Ectopic Pregnancy
Introduction
World-wide, ectopic pregnancy occurs in approximately 1-2% of pregnant women. Although it likely is underreported, according to CDC data covering 1970-1989, there was nearly a four-fold increase in the incidence of ectopic pregnancy, from 4.5/1000 to 16.0/1000 of all reported pregnancies.1 While the overall case-fatality rate decreased from 35.5 deaths per 10,000 ectopic pregnancies in 1970 to 3.8 in 1989, the risk of death was 3.4 times higher in minorities as compared to white patients.1 The CDC reported a decrease in the incidence of ectopic pregnancy in 1991 and 1992 to 11.4 and 10.6/1000, respectively; however, these data are from the National Hospital Discharge Survey (NHDS) and more likely reflect a movement toward management of ectopic pregnancy in the outpatient setting rather than a true decline in the incidence.2 Ectopic pregnancy accounts for 9% of all pregnancy-related deaths in the United States.3
With the increase in incidence of pelvic inflammatory disease and assisted reproductive treatment (ART), the incidence of ectopic pregnancy will rise.
Pathophysiology
Implantation of the embryo into sites outside of the endometrial cavity results in continued growth of the embryo, spontaneous absorption of the pregnancy or, in rare occasions, expulsion into the abdominal cavity, where it will either be absorbed or continue to develop. The precise number of ectopic pregnancies that spontaneously absorb is unknown, but it has been reported in 47.7 to 70% of cases.4,5 Continued growth of the ectopic embryo is problematic for several reasons. The implanting trophoblast invades surrounding blood vessels needed for growth, but the tissue is not appropriately designed to support a viable pregnancy and there is insufficient space. Over time, distention at the site of the implanted structure may lead to rupture of the site of implantation and accompanying vasculature.
The most common location for ectopic pregnancy is the fallopian tubes (93%).6 (See Table 1.) The incidence of cervical ectopic pregnancy is least common and is estimated to be less than 1/455 of ectopic pregnancies in patients without assisted reproductive treatment (ART). However, the prevalence of cervical ectopic pregnancy has been cited as high as 9.8% of ectopic pregnancy after ART, specifically in vitro fertilization (IVF).7 Although very rare, diagnosis of cervical ectopic pregnancy often is delayed due to decreased accuracy of ultrasound, leading to rupture and emergent hysterectomy.7
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Cornual (interstitial) ectopic pregnancy implants in the myometrium in the proximal portion of the fallopian tube. Although 0.7 mm wide and 1-2 cm long, this area is more distensible than the fallopian tube and typically presents after 8 weeks' gestation.8 However, rupture may occur as early as 5 weeks' gestation.8 Maternal mortality rate for cornual ectopic pregnancy is 2-3%.8 Cornual ectopic pregnancy is diagnosed on ultrasound in only 65-71% of cases, and laparoscopic diagnosis remains the most accurate tool.8
Risk Factors
Many factors predispose patients to having this condition. (See Table 2.) However, between 40% and 50% of patients with confirmed ectopic pregnancy have no risk factors, so the absence of such factors does not rule out the diagnosis.4,9 Theoretically, anything that injures the fallopian tube will put a patient at higher risk for ectopic pregnancy. The incidence of ectopic pregnancy is as high as 20% in patients who have had prior tubal surgery.10
ART is a well-established risk factor for ectopic pregnancy. The incidence varies depending on the type of ART used. The incidence of ectopic pregnancy after in vitro fertilization generally is less than 5% but may be as high as 11% in patients with tubal factor infertility.10
In utero exposure to diethylstilbestrol (DES) is a risk factor for ectopic pregnancy. An estrogen derivative, DES was prescribed to pregnant women between 1938 and 1971 to prevent miscarriages and premature deliveries. It was discontinued in 1971 when it was found to be linked to clear cell carcinoma. Animal research found that in utero exposure to DES causes abnormal or malformed oviducts leading to an increased risk for infertility and ectopic pregnancy.11
Cigarette smoking also is a risk factor for ectopic pregnancy. Nicotine interferes with tubal motility (due to lower estrogen levels), delays blastocyst implantation, and alters the spacing of implantation sites in animals.12 Smokers may have decreased immunity, which may increase the risk of pelvic inflammatory disease (PID). Saraiya et al. found that black women who smoked cigarettes had a two-fold increased risk for ectopic pregnancy compared to non-smokers.13
The incidence of ectopic pregnancy is increased two- to four-fold in adults compared to adolescents.1,14 According to the CDC, women 35 to 44 years old had the highest rates of ectopic pregnancy in all racial groups when compared to patients in the 15- to 24-year-old age group.1 This likely is due to the fact that patients may be exposed to more risk factors with increasing age. One study that compared risk factors for ectopic pregnancy in adult and adolescent patients found that adults ( > 20 years old) were more likely to have a history of prior tubal surgery, prior ectopic pregnancy, and use of IUD.14 The incidence of ectopic pregnancy in the adolescent group was 9.7% and 21.7% in the adult group.14
Clinical Features
The symptoms of ectopic pregnancy are similar to those of other conditions, such as ovarian torsion, appendicitis, and spontaneous abortion. In addition, ectopic pregnancy may cause nausea, vague abdominal pain, and breast tenderness similar to the early stages of a normal pregnancy. The classic clinical triad for ectopic pregnancy is amenorrhea, abdominal pain, and vaginal bleeding. Unfortunately, this combination of symptoms is present in a very small percentage of patients and is neither sensitive nor specific. The most common clinical presentation of patients with ectopic pregnancy is abdominal pain (80%). Vaginal bleeding is reported by 50-80% and ranges from spotting to profuse.15 Amenorrhea is reported in 75-95% of patients with ectopic pregnancy.
