Ectopic pregnancy

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Cervix
Endometriosis
Infertility
Pelvic inflammatory disease (PID)
Tubal ligation

An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb (uterus).
The baby (fetus) cannot survive, and often does not develop at all in this type of
pregnancy.

Causes

An ectopic pregnancy occurs when a pregnancy starts outside the womb (uterus). The
most common site for an ectopic pregnancy is within one of the tubes through which the
egg passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic
pregnancies can occur in the ovary, stomach area, or cervix.

An ectopic pregnancy is often caused by a condition that blocks or slows the movement
of a fertilized egg through the fallopian tube to the uterus. This may be caused by a
physical blockage in the tube by hormonal factors and by other factors, such as smoking.

Most cases of scarring are caused by:

• Past ectopic pregnancy

• Past infection in the fallopian tubes
• Surgery of the fallopian tubes

Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of
the fallopian tubes (salpingitis) or pelvic inflammatory disease (PID).

Some ectopic pregnancies can be due to:

• Birth defects of the fallopian tubes

• Complications of a ruptured appendix
• Endometriosis
• Scarring caused by previous pelvic surgery

The following may also increase the risk of ectopic pregnancy:

• Age over 35
• Having had many sexual partners
• In vitro fertilization
In a few cases, the cause is unknown.

Sometimes, a woman will become pregnant after having her tubes tied (tubal
sterilization). Ectopic pregnancies are more likely to occur 2 or more years after the
procedure, rather than right after it. In the first year after sterilization, only about 6% of
pregnancies will be ectopic, but most pregnancies that occur 2 - 3 years after tubal
sterilization will be ectopic.

Ectopic pregnancy is also more likely in women who have:

• Had surgery to reverse tubal sterilization in order to become pregnant

• Had an intrauterine device (IUD) and became pregnant (very unlikely when IUDs
are in place)

Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies.

Symptoms

• Abnormal vaginal bleeding

• Amenorrhea
• Breast tenderness
• Low back pain
• Mild cramping on one side of the pelvis
• Nausea
• Pain in the lower abdomen or pelvic area

If the area of the abnormal pregnancy ruptures and bleeds, symptoms may get worse.
They may include:

• Feeling faint or actually fainting

• Intense pressure in the rectum
• Pain that is felt in the shoulder area
• Severe, sharp, and sudden pain in the lower abdomen

Internal bleeding due to a rupture may lead to low blood pressure and fainting in around 1
out of 10 women.

Exams and Tests

The health care provider will do a pelvic exam, which may show tenderness in the pelvic
area.

Tests that may be done include:

• Culdocentesis Culdocentesis is a procedure that checks for abnormal fluid in the

space just behind the vagina
 • Hematocrit

Hematocrit is a blood test that measures the percentage of the volume of whole blood that
is made up of red blood cells. This measurement depends on the number of red blood
cells and the size of red blood cells.

The hematocrit is almost always ordered as part of a complete blood count

• Pregnancy test

A pregnancy test measures a hormone called human chorionic gonadotropin (HCG).

HCG is a hormone produced during pregnancy. It appears in the blood and urine of
pregnant women as early as 10 days after conception.

• Quantitative HCG blood test

A quantitative human chorionic gonadotropin (HCG) test measures the specific level
of HCG in the blood. HCG is a hormone produced during pregnancy.

• Serum progesterone level

Serum progesterone is a test to measure the amount of progesterone in the blood.

Progesterone is a hormone produced mainly in the ovaries.

In women, progesterone plays a vital role in pregnancy. After an egg is released by the
ovaries (ovulation), progesterone helps make the uterus ready for implantation of a
fertilized egg. It prepares the womb (uterus) for pregnancy and the breasts for milk
production.

Men produce some amount of progesterone, but it probably has no normal function
except to help produce other steroid hormones.

• Transvaginal ultrasound or pregnancy ultrasound

Transvaginal ultrasound is a type of pelvic ultrasound. It is used to look at a woman's

reproductive organs, including the uterus, ovaries, cervix, and vagina. Transvaginal
means across or through the vagina.

A pregnancy ultrasound is an imaging test that uses sound waves to see how a baby is
developing in the womb. It is also used to check the female pelvic organs during
pregnancy.
 • White blood count

A WBC count is a blood test to measure the number of white blood cells (WBCs).

