 weeks after last menstrual period. The discriminatory zone is the level of bhCG, using the Third International Standard for quantitative bhCG, at which all intrauterine pregnancies should be visible on US.
While free fluid could represent hemoperitoneum, it is not specific for ruptured ectopic pregnancy. A study of 304 patients at high risk for ectopic pregnancy found that the use of color-flow Doppler US, compared with transvaginal US alone, increases the diagnostic sensitivity from 71-87% for ectopic pregnancy, from 24-59% for failed intrauterine pregnancy, and from 90-99% for viable intrauterine pregnancy. Furthermore, color-flow Doppler US can potentially be used to identify involuting ectopic pregnancies that may be candidates for expectant management. It is performed by inserting a needle through the posterior fornix of the vagina into the cul-de-sac and attempting to aspirate blood.
It is associated with a high false-negative rate (10-14%) usually reflecting blood from an unruptured ectopic pregnancy, ruptured corpus luteum, incomplete abortion, and retrograde menstruation. Laparoscopy allows assessment of the pelvic structures, size and exact location of ectopic pregnancy, presence of hemoperitoneum (see image below), and presence of other conditions, such as ovarian cysts and endometriosis, which, when present with an intrauterine pregnancy, can mimic an ectopic pregnancy.
Laparoscopic picture of an unruptured right ampullary tubal pregnancy with bleeding out of the fimbriated end resulting in hemoperitoneum. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies, and, as more ectopic pregnancies are diagnosed earlier in gestation, the rate of false-negative results with laparoscopy would be expected to rise. With evolving experience with methotrexate, the treatment of selected ectopic pregnancies has been revolutionized.
Drug adverse effects include nausea, vomiting, stomatitis, diarrhea, gastric distress, and dizziness.
She must be hemodynamically stable, with no signs or symptoms of active bleeding or hemoperitoneum.
Initial experience used multiple doses of methotrexate with leucovorin to minimize adverse effects.
Patients should be aware of the signs and symptoms associated with tubal rupture and be advised to contact their physician with significantly worsening abdominal pain or tenderness, heavy vaginal bleeding, dizziness, tachycardia, palpitations, or syncope.
Increased abdominal pain is believed to be caused by the separation of the pregnancy from the implanted site. A signed written consent demonstrating the patient's comprehension of the course of treatment must be obtained. Surgical treatment in these cases is often associated with increased risk of hemorrhage, often resulting in hysterectomy or oophorectomy. Direct local injection (salpingocentesis) of methotrexate into the ectopic pregnancy under laparoscopic or US guidance has also been reported in the literature; however, reports from these studies have yielded inconsistent results, and its advantage over intramuscular injection remains to be established.
The physician must emphasize the importance of patient follow-up and have patient information on hand, including the patient's home address, telephone numbers at home and work, and the means to reach a contact person in case attempts to reach the patient directly are unsuccessful.
Within the last 2 decades, a more conservative surgical approach to unruptured ectopic pregnancy using minimally invasive surgery has been advocated to preserve tubal function. Laparotomy is usually reserved for patients who are hemodynamically unstable or patients with cornual ectopic pregnancies. Ectopic pregnancies in the ampulla are usually located between the lumen and the serosa and, thus, are ideal candidates for linear salpingostomy. To minimize bleeding, a dilute solution containing 20 U of vasopressin in 20 mL of isotonic sodium chloride solution may be injected into the mesosalpinx just below the ectopic pregnancy. Linear incision being made at the antimesenteric side of the ampullary portion of the fallopian tube.
However, this approach carries with it a higher rate of bleeding, persistent trophoblastic tissue, tubal damage, and recurrent ectopic pregnancy (33%).
At this point, the tube is separated from the uterus by coagulating and excising with scissors or laser.
The presence of uncontrolled bleeding and hemodynamic instability warrants radical surgery over conservative methods. Remove large gestations in an endoscopic bag, and perform copious irrigation and suctioning to remove any remaining fragments.
Most often, patients treated with laparoscopy are discharged on the same day of surgery; however, overnight admission may be necessary for some patients to monitor postoperative bleeding and achieve adequate pain control. This is especially true following treatment with conservative surgery, ie, salpingostomy, which carries a 5-15% rate of persistent trophoblastic tissue.