Monitor vital signs closely in patients with suspected ectopic pregnancy. Vital signs may not be abnormal unless the ectopic pregnancy has ruptured and there has been significant blood loss. Hypotension and tachycardia are not predictive of ectopic pregnancy.16 Moreover, the vital signs may not correlate with hemoperitoneum caused by a ruptured ectopic pregnancy. Hick et al. retrospectively looked at the vital signs documented in the emergency department of 51 patients with ruptured ectopic pregnancy. Of the 15 patients who had hemoperitoneum of > 1500 ml, 20% had systolic blood pressures > 90 mmHg, and 33% had heart rates < 100 bpm.17
Physical findings predictive of ectopic pregnancy include moderate to severe abdominal or pelvic tenderness, peritoneal signs, uterus size less than 8 weeks, and cervical motion tenderness.16 The presence of an adnexal mass is noted in only 10% of patients and is not predictive of ectopic pregnancy.16 Ruptured ectopic pregnancy should be strongly considered in any patient who has peritoneal signs, hypotension, or shoulder pain. Roussos et al. found that patients who had a prior normal pregnancy and no history of prior ectopic pregnancy had a higher incidence of rupture. He suggested that the diagnosis may be delayed in these patients because the clinician is less suspicious of ectopic pregnancy.18
Diagnostic Studies
Since no single sign or symptom or combination of signs and symptoms can definitely diagnose ectopic pregnancy, a variety of diagnostic studies, including laboratory tests, ultrasound, and surgical procedures, can help differentiate these various conditions and establish a diagnosis.
Any woman of reproductive age with abdominal complaints should be screened for pregnancy, and any woman with abdominal pain, cramping, or vaginal bleeding should be considered at risk for ectopic pregnancy. Transvaginal ultrasound (TVU) in conjunction with a quantitative serum human beta-chorionic gonadotropin (beta-hCG) level is used to differentiate between a normal intrauterine pregnancy, a nonviable intrauterine pregnancy, and an ectopic pregnancy.
Transvaginal Ultrasound. TVU will reveal a definite intrauterine pregnancy (IUP), a definite ectopic, or a pregnancy in an undefined location (PUL).
A double decidual sign is one of the first signs that is seen in an IUP and should be visualized 5 weeks after the last menstrual period. The double decidual sign is described as two echogenic rings surrounded by intrauterine fluid collection. (See Figure 1.) Caution should be taken, however, to differentiate this from a pseudogestational sac, which can be seen in ectopic pregnancy.4,19 This pseudogestational sac (see Figure 2) is due to a small amount of fluid being trapped within the endometrial canal, mimicking the appearance of the double decidual sign. Because of the risk of potential misinterpretation, there is controversy about using the double decidual sign to rule in an IUP.
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The intradecidual sign is a linear echo in the uterine cavity in a pregnancy < 9 weeks in conjunction with a gestational sac or an echogenic area of early implantation located within a markedly thickened uterine cavity.20 (See Figure 3.) These findings may be mistaken for a decidual cyst or an endometrial cyst, which may coexist with ectopic pregnancy and makes the intradecidual sign controversial as a reliable finding for an IUP.21
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By 5.5 weeks from the last menstrual period, a yolk sac should be visualized within the gestational sac. (See Figure 4.) This is the earliest definitive sign of an intrauterine pregnancy.4,21,22 Gestations longer than 5.5 weeks have a visible IUP seen nearly 100% of the time.4,23,24 Operator expertise, however, decreases the sensitivity of TVU to 73-93%.4,23,24 If a definite IUP is seen and the patient is not at risk for heterotopic pregnancy (ectopic pregnancy and IUP), the patient does not have an ectopic pregnancy.