White blood cells help fight infections. They are also called leukocytes. There are five
major types of white blood cells:

• Basophils
• Eosinophils
• Lymphocytes (T cells and B cells)
• Monocytes
• Neutrophils

A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an
ectopic pregnancy. Women with high levels should have a vaginal ultrasound to identify
a normal pregnancy.

Other tests may be used to confirm the diagnosis, such as:

• D and C

D and C is a procedure to scrape and collect the tissue (endometrium) from inside the
uterus.

• Dilatation ("D") is a widening of the cervix to allow instruments into the uterus.
• Curettage ("C") is the scraping of the walls of the uterus.

• Laparoscopy

Diagnostic laparoscopy is a procedure that allows a health care provider to look

directly at the contents of a patient's abdomen or pelvis, including the fallopian tubes,
ovaries, uterus, small bowel, large bowel, appendix, liver, and gallbladder.

• Laparotomy

Abdominal exploration is surgery to examine the contents of the abdomen. Surgery

that opens the abdomen is called a laparotomy. Laparotomy may also be done to treat
certain health problems and conditions.

Treatment
Ectopic pregnancies cannot continue to birth (term). The developing cells must be
removed to save the mother's life.

You will need emergency medical help if the area of the ectopic pregnancy breaks open
(ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may
include:

• Blood transfusion
• Fluids given through a vein
• Keeping warm
• Oxygen
• Raising the legs

If there is a rupture, surgery (laparotomy) is done to stop blood loss. This surgery is also
done to:

• Confirm an ectopic pregnancy

• Remove the abnormal pregnancy
• Repair any tissue damage

In some cases, the doctor may have to remove the fallopian tube.

A minilaparotomy and laparoscopy are the most common surgical treatments for an
ectopic pregnancy that has not ruptured. If the doctor does not think a rupture will occur,
you may be given a medicine called methotrexate and monitored. You may have blood
tests and liver function tests.

Outlook (Prognosis)

One-third of women who have had one ectopic pregnancy are later able to have a baby. A
repeated ectopic pregnancy may occur in one-third of women. Some women do not
become pregnant again.

The likelihood of a successful pregnancy depends on:

• The woman's age

• Whether she has already had children
• Why the first ectopic pregnancy occurred

The rate of death due to an ectopic pregnancy in the United States has dropped in the last
30 years to less than 0.1%.

Possible Complications

The most common complication is rupture with internal bleeding that leads to shock.
Death from rupture is rare.
When to Contact a Medical Professional

If you have symptoms of ectopic pregnancy (especially lower abdominal pain or

abnormal vaginal bleeding), call your health care provider. You can have an ectopic
pregnancy if you are able to get pregnant (fertile) and are sexually active, even if you use
birth control.

Prevention

Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not
preventable. However, a tubal pregnancy (the most common type of ectopic pregnancy)
may be prevented in some cases by avoiding conditions that might scar the fallopian
tubes.

The following may reduce your risk:

• Avoiding risk factors for pelvic inflammatory disease (PID) such as having many
sexual partners, having sex without a condom, and getting sexually transmitted
diseases (STDs)
• Early diagnosis and treatment of STDs
• Early diagnosis and treatment of salpingitis and PID
• Stopping smoking

Alternative Names

Tubal pregnancy; Cervical pregnancy; Abdominal pregnancy

An ectopic pregnancy, or eccyesis, is a complication of pregnancy in which the

pregnancy implants outside the uterine cavity.[1] With rare exceptions, ectopic
pregnancies are not viable. Furthermore, they are dangerous for the mother, internal
bleeding being a common complication. Most ectopic pregnancies occur in the Fallopian
tube (so-called tubal pregnancies), but implantation can also occur in the cervix,
ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if
not treated properly, can lead to death.
Contents
[hide]

• 1 Overview
• 2 Classification
o 2.1 Tubal pregnancy
o 2.2 Nontubal ectopic pregnancy
o 2.3 Heterotopic pregnancy
o 2.4 Persistent ectopic pregnancy
• 3 Signs and symptoms
• 4 Causes
o 4.1 Cilial damage and tube occlusion
o 4.2 Other
• 5 Diagnosis
• 6 Treatment
o 6.1 Medical
o 6.2 Surgical
• 7 Complications
• 8 Prognosis
o 8.1 Future fertility
• 9 Cases with live birth
• 10 In other animals
• 11 References