Although most of these cases are caused by incomplete removal of trophoblastic tissue, some actually may represent multiple ectopic pregnancies in which only one gestation is initially recognized and treated.
Ectopic pregnancies that previously would have resulted in tubal abortion or complete spontaneous reabsorption and remained clinically undiagnosed are now detected.
Furthermore, rupture despite low and declining serum levels of bhCG has been reported, making close follow-up and patient compliance of paramount importance. Failure to make the prompt and correct diagnosis of ectopic pregnancy could result in tubal or uterine rupture, depending on the location of the pregnancy, which could lead to massive hemorrhage, shock, disseminated intravascular coagulopathy (DIC), and death. These include bleeding, infection, and damage to surrounding organs, such as bowel, bladder, ureters, and the major vessels nearby. Assessment of successful treatment and future reproductive outcome with various treatment options is often skewed by selection bias. Despite the risk of persistent ectopic pregnancy, some studies have shown salpingostomy to improve reproductive outcome in patients with contralateral tubal damage. In 1996, Clausen reported on a review of the past 40 years and concluded that only a small number of investigators have suggested indirectly that conservative tubal surgery increases the rate of subsequent intrauterine pregnancy, and the more recent studies may reflect an improvement in surgical technique. Several other studies have reported that the status of the contralateral tube, the presence of adhesions, and the presence of other risk factors such as endometriosis have a more significant impact on future fertility than choice of surgical procedure.
Salpingectomy by laparotomy carries a subsequent intrauterine pregnancy rate of 25-70%, compared to laparoscopic salpingectomy with rates of 50-60%. However, if the treating surgeon has neither the laparoscopic skill nor the instrumentation necessary to atraumatically remove the trophoblastic tissue via linear salpingostomy, then salpingectomy by laparoscopy or laparotomy is not the wrong choice for operation. The average success rates using the multiple-dosage regimen are in the range of 91-95%, demonstrated by multiple investigators. Already, with improving technology, physicians are treating ectopic pregnancies with minimally invasive surgery or no surgery at all. By the end of the 19th century, the mortality rate dropped to five percent because of surgical intervention. The incidence of heterotopic pregnancy has risen in recent years due to the increasing use of IVF (in vitro fertilization) and other assisted reproductive technologies (ARTs). About the intratubal bleeding or the call it “hematosalpinx” is the one which expels the implantation out from the tubal end and becomes a tubal abortion.
For ectopic pregnancy, the methotrexate treatment has lessen the need for surgery; perhaps, surgical intervention always required in some cases where the fallopian tube has ruptured or is in danger to even take the risk to do so. This website will help you keep track and keep both eyes with your pregnancy from 1 week till birth and even before conceiving , including in which size your baby today and how your belly and body is changing. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation.
In 1970, the Centers for Disease Control and Prevention (CDC) began to record the statistics regarding ectopic pregnancy, reporting 17,800 cases.
As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development.
The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection; however, most patients presenting with an ectopic pregnancy have no identifiable risk factor. Surgeries carrying higher risk of subsequent ectopic pregnancy include salpingostomy, neosalpingostomy, fimbrioplasty, tubal reanastomosis, and lysis of peritubal or periovarian adhesions. Failure after bipolar tubal cautery is more likely to result in ectopic pregnancy than occlusion using suture, rings, or clips. In a study of 3000 clinical pregnancies achieved through in vitro fertilization, the ectopic pregnancy rate was 4.5%, which is more than double the background incidence.
One proposed explanation involves the myoelectrical activity in the fallopian tube, which is responsible for tubal motility.
Studies of serial histopathological sections of the fallopian tube have revealed that approximately 50% of patients treated with salpingectomy for ectopic pregnancy have evidence of salpingitis isthmica nodosum.
Patients may present with other symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia. Fortunately, using modern diagnostic techniques, most ectopic pregnancies may be diagnosed prior to rupturing.
Intrauterine pregnancies with other abdominal or pelvic problems such as degenerating fibroids must also be included in the differential diagnosis. The patient must be hemodynamically stable, with no signs or symptoms of active bleeding or hemoperitoneum. Hence, screen any female patient in the reproductive years presenting with abdominal pain, cramping, or vaginal bleeding for pregnancy.