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Diagnostic criteria for a tubal ectopic pregnancy on TVU include an empty endometrial cavity with either a heterogeneous adnexal mass (seen in approximately 60% of cases), an extra-uterine gestation sac with a yolk sac that may have a fetal pole +/- cardiac activity (seen in 13% of cases), or a ring sign.25,26 A ring sign is a mass in the adnexa with a hyperechoic ring around the gestational sac seen on TVU in approximately 20% of cases.4,25-27 (See Figure 5.) Diagnostic criteria for interstitial/cornual ectopic pregnancy include an empty endometrial cavity with a pregnancy visualized outside of the endometrial echo and surrounded by myometrium within the interstitial region.25
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Studies have shown that the overall sensitivity of TVU for diagnosing ectopic pregnancy ranges between 74% and 98% and has a specificity of 99.9%.25,26,28 Patients with PUL on an initial TVU may in fact have an ectopic and should be followed closely.25
In the event of rupture of the ectopic pregnancy, free fluid may be seen on TVU as an anechoic area around the uterus, in the pelvis or Morrison's pouch. (See Figure 6.)
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Quantitative Beta-hCG Levels. A single beta-hCG level cannot rule in or rule out an ectopic pregnancy. However, there is a level of beta-hCG above which an IUP can always be visualized by TVU, called the discriminatory zone. Initially established to be 1500 IU/L, the trade-off for high sensitivity was lower specificity and, thus, clinicians risked diagnosing a potentially early viable IUP as an abnormal gestation.4,29 Thus, the discriminatory zone has been extended into a range of 1500-3000 IU/L and is dependent on the quality of equipment and technicians used to correctly diagnose ectopic pregnancy at a given hospital. The use of a range increases the specificity at the higher level and provides somewhat of a more conservative upper limit for the beta-hCG level.
While at levels above the discriminatory zone, the sensitivity for IUP on ultrasound nears 100%, the sensitivity and predictive value for diagnosing IUP, miscarriage, and ectopic pregnancy in women with serum beta-hCG < 1500 IU/L is significantly lower.4 Some defer transvaginal ultrasound in patients with serum beta-hCG levels < 1500 IU/L. However, patients who present to the ED with abdominal pain or vaginal bleeding and have a beta-hCG < 1500 IU/L are less likely to have a normal IUP. A beta-hCG < 1500 IU/L in these patients more than doubled the odds of having an ectopic pregnancy (likelihood ratio = 2.24).30 Women can rupture an ectopic pregnancy with beta-hCG levels < 1500 IU/L, even at undetectable or negative levels.31-34 The risk of ectopic pregnancy is in fact increased when the likelihood of a normal IUP is low. Therefore, transvaginal ultrasound should be considered in women at risk for ectopic pregnancies regardless of the beta-hCG level.30,35
In addition, beta-hCG levels cannot predict which ectopic pregnancy is likely to rupture. In one study that compared beta-hCG levels of ruptured and non-ruptured ectopic pregnancies, the beta-hCG levels ranged from 8-75,071 and 15-89,504, respectively.36
Serum beta-hCG levels can be used serially to follow the progression of a pregnancy in patients with PUL on TVU or identify a resolving spontaneous abortion. When following serial beta-hCG levels, the rate of change is important rather than the absolute value. Previously, it had been reported that the majority of viable intrauterine pregnancies showed an increase in their beta-hCG levels of 66% in two days.4,37-39 However, more recently it has been demonstrated that 99% of viable intrauterine pregnancies are associated with an increase of at least 53% in two days.4 Declining beta-hCG levels indicate that the pregnancy is abnormal or failing. Barnhart et al. found that the rate of decline after two days in spontaneous abortion ranges between 12-35%, depending on the initial beta-hCG level.4 Unfortunately, there is no pattern of increase or decline of beta-hCG levels in ectopic pregnancy. One study showed that although the majority of diagnosed ectopic pregnancies (71%) had beta-hCG levels that either increased or declined at rates outside of that expected for a normal pregnancy or spontaneous miscarriage, 21% of ectopic pregnancies presented with beta-hCG levels that rose at the lower end of normal for viable IUP, and 8% declined similarly to those levels seen with completed spontaneous abortion.4,40 Patients who have decreasing beta-hCG levels should have serial levels followed until undetectable.