• 12 External links

[edit] Overview

Ruptured tubal pregnancy with approx 6-weeks-embryonic-age or 8-weeks-gestational-

age embryo, with intact amniotic sac
Oviduct with an ectopic pregnancy (tubal pregnancy) showing an embryo of approx. 6-7
menstrual weeks

Another example of a tubal pregnancy (fetus is 8 weeks gestational age, 6 weeks from
conception)

In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine
lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an
ectopic location with implantation not occurring inside of the womb, and of these 98%
occur in the Fallopian tubes.[2]

In other words it can be said that in an ectopic pregnancy the embryonic implantation
occurs outside the uterus, most commonly in the fallopian tubes but at times also in the
extra tubal locations. It poses serious threat to the general and reproductive health of the
mother.

Ectopic pregnancy comprises 2% of all pregnancies reported to the Centre for Disease
Control and Prevention [CDC].

It has been noted that ectopic pregnancy is steadily and persistently rising since 1970.

Between 1970 and 1992, the rate of ectopic pregnancy increased from 4.5 to 19.7 per
1000 reported pregnacies [including live birth, legal abortions and ectopic pregnancies].[3]
[4]
Detection of ectopic pregnancy in early gestation has been achieved mainly due to
enhanced diagnostic capability.

Despite all these notable successes in diagnostics and detection techniques ectopic
pregnancy remains a source of serious maternal morbidity and mortality all over the
world.

In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres
to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal
lining. Most commonly this invades vessels and will cause bleeding. This intratubal
bleeding (hematosalpinx) expels the implantation out of the tubal end as a tubal abortion.
Some women thinking they are having a miscarriage are actually having a tubal abortion.
There is no inflammation of the tube in ectopic pregnancy. The pain is caused by
prostaglandins released at the implantation site, and by free blood in the peritoneal cavity,
which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the
health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis,
but sometimes, especially if the implantation is in the proximal tube (just before it enters
the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier
than usual.

If left untreated, about half of ectopic pregnancies will resolve without treatment. These
are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has
reduced the need for surgery; however, surgical intervention is still required in cases
where the Fallopian tube has ruptured or is in danger of doing so. This intervention may
be laparoscopic or through a larger incision, known as a laparotomy.

[edit] Classification

[edit] Tubal pregnancy

The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can
grow in the fimbrial end (5% of all ectopics), the ampullary section (80%), the isthmus
(12%), and the cornual and interstitial part of the tube (2%).[5] Mortality of a tubal
pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is
increased vascularity that may result more likely in sudden major internal hemorrhage. A
review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused
by a combination of retention of the embryo within the fallopian tube due to impaired
embryo-tubal transport and alterations in the tubal environment allowing early
implantation to occur. [6]

[edit] Nontubal ectopic pregnancy

Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal.
Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An
ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[7]
While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has
been delivered from an abdominal pregnancy. In such a situation the placenta sits on the
intraabdominal organs or the peritoneum and has found sufficient blood supply. This is
generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic
(liver) artery or even aorta have been described. Support to near viability has occasionally
been described, but even in third world countries, the diagnosis is most commonly made
at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy.
Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to
remove the placenta from the organs to which it is attached usually lead to uncontrollable
bleeding from the attachment site. If the organ to which the placenta is attached is
removable, such as a section of bowel, then the placenta should be removed together with
that organ. This is such a rare occurrence that true data are unavailable and reliance must
be made on anecdotal reports.[8][9][10] However, the vast majority of abdominal pregnancies
require intervention well before fetal viability because of the risk of hemorrhage.

[edit] Heterotopic pregnancy

In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the
uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine
pregnancy is discovered later than the ectopic, mainly because of the painful emergency
nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and
removed very early in the pregnancy, an ultrasound may not find the additional
pregnancy inside the uterus. When hCG levels continue to rise after the removal of the
ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable.
This is normally discovered through an ultrasound.

Although rare, heterotopic pregnancies are becoming more common. The survival rate of
the uterine fetus of an ectopic pregnancy is around 70%.[11]

Successful pregnancies have been reported from ruptured tubal pregnancy continuing by
the placenta implanting on abdominal organs or on the outside of the uterus.

