eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Surgical Management of Ectopic Pregnancy: Treatment

Author: Allahyar Jazayeri, MD, PhD, Medical Director of Perinatal Services, Bellin Health Hospital Center
Coauthor(s): Herbert S Coussons, MD, FACOG, Private Practice in Obstetrics and Gynecology, Women's Specialty Care
Contributor Information and Disclosures

Updated: Jan 7, 2008

Treatment

Medical Therapy

The greatest advance in the management of ectopic pregnancy since Tait's endeavors has been the development of medical management that became available in the mid 1980s. Initial protocols required long-term hospitalization and multiple doses of methotrexate and were associated with significant side effects. Modification and refinements of the protocols for medical therapy of ectopic pregnancy have allowed single-dose outpatient therapy.

While methotrexate has remained the most effective and popular drug used in medical therapy for an ectopic pregnancy, other protocols have been used, such as potassium chloride, hyperosmolar glucose, RU 486, and prostaglandins, and these have been administered orally, systemically, and locally into the ectopic pregnancy directly. These therapies remain experimental at present since experience in using them and the efficacy of such treatments as well as advantages over standard methotrexate protocol has not been established. Therefore, the focus of this article is on the use of methotrexate therapy.

In certain carefully selected patients, intramuscular methotrexate can be both safe and effective therapy.

To determine acceptable candidates for methotrexate therapy, first establish the diagnosis by one of the following criteria:

• Abnormal doubling rate of the β-hCG level and sonographic identification of a gestational sac outside of the uterus
• Abnormal doubling rate of the β-hCG level, an empty uterus, and menstrual aspiration with no chorionic villi

Once the diagnosis is established, the following criteria should also be met:

1. Hemodynamically stable
2. Reliable, compliant patient who will return for follow-up care
3. Ectopic pregnancy smaller than 4 cm in diameter or smaller than 3.5 cm with cardiac activity
4. Absence of fetal cardiac activity on ultrasonographic findings
5. No evidence of tubal rupture
6. β-hCG level less than 5000 mIU/mL

Criteria 1 and 2 must be met by every patient. Criteria 3-6 are relative contraindications to medical therapy but are not absolute. The best predictor of success of medical therapy is the initial hCG level. Based on efficacy studies done by Lipscomb et al, success exceeded 90% for single-dose methotrexate when hCG levels were less than 5000 mIU/mL and dropped to about 80% when levels were 5-10,000 mIU/mL, and success was less than 70% with an initial hCG level of greater than 15,000 mIU/mL.²  

The protocol for single-dose methotrexate is as follows:

Day 0

hCG, ultrasonography, and +/- D&C

Day 1 

hCG, SGOT/SGPT BUN, creatinine

Evidence of hepatic or renal compromise is a contraindication to methotrexate therapy. Blood type, Rh status, and antibody screening are also performed, and all Rh-negative patients are given Rh immunoglobulin. 

Methotrexate (50 mg/m²) is administered by intramuscular injection. Advise patients not to take vitamins with folic acid until complete resolution of the ectopic pregnancy. They should also refrain from alcohol consumption and intercourse for the same period.

Day 4

The patient returns for measurement of the β-hCG level. The level may be higher than the pretreatment level. The day-4 hCG level is the baseline level against which subsequent levels are measured.

Day 7

Draw β-hCG and AST levels, and perform a CBC count. If the β-hCG level has dropped 15% or more since day 4, obtain weekly hCG levels until they have reached the negative level for the lab. If the weekly levels plateau or increase, a second course of methotrexate may be administered.

If the β-hCG level has not dropped at least 15% from the day-4 level, administer a second intramuscular dose of methotrexate (50 mg/m²) on day 7 and observe the patient similarly. If no drop has occurred by day 14, surgical therapy is indicated.

If the patient develops increasing abdominal pain after methotrexate therapy, repeat a transvaginal scan to evaluate for possible rupture.

Using this protocol, Stovall et al achieved a 96% success rate with a single injection of methotrexate.³

Medications

Surgical Therapy

Surgical therapy may be either open laparotomy or via the laparoscopic route. Ideally, all ectopic pregnancies requiring surgery should be treated laparoscopically. Risk factors for converting laparoscopy to laparotomy should be considered and include multiple prior surgeries, pelvic adhesions, skill of the surgeon and surgical staff, availability of the equipment, and condition of the patient.

Preoperative Details

Obtain large-bore venous access and start fluid resuscitation; make sure blood is available. Do not delay the operation. The patient has an active bleeding site, and it must be stopped as soon as possible.

