Click here to view next page of this article


New Treatments for Ectopic Pregnancy

Ectopic pregnancy occurs in about 2 out of 100 pregnancies. Most of the patients who do have ectopic pregnancies do not have any of these risk factors. But the ones we need to keep in mind would be current IUD use; this is much more common with the Progestasert IUD, partially because of the progesterone activity, and probably partially because it acts within the uterus and you may have more fertilized embryos that can implant in the tubes. It has been pretty much been shown recently that a current user of a copper IUD doesn't have a higher risk of tubal pregnancy.

Patients who have had prior tubal surgery are at an increased risk of an ectopic. They probably don't have a normal endosalpinx. A lot of sources quote the risk as twenty times higher than the average patient. Certainly, if someone has had a tubal ligation and has had it reversed.

Prior evidence of pelvic inflammatory disease increases the risk of an ectopic by about four times higher than the average rate for an ectopic. But these are patients who have had pelvic inflammatory disease diagnosed and treated. There are a lot of patients who may have had chlamydia or even gonorrhea and don't get any treatment.

Infertility is a risk group because a lot of these women have some tubal damage, but they may also be undergoing induction of ovulation to have multiple embryos available for implantation. Some of the hormone changes that go along with those treatments have been hypothesized to increase the ectopic rate by having superphysiological levels of progesterone and estrogen.

Adhesions increase the risk of ectopic pregnancy, although it is hard to know how much adhesions would damage a tube in terms of producing an ectopic, but there is a correlation.

Progestin-only contraceptives would increase the risk of ectopic. Prior abdominal surgery is a controversial increased risk. If somebody has a very simple laparotomy without any evidence of infection, there probably is no change in the tubal status. But anything more complicated than that, like endometritis or infection at the time of surgery, dermoid cyst on the ovary, all of these predispose patients to having subtle or not so subtle tubal damage.

Smoking has been shown to increase the risk of ectopic pregnancy about twofold. It does not seem to be correlated to other things that go along with smoking. Another factor that has been published in the literature is that women who douche regularly have a higher rate of ectopics. Again, it is a little unclear if this is due to other things going along with that particular habit or whether it is simply from that procedure.

When you think of ectopic, more than ninety-five to ninety-seven percent of them will be someplace within the fallopian tube and most of them will be in the ampullary region; some will be in the isthmic region; then there is the interstitial region and the cornua, which really are connected. A lot of times, I have a little trouble deciding where the cornua ends and the interstitial region begins. Anything that takes up space within the uterus, whether it started here or there, is in this other region. Those are still only about one percent of the ectopic pregnancies that we see. The other sites are all less than one percent.

Classic signs and symptoms of an ectopic pregnancy would include any sort of abdominal pain that goes along with amenorrhea would make you worried. If they are having some abnormal bleeding, they could have a normal pregnancy, a threatened miscarriage or an ectopic. These

The workup that everyone gets these days is to measure the hCG levels and to follow that. At some point, I would say that anyone thinking of an ectopic is going to have an ultrasound. There

If someone comes into the emergency room who seems to have a bleeding ectopic pregnancy, they obviously need to have surgery. The surgery itself could be a conservative surgery; it could still be a laparoscopy, depending on how stable the patient is.

The vast majority of patients are neither one of these groups. The vast majority of patients are either in the group where you see an ectopic on ultrasound, or you see that the beta hCG's aren't doubling and there is no intrauterine pregnancy. Then you come to the point where you have to decide which treatment to pick for the patient - medical or surgical.

Most patients can be managed with elective laparoscopic treatment, which is obviously more cost effective, with shorter recovery and probably decreased adhesions to remove an ectopic. The ectopic can be removed with a salpingectomy or with a more conservative salpingostomy. There are some older studies of investigators who looked at their series; they were almost all

Looking at tubal patency after doing a surgical technique versus just doing nothing, you still have a very high tubal patency after salpingostomy and you do have a similar fifty percent intrauterine pregnancy rate after surgery. So again, we can feel like we haven't necessarily harmed the patient's chances for future pregnancy. At laparoscopy, we can use needlepoint cautery to open

Since you obviously can't be sure you have gotten every piece of trophoblast out of a tube, there is a rate of persistent ectopic pregnancy which usually isn't noticed to be a growing ectopic pregnancy, but it is noticed to be a persistent hCG titer of about five percent. Most of the time, those patients need to be managed with methotrexate. Usually, one dose gets rid of whatever is persistent. The alternative would be to take out the section of tube and leave it unconnected, a

With conservative treatment, sixty-four percent of patients overall have an intrauterine pregnancy. But in the average patient who has not had prior infertility or prior ectopics, it is actually more like eighty-five percent. In the patients that I see, if they have had tubal surgery or a prior ectopic or years of infertility, only about twenty percent have an

What about the medical treatment? A variety of agents have been postulated to stop the growth of the trophoblast and cause regression. The most common one is methotrexate, but people have also experimented with potassium chloride injection into the ectopic, a hypertonic solution of glucose, a little bit with RU-486, but I would say that that the most common protocol is the use of methotrexate. It has been used in trophoblastic disease before, so people know a lot

Stovall, who has published probably the most on this, found that with the single dose and a couple of patients who needed two doses, ninety-four percent were successful and only six percent needed surgery. He also followed some of the patients again for future fertility and he

As I mentioned, the interstitial or cornual ectopics often need a laparotomy to be able to open up that area of the uterus and repair it. Occasionally you can, if you find it early, inject these agents directly into that area. You can even leave an intrauterine pregnancy intact while you take care of this other abnormal pregnancy. People have mostly used KCl for that, but local methotrexate will also preserve an intrauterine pregnancy.

How are you going to decide what to do? Obviously, the patient needs to decide a little bit about what their future fertility is going to be. You may not have any choices if they are unstable and have already ruptured a tube.

The last thing I want to talk about is what to do with the patient who has seriously damaged tubes. This impacts on what we know about doing in vitro fertilization in patients. It used to be said that if you went in to take out an ectopic and the tube looked so hopelessly damaged, you

What about the patient who is going to go ahead and try in vitro fertilization? There has been a lot of information lately that perhaps large hydrosalpinges not only allow ectopic pregnancies, they allow the hydrosalpinx fluid to leak back into the uterus at some point and decrease the