Management of Ectopic Pregnancies

July 17, 2005.

Hedwige Saint-Louis, MD
Case 1
37 yo woman is referred to your office after the pathology report from her abortion a week
ago shows no chorionic viilli.
Your pelvic ultrasound shows the following image,

The endometrial cavity/stripe is marked by the arrow and the cornual ectopic is on the patients
left. Notice that the myometrium surrounding the posterior and llateral aspect of the gestational
sac is thinner than the myometrium anterior and medial to the sac. Early and accurate diagnosis
of cornual ectopic pregnancy is critical, since rupture can cause sudden catastrophic bleeding.
What is your diagnosis? What is the incidence of this condition?
This is a corneal ectopic pregnancy. The incidence of corneal ectopic pregnancies is 1-2 % of all
ectopic pregnancies, as compared to ampullary (80%), Isthmic (12%), fimbrial (5%), ovarian
(0.2%), or cervical ( 0.2%). 3
How do you manage this patient?
Cornual ectopic pregnancies can cause massive hemorrhage with sudden rupture of the cornua,
which is a very vascular portion of the uterus and Fallopian tube. Cornual pregnancies can
become quite large before the patient is symptomatic, giving the appearance of a bicornuate
uterus or vascular appearing fibroid at the time of laparoscopy. These cases are better managed
by laparotomy as cornual resection with proper hemostasis can not always be obtained by
laparoscopy in such case.

CORNUAL
RESECTION

Technique:
1) Place stay sutures using #1Chromic to minimize
blood supply to the ectopic:
a. Purse string stitch proximal to the ectopic
OR
b. OLeary type stitch below and above the
ectopic.
2) Clamp involved fallopian tube.
3) Excise the ectopic by making a wedge incision
distal to your stay sutures, leaving enough
uterine serosa and myometrium to close the
uterine defect.
4) Close the uterine myometrium and serosa in
layers, as with a myomectomy.
5) Consider covering cornual incision site with an
anti-adhesive film (Sepra-film or Interceed) after
good hemostasis is achieved.

Case 2
32 yo woman is referred to you with a positive UCG, an empty uterus by US and no
symptoms.
What other information do you need?
In order to complete your evaluation of this patient, you need a serum -hCG. The -hCG level
will help you differentiate between an early pregnancy and a likely ectopic pregnancy.

Her serum -hCG is 3500.

What is your differential diagnosis? Ectopic pregnancy vs early multiple gestation vs other
abnormal pregnancy vs lab error.
What treatment options can you offer this patient?
Assess her desire to continue this pregnancy and her interest in future fertility. At this point you
should counsel the patient about the likelihood of this being an ectopic pregnancy and treatment
options, including expectant management versus medical management.
If this is a desired pregnancy and the patient is stable and reliable, expectant management would
be a reasonable option but emphasize the need for close follow-up, give ectopic pregnancy
warnings. Bring her back for repeat -hCG in 48 hours.
If this is an unwanted pregnancy, patient should be offered expectant management (with risk of
continued pregnancy growth and possible ectopic rupture necessitating surgical intervention) or
methotrexate therapy, with risk that this may be an early IUP. In this scenario, surgical
intervention would result in unnecessary cost and surgical risks since the patient is
asymptomatic, and no masses or free fluid are seen on ultrasound.
What is the management protocol for Methotrexate?
Prior to initiating Methotrexate therapy, the following baseline labs should be obtained:
Blood type, CBC, +/- AST, BUN and creatinine. If all the labs are normal, methotrexate
50mg/ m2 should be given IM . The patients body surface area can be calculated using her
height, weight and a normogram or using the following formula:
[(Height (cm) x Weight (kg))/ 3600}1/2 or [(Height (in)x Weight (lbs))/ 3131]1/2
or access www.halls.md/body-surface-area/refs.htm to calculate dose.
Day #1: Check serum -hCG and Administer Methotrexate 50 mg/m2
Day #4: Check serum -hCG and re-assess patients symptoms. NO PELVIC EXAM! This
-hCG level may be higher than than Day #1 levels and patient may have slight increase in
pain. Reassure patient and re-assess on Day # 7 if patient is clinically stable.
Day #7: Check serum -hCG and re-assess patients symptoms. If the serum -hCG level
has not dropped by at least 15% when compared to Day #4 level, then she will need a 2nd
dose of Mtx. If the serum -hCG level has dropped appropriately and the patient is clinically
stable, re-assess serum -hCG levels weekly til negative this level should decline by at
least 15% when compared to the previous week.

What are the criteria for Methotrexate therapy?

The criteria for Methotrexate therapy include the following:
Unruptured mass <3.5- 4.0 cm in size (increase size may increase risk of rupture or
necessitate more than a single dose of methotrexate).
No fetal cardiac motion (cardiac activity indicates more advanced pregnancy and
increases the risk of rupture or single dose methotrexate failure)
No evidence of rupture or hemoperitoneum.
Hemodynamically stable
Diagnosis of ectopic pregnancy is certain and does not necessitate laparoscopic diagnosis.
Patient desires future fertility (if future fertility is not desired, consider laparoscopic
treatment of ectopic with tubal ligation of the contra-lateral tube)
General anesthesia poses a significant risk
Patient is reliable / compliant and willing to return for follow up
Patient has no contra-indications to Methotrexate
+/- Serum -hCG less than 6,000 15,000 mIU/mL (depending on the International
Standard being used and the Your labs standards)
What are the contra-indications to Methotrexate?
The contra-indications include:
Absolute contra-indication
Ruptured ectopic with hemoperitoneum
Breastfeeding
Overt immunodeficiency
Alcoholism, alcoholic liver disease and other chronic liver disease
Pre-existing blood dyscrasias, such as bone marrow hypoplasia, leukopenia,
thrombocytopenia, significant anemia
Known sensistivity to Methotrexate
Active pulmonary disease
Peptic ulcer disease
Hepatic, renal or hematologic dysfunction
Relative contra-indications
Gestational sac > 3.5 cm
Embryonic cardiac motion
References
1. Lipscomb GH, Stovall TG, Ling FW. Nonsurgical Treatment of Ectopic Pregnancy. NEJM
343(18):1325-1329
2. Medical Management of Tubal Pregnancy, ACOG Practice Bulletin Number 3, December
1998. ACOG Compendium 2005
3. http://www.cgmh.org.tw/intr/intr5/c6700/OBGYN/f/web/Ectopic/
4. Ectopic Pregnancy Tutorials. Retrieved 07/10/2005 from
http://www.infertilitytutorials.com/ectopic_members/general.cfm