An increase in bhCG of less than 66% is associated with an abnormal intrauterine pregnancy or an extrauterine pregnancy. Hence, additional diagnostic modalities, including US and other biochemical markers, are needed. However, no consensus on a single value that differentiates between a normal and an abnormal pregnancy currently exists.
Visualization of an intrauterine sac, with or without fetal cardiac activity, often is adequate to exclude ectopic pregnancy. It has a thick echogenic rim surrounding a sonolucent center corresponding to the trophoblastic decidual reaction surrounding the chorionic sac. Therefore, if a multiple gestation is suspected, as in pregnancies resulting from assisted reproduction, the bhCG discriminatory zone must be used cautiously. If, however, the patient's bhCG levels failed to rise appropriately (ie, at least 66% in 2 d), operative intervention was undertaken with dilatation and curettage or laparoscopy to exclude the diagnosis of ectopic pregnancy. Free fluid on US can represent physiological peritoneal fluid or blood from retrograde menstruation and unruptured ectopic pregnancies. Once an abnormal pregnancy is established by bhCG or progesterone levels, curettage can help differentiate between an intrauterine or ectopic pregnancy.


When nonclotting blood is found in conjunction with a suspected ectopic pregnancy, operative intervention is indicated because the likelihood of a ruptured ectopic pregnancy is high.
Furthermore, the improved technology with US and hormonal assays is far superior in sensitivity and specificity in reaching the correct diagnosis. Medical therapy of ectopic pregnancy is appealing over surgical options for a number of reasons, including eliminating morbidity from surgery and general anesthesia, potentially less tubal damage, and less cost and need for hospitalization.
Methotrexate has long been known to be effective in the treatment of leukemias, lymphomas, and carcinomas of the head, neck, breast, ovary, and bladder. There is an inverse association between bhCG levels and successful medical management of an ectopic pregnancy. Leucovorin is folinic acid that is the end product of the reaction catalyzed by dihydrofolate reductase, the same enzyme inhibited by methotrexate. Studies comparing the multiple methotrexate dosage regimen to the single dosage regimen have demonstrated the 2 methods to be similar in efficacy.
It can be differentiated from tubal rupture in that it is milder, of limited duration (lasting 24-48 h), and is not associated with signs of acute abdomen or hemodynamic instability.
Provide an information pamphlet to all patients receiving methotrexate; the pamphlet should include a list of adverse effects, a schedule of follow-up visits, and a method of contacting the physician or the hospital in case of emergency. A repeat single dose of methotrexate can also be a viable option after reevaluation of the patients' indications and contraindications (including repeat US) for medical therapy. Proper documentation of attempts to reach the patient, including records of telephone calls and certified mail are important medical-legal considerations. The conservative approaches include linear salpingostomy and milking the pregnancy out of the distal ampulla.
It also is a preferred method for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is difficult (eg, secondary to the presence of multiple dense adhesions, obesity or massive hemoperitoneum).
Several studies have demonstrated no benefit of primary closure (salpingotomy) over healing by secondary intention (salpingostomy).
Make sure that the needle is not in a blood vessel by aspirating before injecting because intravascular injection of vasopressin may precipitate acute arterial hypertension and bradycardia. These patients do poorly with linear salpingostomy, with a high rate of recurrent ectopic pregnancy.
The average time for bhCG to clear the system is 2-3 weeks, but up to 6 weeks can be required. While resolution without any further intervention is the general rule, the persistence of trophoblastic tissue has been associated with tubal rupture and hemorrhage even in the presence of declining bhCG levels. Some investigators have questioned the need for unnecessary surgical or medical intervention in very early cases and have advocated expectant management in select cases.
They must be fully compliant and must be willing to accept the potential risks of tubal rupture. Ectopic pregnancy is the leading cause of maternal death in the first trimester, accounting for 9-13% of all pregnancy-related deaths. For example, comparing a patient who was managed expectantly to a patient who received methotrexate or to a patient who had a laparoscopic salpingectomy is difficult. Leaving a scarred charred fallopian tube behind after removing the ectopic pregnancy but requiring extensive cautery to control bleeding does not preserve reproductive outcome.
One study of 77 patients desiring subsequent pregnancy showed intrauterine pregnancies in 64%, and recurrent ectopic pregnancy occurred in 11%.