[edit] Persistent ectopic pregnancy

A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a

surgical intervention to remove an ectopic pregnancy. After a conservative procedure that
attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15-20%
the major portion of the ectopic may have been removed, but some trophoblastic tissue
perhaps deeply embedded has escaped removal and continues to growth, generating a
new rise in hCG levels.[12] After weeks this may lead to new clinical symptoms including
bleeding. For this reason hCG levels may have to be monitored after removal of an
ectopic to assure their decline, also methotrexate can be given at the time of surgery
prophyllactically.
[edit] Signs and symptoms

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy
occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to
8 weeks. Later presentations are more common in communities deprived of modern
diagnostic ability.

Early signs include:

• Pain in the lower abdomen, and inflammation (Pain may be confused with a
strong stomach pain, it may also feel like a strong cramp)
• Pain while urinating
• Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal
pregnancy may give very similar symptoms.
• Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing
pregnancy and falling levels of progesterone from the corpus luteum on the ovary
cause withdrawal bleeding. This can be indistinguishable from an early
miscarriage or the 'implantation bleed' of a normal early pregnancy.
• Pain while having a bowel movement

Patients with a late ectopic pregnancy typically experience pain and bleeding. This
bleeding will be both vaginal and internal and has two discrete pathophysiologic
mechanisms:

• External bleeding is due to the falling progesterone levels.

• Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected
tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and
early normal pregnancy. The presence of a positive pregnancy test virtually rules out
pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory
Disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is
PID.

More severe internal bleeding may cause:

• Lower back, abdominal, or pelvic pain.

• Shoulder pain. This is caused by free blood tracking up the abdominal cavity and
irritating the diaphragm, and is an ominous sign.
• There may be cramping or even tenderness on one side of the pelvis.
• The pain is of recent onset, meaning it must be differentiated from cyclical pelvic
pain, and is often getting worse.

Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other
gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory
disease and other gynaecologic problems.
[edit] Causes

There are a number of risk factors for ectopic pregnancies. However, in as many as one
third[13] to one half[14] of ectopic pregnancies, no risk factors can be identified. Risk
factors include: pelvic inflammatory disease, infertility, use of an intrauterine device
(IUD), those who have been exposed to DES, tubal surgery, smoking, previous ectopic
pregnancy, and tubal ligation.[15]

[edit] Cilial damage and tube occlusion

Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized
egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an
ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is
likely to lead to an ectopic pregnancy.[16] Women with pelvic inflammatory disease (PID)
have a high occurrence of ectopic pregnancy.[17] This results from the build-up of scar
tissue in the Fallopian tubes, causing damage to cilia.[5] If however both tubes were
completely blocked, so that sperm and egg were physically unable to meet, then
fertilization of the egg would naturally be impossible, and neither normal pregnancy nor
ectopic pregnancy could occur. Tubal surgery for damaged tubes might remove this
protection and increase the risk of ectopic pregnancy[citation needed].

Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after
tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine[citation
needed]
. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy.
This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal
of the tubes) have been used than less destructive methods (tubal clipping). A history of a
tubal pregnancy increases the risk of future occurrences to about 10%.[5] This risk is not
reduced by removing the affected tube, even if the other tube appears normal. The best
method for diagnosing this is to do an early ultrasound.

[edit] Other

Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has been
noted that smoking is associated with ectopic risk. Vaginal douching is thought by some
to increase ectopic pregnancies.[5] Women exposed to diethylstilbestrol (DES) in utero
(aka "DES Daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the
risk of unexposed women[citation needed].

[edit] Diagnosis

An ectopic pregnancy should be considered in any woman with abdominal pain or

vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational
sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy.

An abnormal rise in blood β-human chorionic gonadotropin (β-hCG) levels may indicate
an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy is around
1500 IU/ml of β-hCG. A high resolution, transvaginal ultrasound showing no intrauterine
pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold
of discrimination for β-hCG has been reached. An empty uterus with levels higher than
1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an
intrauterine pregnancy which is simply too small to be seen on ultrasound. If the
diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work.
This can be done by measuring the β-hCG level approximately 48hrs later and repeating
the ultrasound. If the β-hCG falls on repeat examination, this strongly suggests a
spontaneous abortion or rupture.

