Ectopic Pregnancy: Diagnosis and Management

Jennifer L Kulp; Kurt T Barnhart

Women's Health. 2008;4(1):79-87.

Signs & Symptoms

Patients with ectopic pregnancy may present in the first trimester of pregnancy with vaginal bleeding and pelvic pain. These symptoms are neither sensitive nor specific and are also associated with other pregnancy complications, such as miscarriage. Furthermore, patients with an ectopic pregnancy may be asymptomatic. Certain symptoms are suggestive of possible tubal rupture with intra-abdominal hemorrhage and require immediate intervention. These include hypovolemic shock and syncope. Other suggestive findings on physical examination are abdominal tenderness with rebound or guarding. Findings on pelvic examination may be nonspecific and include a tender adnexal mass, which may not been seen in most patients with ectopic pregnancy.^[9,10,11]

1 2 3 4 5 6 7

Next Section

Cite this: Ectopic Pregnancy: Diagnosis and Management - Medscape - Jan 01, 2008.

Table 1. Risk Factors for Ectopic Pregnancy
Risk factor	Odds ratio*
High risk
Tubal surgery	21.0
Tubal ligation	9.3
Previous ectopic pregnancy	8.3
In uteroexposure to diethystilbestrol	5.6
Use of intrauterine devices	4.2-45.0
Tubal pathology	3.8-21.0
Assisted reproduction	4.0
Moderate risk
Infertility	2.5-21.0
Previous genital infections	2.5-3.7
Multiple sexual partners	2.1
Salpingitis isthmica nodosa	1.5
Low risk
Previous pelvic infection	0.9-3.8
Cigarette smoking	2.3-2.5
Vaginal douching	1.1-3.1
First intercourse <18 years	1.6

*Single values, common odds ratio from homogenous studies; point estimates, range of values from heterogenous studies.
Adapted from reference 55.

Table 2. Methotrexate Protocols
Day	Single-dose protocol	Multidose protocol	Two-dose protocol
0	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 1 mg/kg Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative
1		Leucovorin 0.1mg/kg
2		ß-hCG level Methotrexate
3		Leucovorin
4	ß-hCG level	ß-hCG level Methotrexate	ß-hCG level Methotrexate
5		Leucovorin
6		ß-hCG level Methotrexate
7	ß-hCG level, CBC, LFTs, creatinine Repeat methotrexate if <15% decrease in ß-hCG level from day 4	Leucovorin	ß-hCG level, CBC, LFTs, creatinine, Repeat methotrexate if <15% decrease in ß-hCG level from day 4
11	ß-hCG level, if repeat dose is given		ß-hCG level Repeat methotrexate if <15% decrease in ß-hCG level from day 7
14	ß-hCG level, if repeat dose is given		ß-hCG level CBC, LFTs, creatinine, if repeat dose is given
14	Maximum two doses of methotrexate	Continue methotrexate and leucovorin until 15% decrease in hCG levels between two consecutive titers Maximum four doses of methotrexate	Maximum four doses of methotrexate

For all protocols, after initial decline in ß-hCG, check weekly levels until undetectable or, in the multidose protocol, until <15 IU/l.
ß-hCG: ß-human chorionic gonadotropin; CBC: Complete blood count; LFT: Liver-function tests.

Table 2. Methotrexate Protocols
Day	Single-dose protocol	Multidose protocol	Two-dose protocol
0	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 1 mg/kg Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative
1		Leucovorin 0.1mg/kg
2		ß-hCG level Methotrexate
3		Leucovorin
4	ß-hCG level	ß-hCG level Methotrexate	ß-hCG level Methotrexate
5		Leucovorin
6		ß-hCG level Methotrexate
7	ß-hCG level, CBC, LFTs, creatinine Repeat methotrexate if <15% decrease in ß-hCG level from day 4	Leucovorin	ß-hCG level, CBC, LFTs, creatinine, Repeat methotrexate if <15% decrease in ß-hCG level from day 4
11	ß-hCG level, if repeat dose is given		ß-hCG level Repeat methotrexate if <15% decrease in ß-hCG level from day 7
14	ß-hCG level, if repeat dose is given		ß-hCG level CBC, LFTs, creatinine, if repeat dose is given
14	Maximum two doses of methotrexate	Continue methotrexate and leucovorin until 15% decrease in hCG levels between two consecutive titers Maximum four doses of methotrexate	Maximum four doses of methotrexate

Table 2. Methotrexate Protocols
Day	Single-dose protocol	Multidose protocol	Two-dose protocol
0	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 1 mg/kg Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative
1		Leucovorin 0.1mg/kg
2		ß-hCG level Methotrexate
3		Leucovorin
4	ß-hCG level	ß-hCG level Methotrexate	ß-hCG level Methotrexate
5		Leucovorin
6		ß-hCG level Methotrexate
7	ß-hCG level, CBC, LFTs, creatinine Repeat methotrexate if <15% decrease in ß-hCG level from day 4	Leucovorin	ß-hCG level, CBC, LFTs, creatinine, Repeat methotrexate if <15% decrease in ß-hCG level from day 4
11	ß-hCG level, if repeat dose is given		ß-hCG level Repeat methotrexate if <15% decrease in ß-hCG level from day 7
14	ß-hCG level, if repeat dose is given		ß-hCG level CBC, LFTs, creatinine, if repeat dose is given
14	Maximum two doses of methotrexate	Continue methotrexate and leucovorin until 15% decrease in hCG levels between two consecutive titers Maximum four doses of methotrexate	Maximum four doses of methotrexate

Table 2. Methotrexate Protocols
Day	Single-dose protocol	Multidose protocol	Two-dose protocol
0	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 1 mg/kg Rhogam if Rh negative	Labs (pretreatment) - ß-hCG level, CBC, LFTs, creatinine, type and screen Methotrexate 50 mg/m² Rhogam if Rh negative
1		Leucovorin 0.1mg/kg
2		ß-hCG level Methotrexate
3		Leucovorin
4	ß-hCG level	ß-hCG level Methotrexate	ß-hCG level Methotrexate
5		Leucovorin
6		ß-hCG level Methotrexate
7	ß-hCG level, CBC, LFTs, creatinine Repeat methotrexate if <15% decrease in ß-hCG level from day 4	Leucovorin	ß-hCG level, CBC, LFTs, creatinine, Repeat methotrexate if <15% decrease in ß-hCG level from day 4
11	ß-hCG level, if repeat dose is given		ß-hCG level Repeat methotrexate if <15% decrease in ß-hCG level from day 7
14	ß-hCG level, if repeat dose is given		ß-hCG level CBC, LFTs, creatinine, if repeat dose is given
14	Maximum two doses of methotrexate	Continue methotrexate and leucovorin until 15% decrease in hCG levels between two consecutive titers Maximum four doses of methotrexate	Maximum four doses of methotrexate

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.