Physicians have been able to reduce the mortality rate secondary to ectopic pregnancy despite its growing incidence.
A molar pregnancy differs from an ectopic pregnancy in that it is usually a mass of tissue derived from an egg with incomplete genetic information that grows in the uterus in a grape-like mass that can cause symptoms to those of pregnancy. Statistics suggest with current advances in early detection, the mortality rate has improved to less than five in 10,000. This called intervention and known as a laparotomy may be through a larger incision or through laparoscopic. But you still have to have regular check-up and consultation to your doctor to be able to learn and be aware when will you expect you baby. Other organisms causing PID, such as Neisseria gonorrhoeae, increase the risk of ectopic pregnancy. Furthermore, studies have demonstrated that up to 1% of pregnancies achieved through IVF or GIFT can result in a heterotopic gestation, compared to an incidence of 1 in 30,000 pregnancies for spontaneous conceptions. Nevertheless, if a woman ultimately conceives with an IUD in place, it is more likely to be an ectopic pregnancy. Based on laboratory studies in humans and animals, researchers have postulated several mechanisms by which cigarette smoking might play a role in ectopic pregnancies. The etiology of salpingitis isthmica nodosum is unclear, but proposed mechanisms include postinflammatory and congenital as well as acquired tubal changes such as observed with endometriosis.
Astute clinicians should have a high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness.
In recent years, serum and urine assays for the beta subunit of human chorionic gonadotropin (bhCG) have been developed to detect a pregnancy before the first missed period. Remember that 15% of healthy intrauterine pregnancies do not increase by 66% and that 13% of all ectopic pregnancies have normally rising bhCG levels of at least 66% in 2 days.
The exception to this is in the case of heterotropic pregnancies, which occur from 1 in 4000 to 1 in 30,000 spontaneous pregnancies.
If transvaginal US does not reveal an intrauterine pregnancy when the discriminatory bhCG levels are reached, the pregnancy generally can be considered extrauterine. Remember that a discriminatory zone is operator and institution dependent, and the clinician must be aware of the zone used by that institution prior to interpreting results.
Furthermore, US can be used to detect the presence of other pathological conditions that may display the signs and symptoms of ectopic pregnancy.
If tissue obtained is positive for villi by floating in saline or by histological diagnosis on frozen or permanent section, then a nonviable intrauterine pregnancy has occurred. It has also been used as an immunosuppressive agent in the prevention of graft versus host disease and in the treatment of severe psoriasis and rheumatoid arthritis. Serious reactions, such as bone marrow suppression, dermatitis, pleuritis, pneumonitis, and alopecia, can occur with higher doses and are rare with doses used in the treatment of ectopic pregnancy. Another factor is size of the gestation, which should not exceed 3.5 cm at its greatest dimension on US measurement.
Normal dividing cells preferentially absorb leucovorin; hence, it decreases the action of methotrexate, thereby decreasing its systemic adverse effects. With smaller dosing and fewer injections, fewer adverse effects are anticipated and the use of leucovorin can be abandoned.
The more radical approach includes resecting the segment of the fallopian tube that contains the gestation with or without reanastomosis.
Multiple studies have demonstrated that laparoscopic treatment of ectopic pregnancy results in fewer postoperative adhesions than laparotomy. Segmental tubal resection is performed by grasping the tube at the proximal and distal borders of the segment of the tube containing the gestation and coagulating thoroughly from the antimesenteric border to the mesosalpinx. In all instances, regardless of desired fertility, fully inform the patient of the possibility of a laparotomy with bilateral salpingectomy.
Further medical treatment with methotrexate or surgery in symptomatic patients may be necessary if bhCG levels do not decline or persist. Distinguishing patients who are experiencing spontaneous resolution of their ectopic pregnancies from patients who have proliferative ectopic pregnancies could pose a clinical dilemma.
A patient with spotting, no abdominal pain, and a low initial bhCG level that is falling may be managed expectantly, while a patient who presents with hemodynamic instability, an acute abdomen, and high initial bhCG levels must be managed surgically.
The rate of persistent ectopic pregnancy between the two groups is similar, ranging from 5-20%. Other studies have demonstrated similar results, with intrauterine pregnancy rates ranging from 20-80%. Other studies have reported similar results with some mild adverse effects and lower reproductive outcomes.
