Ectopic Pregnancy
Incidence




2% of all pregnancies
6% of maternal mortality
6 fold increase in ectopic 1970 to 1992
19.7 ectopics per 1000 pregancies, stable
since 1992
Risk Factors






Prior PID especially chlamydia
Prior ectopic pregnancy
Prior tubal surgery
History of infertility
History of IUD usage
In vitro fertilization
Diagnostic Tools




Clinical triad of delayed menes, pain, and
abnormal bleeding
Ultrasound
Beta HCG
Progesterone
Surgery

Laparotomy verses Laparoscopy

Conservative verses radical surgery
Methotrexate

Single dose


50 mg/sq meter IM
Multiple dose


MTX 1 mg/kg on d 0,2,4,6
Leucovorin 0.1 mg/kg d 1,3,5,7
Side Effects Associated
with Methotrexate
Treatment
Nausea
Vomiting
Stomatitis
Diarrhea
Gastric distress
Dizziness
Severe neutropenia (rare)
Reversible alopecia (rare)
Pneumonitis
Treatment effects
Increase in abdominal pain (occurs in up to two thirds of
patients)
Increase in Beta HCG levels during first 1-3 days of
treatment
Vaginal bleeding or spotting
Signs of treatment failure and tubal
rupture
•Significantly worsening abdominal pain, regardless of
change in hCG levels
• Hemodynamic instability
•Levels of hCG that do not decline by at least 15% between
day 4 and day 7 post injection
•Increasing or plateauing hCG levels after the first week of
treatment
3/2
NJ is a 29 y/o GoPo complaining of no period
PI: one month of intermittant low abd cramps
Spotting on and off
Gyn Hx: sexually active no birth control
PE:
Abdomen soft nontender
Pelvic exam: no vaginal bleeding, Cx if closed,
uterus is nontender, no adnexal mass
or tenderness
Quant Beta HCG = 3633
Ultrasound: 1 cm gestational sac in Left Adenexa
3/3
Methotrexate 50 mg/sq m IM
3/6 (day 4)
Quant = 6019
3/9 (day 7)
Quant = 5817 (3.3% decrease)
3/10
Methotrexate 50 mg/ sq m IM
3/13 (day 4)
Quant = 4100
3/16 (day 7)
Quant = 2609 (54% decrease)
3/2
NJ is a 29 y/o GoPo complaining of no period
PI: one month of intermittant low abd cramps
Spotting on and off
Gyn Hx: sexually active no birth control
PE:
Abdomen soft nontender
Pelvic exam: no vaginal bleeding, Cx if closed,
uterus is nontender, no adnexal mass
or tenderness
Quant = 1500
Ultrasound show gestational sac in the uterus
3/16
CC: cramping continues on and off but the bleed is
more like a menstral period
Pelvic exam shows menstral blood in the vagina
but the cervix is slightly dilated,
uterus and adenexa are tender
but no masses felt
Ultrasound shows thickened endometrium with no
gestational sac as seen 2 weeks ago
Quant = 4500
Path report shows chorionic villi