The most common site is the ampulla of the fallopian tube.
Main risk factor = PID
There are 3 ways to manage ectopic pregnancies. And the following criteria can help to guide you on which method your patient will be able to have.
| Expectant management | Medical management | Surgical management |
|---|---|---|
| Size <35mm | Size <35mm | Size >35mm |
| Unruptured | Unruptured | Can be ruptured |
| Asymptomatic | No significant pain | Pain |
| No fetal heartbeat | No fetal heartbeat | Visible fetal heartbeat |
| hCG <1,000IU/L | hCG <1,500IU/L | hCG >5,000IU/L |
| Compatible if another intrauterine pregnancy | Not suitable if intrauterine pregnancy | Compatible with another intrauterine pregnancy |
| Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed. | Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow-up. | Surgical management can involve salpingectomy or salpingotomySalpingectomy is first-line for women with no other risk factors for infertilitySalpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage |
| • around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy) |
Indications for methotrexate
If the serum hCG is below the institution's discriminatory level (and transvaginal ultrasound does not show intrauterine pregnancy), serial hCG levels are taken every 48-72 hours. If these do not rise appropriately, the diagnosis can be made and the patient treated. If the serum hCG is above the institution's discriminatory level, and transvaginal ultrasound shows an absence of an intrauterine pregnancy and an adnexal mass, the diagnosis can be made and treatment can begin. This patient has a significant serum hCG level, is stable with a relatively small conceptus, and thus may be managed medically. Methotrexate is an antimetabolite that targets the rapidly dividing cells of the early pregnancy and may be used to treat early, stable, unruptured, ectopic pregnancies that are <3.5 cm in size. Before treatment with methotrexate, renal and liver function labs should be drawn to exclude contraindications to this medication.