Click here to view next page of this article Ectopic PregnancyThere has been a significant increase in the number of ectopic pregnancies in the United States over the last two decades, although the incidence has plateaued. When analyzed by race, the data show that the risk of ectopic pregnancy among African Americans and other minorities is 1.6 times greater than the risk among whites ectopic pregnancy or tubal pregnancy. Ectopic pregnancy causes 15% of all maternal deaths, and the risk of death. Once a patient has had an ectopic pregnancy, there is a 7-to 13-fold increase in the risk of recurrence. The precise cause of an ectopic gestation is not known, although factors that have been shown to ovulation induction, and in vitro fertilization increase the risk of ectopic pregnancy. Evaluation The classic symptom triad of pain, amenorrhea, and vaginal bleeding is most commonly found only in patients in whom an tubal pregnancy has ruptured. In general, the history and physical examination alone are inadequate for the diagnosis of an unruptured ectopic pregnancy. Thus, additional tests usually are required to differentiate an early intrauterine pregnancy from an ectopic pregnancy. A single b-hCG measurement, unless negative, has limited usefulness because there is considerable overlap of the values in normal and abnormal pregnancies at any given gestational age. A beta-hCG level greater than the ultrasound. Treatment Ectopic pregnancy can be treated medically or surgically. Both methods are effective, and the choice of treatment depends on the clinical circumstances, the site of the ectopic pregnancy, and the available resources. Also, some ectopic pregnancies will resolve spontaneously and require no treatment. Operative management can be accomplished by either laparoscopy or laparotomy. Once the operative approach has been chosen, it is necessary to consider the operative technique. Linear salpingostomy or segmental resection is the Salpingostomy, salpingectomy, or segmental resection can be accomplished by either laparoscopy or laparotomy. The approach used depends on the hemodynamic stability of the patient, the size and location of the ectopic mass, An ectopic pregnancy can persist after a patient has undergone a conservative surgical procedure for the treatment of ectopic pregnancy and is diagnosed when the [5-hCG levels plateau or begin to increase after surgery. The frequency of this occurrence varies, but it is generally thought to be about 5%. It has been suggested that it occurs most often when a laparoscopic approach is used, although other studies do not confirm this observation. The medical management of ectopic pregnancy most commonly uses methotrexate, although other agents have been studied, including potassium chloride, hyperosmolar glucose, prostaglandins, and mifepristone. These agents may be given systemically (intravenously, intramuscularly, or orally) or locally (laparoscopic direct injection, trans-vaginal Methotrexate is a folic acid analogue that inhibits dehydrofolate reductase and thereby prevents synthesis of DNA. Although side effects are common with a prolonged course of treatment or with high doses, few side effects have been reported with the low doses used for ectopic pregnancy treatment. While a variety of methotrexate protocols Candidates for methotrexate treatment include those with 1) a plateaued or rising b-hCG level after salpingostomy or salpingotomy, 2) a rising or plateaued hCG level 12-24 hours after suction curettage, or 3) the absence of an intrauterine gestational sac or fluid collection detected by transvaginal ultrasonography, with a rising b-hCG level that After initiation of methotrexate, patients can be monitored on an outpatient basis. Patients who report severe or prolonged pain are evaluated by measuring hematocrit levels and performing transvaginal ultrasonography. The Future Fertility Reproductive performance after ectopic pregnancy is evaluated by determining tubal patency, the subsequent intrauterine pregnancy rate, and the recurrent ectopic pregnancy rate. Tubal patency after salpingostomy is approximately 84%, while the chance of having a viable intrauterine pregnancy is only 60%. The incidence of recurrent ectopic gestation is approximately 13-16%. The reproductive performance of patients after |