See Figure 7.
For patients with PUL on initial TVU, the scan may be repeated in 2-7 days to attempt to identify the pregnancy location. Nearly 90% of ectopic pregnancies were identified on a repeat TVU seven days after the initial study. Given the possibility of rupture before the repeat ultrasound is performed, serial beta-hCG values should be obtained in the interim.
Other Studies. Progesterone is produced by the corpus luteum in early pregnancy, and serum levels have no variance during the pregnancy and do not correlate with beta-hCG levels. High progesterone levels (> 80 nmol/L) are highly sensitive for viable pregnancies, and low levels (< 16 nmol/L) are highly sensitive for nonviable pregnancies. However, low levels do not help in differentiating between ectopic pregnancies and spontaneous abortions. Between the levels of 16 and 80 nmol/L, the patient may have a viable IUP, an ectopic pregnancy, or a miscarriage,41 and further evaluation is needed. There is no significant difference in the progesterone levels of patients who had spontaneous miscarriage and ectopic pregnancy.42 In addition, there is no established threshold for a particular progesterone level that distinguishes a normal from an abnormal pregnancy. For these reasons, a progesterone level cannot exclude ectopic pregnancy in the emergency department.
Management
Patients with signs of hypovolemia should be aggressively resuscitated with crystalloids and blood products. Serum beta-hCG level, CBC, coagulation studies, blood type, and Rhesus factor screen should be ordered. The patient's pain should be appropriately managed with narcotics as long as the patient's blood pressure can tolerate it.
Clinical findings consistent with ectopic pregnancy warrant early emergent consultation from an obstetrics and gynecology (Ob/Gyn) specialist. Hemodynamically stable patients with unruptured ectopic pregnancy have the option for expectant, laparoscopic, or medical management. Although definitive management ultimately is performed by the Ob/Gyn specialist, emergency physicians should be familiar with and understand the treatment options to effectively participate in formulating an appropriate management plan. The following section will address these treatment options.
Medical Management
Although methotrexate is the major medication used in the treatment of ectopic pregnancy, it has not been FDA-approved for this use in the United States. It is most toxic in rapidly dividing and replicating cells. Initially used for treatment for carcinomas, its use for ectopic pregnancy was established in the 1980s.
Approximately 40% of patients with ectopic pregnancy meet criteria for medical management.43 Patients must have a definitive diagnosis of ectopic pregnancy prior to receiving methotrexate.43 Patients also must be hemodynamically stable, have a non-ruptured ectopic pregnancy < 4.0 cm without signs of fetal activity, and beta-hCG levels < 5000 IU/L. Patients should be reliable, amenable to the treatment regimen and outpatient follow-up, and have no absolute contraindications to methotrexate therapy. (See Table 3.) Methotrexate is the first-line of treatment for eligible patients who have non-tubal ectopic pregnancies because they are at a higher risk of massive bleeding during surgery.5
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Two methotrexate treatment regimens are currently used: single dose and multiple dose. The single-dose regimen is so named to describe the number of planned injections, but it actually allows for an additional dose if initial treatment is sub-optimal. The single-dose regimen involves methotrexate 50 mg/m2 intramuscular injection on day one of treatment and again on day seven if the beta-hCG level decreases by less than 15% between days 4 and 7. The multiple-dose regimen gives methotrexate 1.0 mg/kg IM on day one, alternating with leucovorin (folinic acid) every other day, with a maximum of four doses of methotrexate. Leucovorin is a methotrexate antagonist and is given to limit the side effects of methotrexate. In both treatment regimens, the beta-hCG levels are monitored to see if more methotrexate is indicated and are followed on a weekly basis until they become undetectable. This may take as few as two weeks but as long as 6-8 weeks if the beta-hCG levels are higher at the start of treatment.43
The overall success rate for methotrexate treatment of ectopic pregnancy is 89%.44 Increases in beta-hCG levels greater than 53% over 2 days following two doses in the single-dose regimen or four doses in the multiple-dose regimen indicate treatment failure.45
Patients may experience transient abdominal pain within 3-7 days after the start of treatment classified as separation pain.43 These patients should be monitored carefully and, if the pain progresses in severity, is persistent, or is accompanied with other signs/symptoms (such as hemodynamic instability or syncope), treatment failure or rupture of the ectopic pregnancy should be suspected. Laparoscopy or laparotomy may be indicated in these cases.
