Management of ectopic pregnancy

Abstract

Ectopic pregnancy is the major cause of maternal mortality during early pregnancy. Most ectopic pregnancies involve the fallopian tube (95%), followed by the ovarian site (3.2%), abdominal site (1.3%), cervical site (0.15%), and cesarean scar site. Ectopic pregnancy, such as cervical, uterine cornual, ovarian, pelvic cavity, or even retroperitoneal pregnancy, can still occur after bilateral salpingectomy. The differential diagnosis should consider other gynecological conditions and nongynecological conditions. Risk factors associated with ectopic pregnancies include advanced maternal age, smoking, history of ectopic pregnancy, tubal damage or tubal surgery, infertility, diethylstilbestrol exposure, and assisted reproductive technologies. There are three pillars of ectopic pregnancy diagnosis: symptoms, human chorionic gonadotropin serum level pattern, and transvaginal ultrasound. Ectopic pregnancy may be managed expectantly, medically, and surgically. The choice of treatment should first consider not only the clinical conditions of the patient but also the patient's preference, after appropriate counseling about monitoring, outcomes, risks, and benefits of each procedure. Medical treatment is based on methotrexate (MTX), and there are three possible regimens. The surgical treatment could be conservative (salpingotomy) or radical (salpingectomy). It is generally performed laparoscopically. Regarding subsequent fertility, studies suggest that around 60% of women affected by an ectopic pregnancy go on to have a viable intrauterine pregnancy. The comparison between medical treatment and surgical conservative treatment did not show statistically significant differences, and the same result is observed when comparing conservative and radical surgery. Interstitial pregnancy is a very rare form of ectopic gestation. It occurs when the ovum is implanted in the interstitial portion of the tube. Interstitial and angular ectopic pregnancies can be used in place of each other. However, they actually describe two different entities. Angular implantation describes ectopic pregnancies in the upper and lateral uterine cavities, whereas interstitial denotes those implanted within the proximal intramural portion of the tube. Cornual pregnancies are those implanted in a horn of an anomalous uterus (i.e., unicorunate, bicornuate, didelphys, or septate uterus). Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, and its incidence may have been increased because of the increased rate of cesarean sections performed. The early diagnosis of CSP led to a high success rate of conservative treatment using local MTX administration alone.