Ectopic Pregnancy: Diagnosis and Management

Jennifer L Kulp; Kurt T Barnhart

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

Conclusion

With the use of transvaginal ultrasound and serial ß-hCG levels, and in some cases uterine curretage, most ectopic pregnancies can be diagnosed and treated at an early stage. Medical treatment of ectopic pregnancy with methotrexate avoids surgery and, in properly selected patients, is highly successful and well tolerated. The optimal methotrexate protocol is the focus of ongoing research and initial data suggest that the two-dose methotrexate protocol is promising. Medical and surgical treatment of ectopic pregnancy have similar success rates. Future fertility is comparable in medically and surgically treated patients.

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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

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