Prior to discharge, patients should be aware of the possibility of separation pain and other effects of methotrexate treatment, which include vaginal bleeding and increase in abdominal girth. The most common side effects from methotrexate are stomatitis, nausea, vomiting, and dizziness. Patients should be counseled on the importance of follow-up and instructed to avoid sexual intercourse, sunlight, foods and vitamins containing folic acid, alcoholic beverages, aspirin, and gas-forming foods.43,46 Patients should refrain from new conception for at least three months following treatment due to the risk of teratogenicity of methotrexate.46
Surgical Management
Surgery is indicated in patients who have ruptured ectopic pregnancy, who have failed medical treatment, or if there is diagnostic uncertainty. When compared to laparotomy, laparoscopy has been shown to be more cost-effective and to result in shorter hospital stays and less subsequent adhesions.5 In addition, laparoscopy can be safely and effectively performed even in patients who have ruptured ectopic pregnancy. Laparotomy is necessary for patients with extensive hemopertoneum, limited visualization of the pelvis during laparoscopy, hemodynamic instability, or if the surgeon has a limited comfort/skill level with laparoscopic techniques. Surgical options include salpingostomy, removal of the ectopic pregnancy with preservation of the fallopian tube, or salpingectomy with removal of the affected fallopian tube. The determination of salpingectomy versus salpingostomy generally is an intraoperative decision and depends on the severity of damage to the affected tube, the condition of the contralateral tube, history of prior ectopic pregnancy, and the desire to preserve fertility.
Unusual Cases
Heterotopic Pregnancy. Heterotopic pregnancy (HP) is the coexistence of an intrauterine and an extrauterine pregnancy. The majority of cases of HP are thought to arise from multiple ovulations.47 Although its incidence was once considered rare (1/30,000 pregnancies), the incidence has increased significantly since the advent of assisted reproductive technology (ART).48,49 The true incidence of HP is unknown but has been estimated to be as high as 1.5% in women treated with ART, which is 100 times higher than HP that occurs with natural cycles.50
Risk factors for HP are similar to those for ectopic pregnancy and include pre-existing tubal disease, pelvic inflammatory disease, prior ectopic pregnancy, prior tubal surgery, use of intrauterine devices, and ART.51 Patient presentations vary, and some may even be asymptomatic. Presenting signs and symptoms include lower abdominal pain (30-80%), vaginal bleeding (approximately 30%) and adnexal mass (43%), enlarged uterus, and hemorrhagic shock.49,52 Approximately 50% of heterotopic pregnancies present with acute rupture.53
Heterotopic pregnancy presents a major diagnostic challenge for the emergency physician as well as the obstetrician. It is common to think that an intrauterine pregnancy on ultrasound rules out an ectopic pregnancy. However, an HP still may exist and, if left undiagnosed or if the diagnosis is delayed, there may be dire maternal consequences. Soriano et al. found that patients with HP were more likely to have hemodynamic instability, to have more free fluid in the pelvis, and to require more blood transfusions than patients with ectopic pregnancy.
Early diagnosis of HP is essential. The majority of heterotopic pregnancies are diagnosed between 5 and 8 weeks (70%), while 20% are diagnosed between 9 and 10 weeks, and the remaining 10% after 11 weeks.51 The serum beta-hCG levels are not helpful because they are usually high and may in fact appropriately increase in serial examinations.
Because 95% of heterotopic pregnancies are located either in the fallopian tubes or the ovaries, transvaginal ultrasound is superior to transabdominal ultrasound in making the diagnosis of HP.54 It is important to keep HP in the differential diagnosis for those pregnant patients who present with shock or continue to complain of severe abdominal pain with or without vaginal bleeding. It is crucial that the adnexal structures be visualized. Consider HP if there is an IUP but the adnexa are poorly visualized or abnormal and there is free fluid in the pelvis.
Treatment of the ectopic pregnancy depends on the patient's clinical presentation. The literature states that laparoscopy for salpingectomy or salpingotomy is the standard treatment for these patients. In stable patients, the use of potassium chloride, methotrexate, RU486, or prostaglandins is useful in the treatment of the ectopic pregnancy but raises concern for possible compromise of the intrauterine gestation.51,53
The survival rate for the intrauterine pregnancy has been documented to be approximately 66% in patients who undergo laparoscopic surgery to remove the ectopic pregnancy.54,55 Maternal hypovolemia due to hemorrhagic shock increases the likelihood of demise of the intrauterine pregnancy. The maternal mortality rate for HP has been cited as being just under 1% as compared to ectopic pregnancy, which carries a mortality rate of 0.3/1000.49 This larger mortality rate likely is due to delays in diagnosis.