Place a Foley catheter prior to starting the procedure.

Either a Hulka tenaculum or a Harris-Kronner uterine manipulator/injector (ie, HUMI) device inserted into the uterus may be helpful in manipulating the tube during surgery.

Intraoperative Details

Regardless of the route of approach, salpingectomy is indicated in the following situations:

• The ectopic pregnancy has ruptured.
• Future fertility is not desired.
• This is a sterilization failure.
• It is a previously reconstructed tube.
• Sterilization is requested.
• Hemorrhage continues after salpingotomy.
• The ectopic pregnancy is in the blind-ending distal segment after a previous partial salpingectomy.
• This is a chronic tubal pregnancy.

In the absence of any of the above indications for salpingectomy, salpingotomy may be performed.

If the ectopic pregnancy is at the fimbria, then fimbrial evacuation is feasible, in the absence of indications for salpingectomy.

Partial salpingectomy may be indicated if the pregnancy is in the mid portion of the tube, none of the indications for salpingectomy is present, and the patient may be a candidate for later tubal reanastomosis.

Laparoscopy

• Salpingectomy technique
  • Desiccate the tube between the uterus and the ectopic pregnancy using bipolar cautery.
  • Compress and desiccate the tuboovarian artery, while preserving the uteroovarian artery and ligament.
  • Cut along the desiccated path, closer to the specimen, leaving a pedicle for hemostasis.
  • Repeat until the tube is free and can be removed.
• Salpingotomy technique
  • Infiltrate the mesosalpinx with vasopressin (20 IU in 50 mL of isotonic sodium chloride solution [ie, normal saline or NS]; some authors use only 10 IU in 50 mL of NS). Avoid intravascular injection because it is contraindicated in patients with ischemic heart disease. It frequently causes hypertension.
  • With the knife or needle electrode, make a 1- to 2-cm incision on the antimesenteric side of the tube.
  • Insert the aquadissector deep into the incision.
  • Fluid from the aquadissector, under pressure, dissects and dislodges the ectopic pregnancy and clots.
  • Irrigate the bed well.
  • If trophoblastic tissue remains, the use of vasopressin may lead to anoxia and death of the trophoblasts, preventing postoperative growth.
  • Further dissection may damage the tube and is not usually performed.
  • The products of conception are then removed through the 12-mm sleeve.
  • If needed, products of conception can be reduced to smaller pieces using biopsy forceps or the aquadissector.
  • Bleeding may be controlled by applying pressure with grasping forceps for 5 minutes.
  • Arterial bleeding may require pinpoint bipolar desiccation.
  • Diffuse venous bleeding is best controlled with monopolar current. A spark or arc is created using a current of 25-50 W through an electrode in noncontact mode.
  • Uncontrollable bleeding may require the application of an endo loop to provide compression for 10 minutes. The ligature is then released.
  • If bleeding continues, suture of the mesosalpingeal vessels may be attempted.
• Fimbrial evacuation technique
  • Grasp the fimbria and rotate it to allow insertion of the aquadissector.
  • Fluid under pressure dissects and dislodges the ectopic pregnancy and clots.
  • Remove the products of conception.
• Partial salpingectomy technique
  • Perform bipolar desiccation across the tube on both sides of the ectopic pregnancy.
  • Divide the tube at the sites of desiccation.
  • The mesosalpinx under the ectopic pregnancy can then be either desiccated or ligated with an endo loop.
  • Remove the products of conception.

