American College of Obstetrics and Gynecology Practice Bulletin – Tubal Ectopic Pregnancy, 2018
Location:
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>90% of ectopics are fallopian, 1% abdominal, 1% cervix, 1-3% ovarian, 1% c-section scar
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Heterotopic pregnancy risk 1/4000 – 1/30,000 in general population
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Heterotopic pregnancy risk in patients receiving in vitro fertilization, up to 1/100
Epidemiology:
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Incidence is estimated to be 1-2% (25 per 1000 pregnancies per CDC).
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CDC Data tracking stopped in 1992.
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2011–2013, ruptured ectopic pregnancy was 2.7% of all pregnancy-related deaths and the leading cause of hemorrhage-related mortality.
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Up to 18% prevalence of ectopic pregnancy in women presenting to an emergency department with first-trimester vaginal bleeding, or abdominal pain
Risk Factors (50% cases have none):
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Single prior ectopic (10% risk), multiple prior ectopics (25% risk)
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Prior fallopian tube damage (surgical or infectious)
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Hx PID
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Hx fallopian or pelvic surgery
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In vitro fertilization (multiple embryo implantation)
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Hx of infertility
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Less significant = cigarettes smoking, age >35
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Use of IUD reduces chances of pregnancy, therefore reduces chances of ectopic compared with women using NO birth control. However, up to 53% of pregnancies with IUD in place are ectopic.
Ultrasound:
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Definitive if gestational sac AND yolk sac or embryo is seen.
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Intrauterine gestational sac and yolk sac should be seen 5-6 weeks by dates.
Beta-hCG:
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Discriminatory level is only accurate in 50-70% of cases
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3500 mIU/ml is recommended by ACOG and is set higher than previous cut offs in order to prevent termination of early pregnancy.
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Levels plateau at 10 weeks near 100,000mIU/ml
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If no pregnancy is seen, level should be rechecked in 2 days
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Expected rate of increase:
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49% for an initial hCG level of less than 1,500 mIU/mL
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40% for an initial hCG level of 1,500–3,000 mIU/mL
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33% for an initial hCG level greater than 3,000 mIU/mL
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99% of normal intrauterine pregnancies will have a rate of increase faster than this minimum
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hCG pattern consistent with IUP or miscarriage does not eliminate the possibility of an ectopic pregnancy
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95% of women with a spontaneous miscarriage will have 21–35% hCG decrease in 2 days
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Decreasing hCG level in a possible ectopic pregnancy should be monitored until non-pregnant levels are reached because rupture of an ectopic pregnancy can occur while levels are decreasing or are very low.
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Reported risk of rupture of an ectopic pregnancy during surveillance was as low as 0.03 % among all women at risk and as low as 1.7% among all ectopic pregnancies diagnosed
Treatment:
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Clinically stable women with non-ruptured ectopic may have surgery or methotrexate therapy.
- Surgical management is necessary if there is hemodynamic instability, ongoing ruptured ectopic mass (pelvic pain), or signs of intraperitoneal bleeding.
- Methotrexate therapy:
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Intramuscular methotrexate is the only medical treatment for ectopic pregnancy
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A high initial hCG level is considered a relative contraindication.
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Failure rate >14.3% if hCG level > 5,000 mIU/mL compared with a 3.7% failure rate for hCG levels less than 5,000 mIU/mL (48)
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Failure rate 3.7% if hCG level < 5,000 mIU/mL
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Success rate 70% to 95%
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Absolute contraindications:
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IUP
- Immunodeficiency
- Moderate to severe anemia, leukopenia, thrombocytopenia
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Active pulmonary disease (except asthma)
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Active PUD
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Clinically significant hepatic or renal dysfunction
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Breastfeeding
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Ruptured ectopic
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Hemodynamic instability
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Inability to obtain follow-up
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Relative contraindications include:
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Embryonic cardiac activity
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High initial HCG
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Ectopic > 4cm size by transvaginal US
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Refusal to accept blood transfusion
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Single, double, and multi dose regimens have been studied for methotrexate.
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Single dose regimen:
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50 mg/m2 IM
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hCG level day 4 + 7
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If the decrease is greater than 15%, measure hCG levels weekly until nonpregnant level
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If decrease is less than 15%, give methotrexate at a dose of 50 mg/m2 intramuscularly and repeat hCG level
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If hCG does not decrease after two doses, consider surgical management
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Two dose regimen:
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50 mg/m2 IM day 1
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50 mg/m2 IM day 4
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If the decrease is greater than 15%, measure hCG levels weekly until non-pregnant level
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If decrease is less than 15%,give methotrexate at a dose of 50 mg/m2 intramuscularly day 7 and repeat hCG level day 11
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If hCG levels decrease 15% between day 7 and 11, continue to monitor weekly until non-pregnant level
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If the decrease is less than 15% between day 7 and 11, give methotrexate on day 11 and check hCG levels on day 14
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If hCG does not decrease after four doses, consider surgical management
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Fixed multi-dose regimen:
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50 mg/m2 IM day 1,3,5,7
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Alternate with folinic acid 0.1 mg/kg IM days 2,4,6,8
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Obtain hCG levels on methotrexate days (1,3,5,7) and continue until 15% decrease from prior measurement.
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If decrease is more than 15%, discontinue methotrexate and measure hCG levels weekly until non-pregnant level.
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If hCG does not decrease after 4 doses, consider surgical management.
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ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018;131(3):e91-e103. PubMed , Free Access