Ectopic Pregnancy Following Hysterectomy. Since 1895, there have been 56 reported cases of ectopic pregnancy following hysterectomy. The majority of cases (31) presented immediately following hysterectomy and presumably were caused by unrecognized ectopic pregnancy at the time of the procedure. The remaining 25 cases presented as late as 12 years following the hysterectomy (72% had vaginal hysterectomies) and are thought to be due to vaginal-peritoneal fistulas that allow sperm to have access to the peritoneal cavity.56
Bilateral Ectopic Pregnancy. Theoretically, for bilateral ectopic pregnancy to occur in a natural cycle (termed primary bilateral ectopic pregnancy), there should be not only pathology of both fallopian tubes but also double spontaneous ovulation. In the past 90 years, there have been more than 200 reported cases of bilateral ectopic pregnancies (BEP). Between 1997 and 2006, 42 cases of bilateral ectopic pregnancy were reported 19 (45%) of which occurred following ART and 7/19 specifically after IVF+ET.57 Of the 42 BEP patients, 50% of primary BEP and 31.6% of secondary BEP presented with hypovolemia or an acute abdomen. Serum beta-hCG levels did not correlate with ultrasound findings, and in fact ultrasound failed to correctly diagnosis all but two cases. Although treatment guidelines have not currently been established, it was found that 36/42 of the patients were managed operatively. This unusual occurrence stresses the point that diligent ultrasound imaging should be performed with visualization of both adnexal structures in all pregnant patients and the index of suspicion for multiple ectopic pregnancy should be raised in patients who receive ART.
Caesarean Scar. Another very rare form of ectopic pregnancy is the implantation of the trophoblast into the scar from a prior Caesarean section. Caesarean scar pregnancy is diagnostically challenging and carries a high risk of maternal morbidity from excessive bleeding and uterine rupture.58 Diagnostic criteria for diagnosis via ultrasound have been established by Jurkovic et al and include empty uterine cavity, gestational sac anterior to the level of the internal os covering the visible or presumed site of the prior lower uterine scar, evidence of functional trophoblastic/placental circulation on Doppler examination, and an absent sliding organs sign.59 The sliding organs sign refers to the occurrence of the gestational sac sliding against the endocervical canal when pressure is applied to the cervix using the ultrasound probe in the event of a miscarriage. Obviously these findings require an experienced ultrasonographer. Diagnostic work-up and treatment plans should be done in conjunction with the Ob/Gyn specialist.
Summary
Ectopic pregnancy accounts for 1-2% of all pregnancies and is the leading cause of first-trimester mortality. With the increased use of assisted reproductive treatment, the risk for not only ectopic but heterotopic pregnancy in that subset of patients is increased. Ectopic pregnancy is a diagnostic challenge for the emergency physician as there are no specific signs or symptoms that lead to its diagnosis. Therefore, it must always be suspected and ruled out in pregnant women who present with abdominal pain or vaginal bleeding. The two main tools used for the diagnostic work-up of ectopic pregnancy are serum quantitative beta-hCG level and transvaginal ultrasound. The sensitivity for diagnosing ectopic pregnancy on TVU is between 74% and 93%, with specificity approaching 100%. Pregnancies that are not identified on TVU must be followed closely and have repeated ultrasound and serial beta-hCG levels. Medical management with methotrexate for a select subset of patients who meet the criteria includes a single- or multiple-dose regimen. Surgical management with laparoscopy is the mainstay and more cost-effective than laparotomy in stable patients. Treatment plans for these patients should be made in conjunction with the obstetric specialist. If discharged, patients need to have a solid understanding of the nature of the pregnancy and their follow-up course, and they should be instructed to return to the ED for any persistence or worsening of symptoms.
Acknowledgement
The authors would like to give special thanks to Dr Ronald Wachsberg, Department of Radiology at UMDNJ, for his generous assistance and contribution of all of the ultrasound images presented in this paper.
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World-wide, ectopic pregnancy occurs in approximately 1-2% of pregnant women. Although it likely is underreported, according to CDC data covering 1970-1989, there was nearly a four-fold increase in the incidence of ectopic pregnancy, from 4.5/1000 to 16.0/1000 of all reported pregnancies.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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