Laparotomy

• Salpingectomy technique
  • Clamp the tube between the uterus and the ectopic pregnancy using a Pean or similar clamp. Cut the pedicle free and ligate the pedicle with a suture ligature. (See Media file 5.)
  • Clamp, cut, and ligate the tuboovarian artery, while preserving the uteroovarian artery and ligament.
  • Continue to clamp, cut, and ligate the mesosalpinx until the tube is free and can be removed.
• Salpingotomy technique
  • Infiltrate the mesosalpinx with vasopressin (20 IU in 50 mL NS). Avoid intravascular injection because it is contraindicated in patients with ischemic heart disease. It frequently causes hypertension.
  • With the knife or needle electrode, make a 1- to 2-cm incision on the antimesenteric side of the tube. (See Media files 6-7).
  • Insert the aquadissector, or a syringe filled with saline, deep into the incision.
  • Fluid from the aquadissector, or syringe, under pressure, dissects and dislodges the ectopic pregnancy and clots.
  • Irrigate the bed well.
  • If trophoblastic tissue remains, the prior injection of vasopressin may lead to anoxia and death of the trophoblasts, preventing postoperative growth.
  • Further dissection may damage the tube and is not usually performed.
  • Bleeding may be controlled by applying pressure with blunt tissue forceps for 5 minutes.
  • Arterial bleeding may require pinpoint bipolar desiccation.
  • Diffuse venous bleeding is best controlled with monopolar current. A spark or arc is created using a current of 25-50 W through an electrode in noncontact mode.
  • Uncontrollable bleeding may require application of a suture ligature to provide compression for 10 minutes. The ligature is then released.
  • If bleeding continues, suture of the mesosalpingeal vessels may be attempted.
  • The tubal incision is left open and not repaired.
• Fimbrial evacuation technique
  • Grasp the fimbria and insert the aquadissector or a syringe filled with saline.
  • Fluid under pressure dissects and dislodges the ectopic pregnancy and clots.
  • Remove the products of conception.
• Partial salpingectomy technique
  • Place a clamp through an avascular area in the mesosalpinx under the ectopic pregnancy. This creates a space through which 2 free ties are placed.
  • Tie the free ties around the tube on each side of the ectopic pregnancy.
  • Cut free and remove the isolated portion of the tube containing the ectopic pregnancy.

Postoperative Details

Most patients with an ectopic pregnancy are able to leave the hospital as soon as they have left the recovery room.

In patients who were in shock or had to receive blood transfusions, the postoperative observation should be longer and should include observation that the kidneys are functioning normally and the patient has regained normal hemodynamics.

Follow-up

All patients who have not had the entire ectopic pregnancy removed by salpingectomy need to have their weekly hCG levels observed until these levels return to nonpregnant values. If, during this time span the hCG level either plateaus or rises, treat the patient with methotrexate.

Patients should all be on some form of effective contraception until such time as their hCG levels have returned to nonpregnant levels.

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Ectopic Pregnancy.

Complications

While not exactly a complication, cervical pregnancy should be discussed. Cervical pregnancy is an ectopic pregnancy that has implanted in the cervix. This can cause severe hemorrhage if it starts to separate from the cervix. Few muscle fibers are in the cervix; thus, no constriction occurs around the hypertrophied blood vessels that developed for the pregnancy. With no pressure on the vessels, profuse hemorrhage can occur.

In recent years, ultrasound diagnosis has improved to the point that the diagnosis is made much more frequently in asymptomatic patients. This leads to many more management options.

Previously, the only treatment was surgical in nature, with curettage of the implantation site. This frequently led to such profuse hemorrhage that surgeons recommended opening the patient's abdomen and placing ligatures around the uterine arteries or hypogastric arteries prior to starting the curettage. Hysterectomy was frequently the result.

Currently, the recommended treatment is either hysterectomy for those who do not desire fertility or methotrexate for those who desire fertility. Because patients who receive methotrexate occasionally develop severe hemorrhage, observe these patients closely for 1-2 weeks after therapy. An interventional radiologist should be available for arterial embolization if severe hemorrhage occurs as the pregnancy separates from the cervix.

Medical pitfalls

Certain diagnostic pitfalls can occur for the physician sonographer in the diagnosis of ectopic pregnancy.

• Low β-hCG levels: Consider β-hCG levels carefully in conjunction with ultrasound findings. Low β-hCG levels may be misleading. Kaplan et al found that 29% of ectopic pregnancies in women with β-hCG levels less than 1000 IU/L were ruptured.⁴ Indeterminate sonographic findings in pregnant patients should prompt further workup despite β-hCG levels.
• Location of gestational sac: An ectopic pregnancy may be mistaken for a hemorrhagic corpus luteum cyst or bowel. Advanced ectopic pregnancies are misdiagnosed as an IUP when the gestational sac and contents have a normal appearance but the sonographer overlooks the extrauterine position of the sac. Using a systematic approach with longitudinal and transverse image planes of the uterus and adnexa is mandatory. The ultrasound examination is not complete when an IUP is identified.
• Pseudogestational sac: A pseudogestational sac can be confused with a gestational sac or with embryonic demise. An ectopic pregnancy may stimulate the endometrium, causing a fluid collection within the endometrium.
• Hemorrhage and hypovolemic shock
• Infection
• Loss of reproductive organs following surgery
• Infertility
• Urinary and/or intestinal fistulas following complicated surgery
• Disseminated intravascular coagulation

• Search for CME/CE on This Topic »

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