The survival rate from ectopic pregnancies is improving even though the incidence of ectopic pregnancies is also increasing. We will also help you have a healthy, calm and happy pregnancy with our pregnancy-safe workouts and diet meal plans. Ectopic pregnancies following tubal sterilizations usually occur 2 or more years after sterilization, rather than immediately after.
These mechanisms include one or more of the following: delayed ovulation, altered tubal and uterine motility, or altered immunity.
Another factor is size of the gestation, which should not exceed 3.5 cm at its greatest dimension on ultrasound (US) measurement. While some commercial urine test kits are able to detect bhCG in early gestation, they are associated with varying false-negative rates.
Screening the adnexa by US is mandatory despite visualization of an intrauterine pregnancy in patients undergoing ovarian stimulation and assisted reproduction because they have a 10-fold increased risk of heterotropic pregnancy. Its effectiveness on trophoblastic tissue has been well established and is derived from experience gained in using methotrexate in the treatment of hydatiform moles and choriocarcinomas.
Treatment effects of methotrexate include an increase in abdominal pain (occurring in up to two thirds of patients), an increase in bhCG levels during first 1-3 days of treatment, and vaginal bleeding or spotting. However, in each case, the risk of surgery must be weighed against any relative contraindication.
An initial increase in bhCG levels often occurs by the third day and is not a cause for alarm.
Furthermore, laparoscopy is associated with significantly less blood loss and a reduced need for analgesia. Some authors have suggested administration of a prophylactic dose of methotrexate after conservative surgery to reduce the risk of persistent ectopic pregnancy.
These two patients probably represent different degrees of tubal damage, and comparing the future reproductive outcomes of the two would be flawed. A slightly higher recurrent ectopic pregnancy rate exists in patients treated by laparotomy (7-28%), regardless of conservative or radical approach, when compared to laparoscopy (6-16%). Once clinically available, it should have a dramatic impact on the frequency of ectopic pregnancy, as well as on the overall health of the female reproductive system.
Some of the ectopic pregnancies can also be occur inside the mother’s Fallopian tube (called it tubal pregnancies), some other can be also implantation occur in the abdomen, cervix and ovaries. But there will be some pains which is caused by prostaglandins that’s released right at the implantation site, and with the free blood in peritoneal cavity, this may cause a local irritant.
You'll learn how to write a birth plan, and we'll tell you what to expect when it times to give birth. The incidence of tubal damage increases after successive episodes of PID (ie, 13% after 1 episode, 35% after 2 episodes, 75% after 3 episodes).
To date, no study has supported a specific mechanism by which cigarette smoking affects the occurrence of ectopic pregnancy. In addition, the need for a quantitative value makes serum bhCG the criterion standard for biochemical testing. Laparoscopy can be performed at that time, or the case may be followed by serial serum bhCG levels and treated medically or surgically at a later time, depending on the clinical setting.
Methotrexate is used in the treatment of ectopic pregnancy as single or multiple intramuscular injections. Because of higher incidence of adverse effects and the increased need for patient motivation and compliance, the multiple dosage regimen has fallen out of favor in the United States. A decline in bhCG levels of at least 15% from days 4-7 postinjection indicates a successful medical response.
The underlying mesosalpinx is also coagulated and excised, with particular attention to minimize the damage to the surrounding vasculature. This surprising finding is believed to be secondary to increased adhesion formation in the group treated by laparotomy.
Ectopic pregnancy remains the leading cause of pregnancy-related death in the first trimester of pregnancy.
Some of the times, the bleeding might be even heavy enough to make this as scary threat for the health and life of the pregnant woman.
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Other effective monitoring protocols have also been reported.7 The patient's bhCG levels should be measured weekly until they become undetectable. Delayed microsurgical reanastomosis can be performed to reestablish tubal patency if enough healthy fallopian tube is present.
In this degree of bleeding is usually due of delay in diagnosis, it’s the most risky and dangerous when the implantation is in the proximal tube (right before it enters the uterus), it will invade in nearby Sampson artery, which will cause a very heavy bleeding earlier than usual.
Take care to minimize the thermal injury to the tube during excision, so that an adequate portion of healthy tube remains for the reanastomosis.



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