David B. Toub, MD

Articles

Sterilization

Hysterectomy: A Reappraisal

Myomectomy As an Alternative to Hysterectomy for Women Who Have Completed Childbearing

Surgical Abortion

Infertility

Ectopic Pregnancy
 David Blair Toub, M.D.
Dept. of Obstetrics and Gynecology
Pennsylvania Hospital

Overview
 • Incidence Increasing (1:66 Pregnancies)
 • Mortality Decreasing With Better Detection
 • Surgical and Medical Treatment Available
 • Recurrence Rate ~ 15%

Risk Factors
 • Previous Ectopic Pregnancy
 • PID
 • Tubal Surgery
 • Infertility
 • ???IUD Use (Probably Not)
 • IVF
 • Kartegener's Syndrome (zebra)

Sites
 •	Ampulla (95%)
•	Isthmus (8%)
•	Cornua (< 2%)
•	Ovary (< 2%)
 •	Abdomen (< 2%)
•	Cervix (< 2%)

Symptoms
 •	Amenorrhea
 •	Abdominal Pain
 •	Vaginal Bleeding
 •	Syncope
 •	Pelvic Mass

Evaluation and Diagnosis
 •	History and Physical Exam
 •	CBC, T+S
 •	Serial Quantitative -hCG (BSU)
 •	Ultrasound
 •	Progesterone Level?
 •	Culdocentesis
 •	Laparoscopy

Serial BSU's
 •	-hCG Levels Double Every 48 Hrs
 •	< 66% Rise / 48 Hrs Consistent With Ectopic
 •	Single Determination Not Helpful
 •	Best If Done Within Same Laboratory
 •	Never Rules Out Ectopic

Ultrasound
 •	May or May Not Be Helpful
 •	Discriminatory Zone:
 	TV: 1500-2000 mIU/ml
 	TA: 6500 mIU/ml
 •	+IUP: Generally Excludes Ectopic

Culdocentesis
 •	Highly Specific if Interpreted Correctly: Presence of Free-Flowing, NON-Clotting Blood 
 •	Negative Tap Inconclusive
 •	May Obviate U/S
 •	Most Helpful in Emergent Situations to Confirm Diagnosis, But Remains Controversial

Progesterone Levels
 •	> 15 ng/ml a/w IUP
 •	< 15: SAb or Ectopic
 •	May Take Several Days for Result 
 •	Clinical Use Not Yet Widespread

Treatment 
 •	Observation
 •	Laparoscopy
 •	Laparotomy
 •	MTX
 •	Hyperosmolar Glucose

Observation	
 •	Many Tubal Pregnancies Abort
 •	Israeli Study: Majority of Untreated Ectopics Resolve
 •	Not Yet Acceptable Standard of Care in US

Laparoscopy
 •	Allows Diagnosis and Treatment 
 •	Salpingostomy
 •	Salpingectomy (Total / Partial)
 •	Cornual Resection
 •	Minimally Invasive, Unlike Laparotomy
 •	Few Contraindications: Unstable Patient (Possibly)

MTX
 •	Toxic to Trophoblast Cells
 •	Minimal Side Effects
 •	May Preserve Fertility in Cases of Cervical Pregnancy
 •	Requires Compliant Patient, Time 
 •	Pain Not Uncommon
 •	BSU May Rise Initially

Persistent Trophoblast
 •	Most Often A/W Salpingostomy
 •	Laparoscopic ~ 3%
 •	Minilap < 1%
 •	Most Easily Treated With MTX

Outcomes
•	15% Repeat Ectopic Rate
 •	 2 Ectopics:
 		33% Pregnancy Rate
 		25% Ectopic
 •	No Benefit To Removing Ovary Along With Tube

Summary
 •	Ectopic Pregnancy is a Common, Treatable Problem
 •	Sensitive BSU Assays Allow Early Detection
 •	Surgical and Medical Options Exist
 •	Ruptured Ectopics Should be Unusual with Compliant Patients and Appropriate Medical Care

Serial BSU's 
•	-hCG Levels Double Every 48 Hrs 
•	< 66% Rise / 48 Hrs Consistent With Ectopic 
•	Single Determination Not Helpful 
•	Best If Done Within Same Laboratory 
•	Never Rules Out Ectopic