A laparoscopy or laparotomy can also be performed to visually confirm an ectopic

pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the
pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal
looking fallopian tube.

Culdocentesis, in which fluid is retrieved from the space separating the vagina and
rectum, is a less commonly performed test that may be used to look for internal bleeding.
In this test, a needle is inserted into the space at the very top of the vagina, behind the
uterus and in front of the rectum. Any blood or fluid found may have been derived from a
ruptured ectopic pregnancy.

Cullen's sign can indicate a ruptured ectopic pregnancy.

[edit] Treatment

[edit] Medical

Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to

surgical treatment[18] since at least 1993.[19] If administered early in the pregnancy,
methotrexate terminates the growth of the developing embryo; this may cause an
abortion, or the tissue may then be either resorbed by the woman's body or pass with a
menstrual period.

[edit] Surgical

If hemorrhage has already occurred, surgical intervention may be necessary. However,

whether to pursue surgical intervention is an often difficult decision in a stable patient
with minimal evidence of blood clot on ultrasound.[citation needed]

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise
the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the
affected tube with the pregnancy (salpingectomy). The first successful surgery for an
ectopic pregnancy was performed by Robert Lawson Tait in 1883.[20]
[edit] Complications

The most common complication is rupture with internal bleeding that leads to shock.
Death from rupture is rare in women who have access to modern medical facilities.
Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.

[edit] Prognosis

[edit] Future fertility

Fertility following ectopic pregnancy depends upon several factors, the most important of
which is a prior history of infertility.[21] The treatment choice, whether surgical or
nonsurgical, also plays a role. For example, the rate of intrauterine pregnancy may be
higher following methotrexate compared to surgical treatment.[22] Rate of fertility may be
better following salpingostomy than salpingectomy.[22]

[edit] Cases with live birth

There have been cases where ectopic pregnancy lasted many months and ended in a live
baby delivered by laparotomy.

On 19 April 2008 an English woman, Jayne Jones (age 37) who had an ectopic pregnancy
attached to the omentum, the fatty covering of her large bowel, gave birth. The baby was
delivered by a laparotomy at 28 weeks gestation. The surgery, the first of its kind to be
performed in the UK, was successful, and both mother and baby survived.[23]

On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic
pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby
girl, Durga, via Caesarean section. She had no problems or complications during the 38-
week pregnancy.[24][25]

The case of Olivia, Mary and Ronan had an extrauterine fetus (Ronan) and intrauterine
twins. All three survived. The intrauterine twins were taken out first.[26]

Medical therapy

Medical therapy involving methotrexate may be indicated in certain patients. A number

of factors must be considered. The patient must be hemodynamically stable, with no
signs or symptoms of active bleeding or hemoperitoneum. Furthermore, she must be
reliable, compliant, and able to return for follow-up. Another factor is size of the
gestation, which should not exceed 3.5 cm at its greatest dimension on ultrasound (US)
measurement. She should not have any contraindications to the use of methotrexate.

Surgical therapy
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). Laparoscopy has become the recommended approach in
most cases. Laparotomy is usually reserved for patients who are hemodynamically
unstable or patients with cornual ectopic pregnancies. 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). 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.

Expectant management

Candidates for successful expectant management are asymptomatic and have no evidence
of rupture or hemodynamic instability. Furthermore, they should portray objective
evidence of resolution, such as declining bhCG levels. They must be fully compliant and
must be willing to accept the potential risks of tubal rupture.

Relevant Anatomy

See Pathophysiology.

Contraindications

Medical therapy

A bhCG level of greater than 15,000 IU/L, fetal cardiac activity, and free fluid in the cul-
de-sac on US (presumably representing tubal rupture) are contraindications to medical
therapy with methotrexate. Other contraindications to the use of methotrexate include
documented hypersensitivity to methotrexate; breastfeeding; immunodeficiency;
alcoholism; alcoholic liver disease or any liver disease; blood dyscrasias; leukopenia;
thrombocytopenia; anemia; active pulmonary disease; peptic ulcer disease; and renal,
hepatic, or hematologic dysfunction.

Surgical therapy

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 these cases, treatment
with methotrexate is an especially attractive option.

In cases involving uncontrolled bleeding and hemodynamic instability, conservative

treatment methods are avoided in favor of radical surgery.