Pregnancies of Special Clinical Interest
The pregnancy test is positive.
As the resolution of ultrasound has improved over the years, so has its ability to find ectopic pregnancies. It still remains true, however, that ultrasound is at its best in defining the presence of normal, intrauterine pregnancies. Some of the criteria for defining an ectopic pregnancy with ultrasound include:
Ultrasound can be misleading at times. Occasionally, "intrauterine" pregnancies are identified that are, in fact, ectopic pregnancies with sufficient inflammatory reaction and bleeding around them to make it appear that they are surrounded by normal uterine muscle. In some other cases, an "intrauterine" pregnancy is identified that is, in fact, a "gestational pseudosac" within the uterus. This pseudosac is a response by the endometrium to the hormones of pregnancy and can mimic the appearance of an intrauterine pregnancy.
Dilatation and curettage is sometimes done in the presence of a clearly abnormal HCG pattern, combined with abnormal ultrasound findings, to confirm or rule out ectopic pregnancy. If the D&C specimen shows chorionic villi, then the pregnancy was intrauterine. If no chorionic villi are found, then ectopic pregnancy is often presumed to be present.
Laparoscopy is a very effective method to diagnose ectopic pregnancy. Unfortunately, it is invasive, carrying its own risks, and may miss very early ectopic pregnancies that have not grown large enough to be appreciated by the operator.
When ectopic pregnancies are found with laparoscopy, it is often possible to remove them surgically at the same time. An incision is made over the antimesenteric border of the tube and the ectopic is teased out. This can be facilitated by the injection of pitressin into the tube, causing the muscularis layer to contract, expelling the ectopic and controlling bleeding. Bleeding usually either stops or is controlled with judicious use of cautery.
Not all cases of ectopic pregnancy lend themselves to laparoscopic surgery. The larger the ectopic, the more difficult and dangerous is the laparoscopic surgery. The more bleeding that is present, the more difficult and dangerous is the laparoscopic surgery. Cornual and some isthmic ectopic pregnancies usually will need laparotomy to effectively control bleeding from the uterine side.
In these cases, the priority is stopping the blood loss. The fastest and simplest way to do that is to clamp across the blood supply of the ectopic, remove it, and sew up the cut edges. This is known as a salpingectomy or partial salpingectomy, depending on the extent.
In the past, great effort was made (and considerable risk taken) to preserve childbearing potential by conserving and repairing the fallopian tube. Given the advanced state of assisted reproductive technology, such risks are only infrequently warranted today. The long-term natural fertility of a woman experiencing an ectopic pregnancy is about the same (about 50%), whether you remove the entire affected tube or try to repair it. In the event of subsequent infertility, egg retrieval, in-vitro fertilization and embryo transfer can usually leap-frog over the need for functional fallopian tubes, so immediate surgical safety and speedy recovery are usually the priorities.
At least half of these patients will have significant abdominal pain, but the treatment will be successful in about 90% of cases in resolving the ectopic pregnancy without resorting to surgery. Some of these patients will still need surgery, either because of persistent or severe pain, hemorrhage, or failure of the HCG to resolve completely. Recovery using this method may require up to several months.
Not everyone with an ectopic pregnancy is a good candidate for this treatment. It works best when:
Not all cases of ectopic pregnancy require surgical or medical treatment. For many ectopic pregnancies, their natural history will be to stop growing, detach and be expelled out the end of the fallopian tube, clinically disappearing.
Expectant management seems to work best when there is a plateau or falling levels of HCG , and the initial HCG is <1,000, in asymptomatic women. In such cases, successful spontaneous resolution can be expected in 75 to 90% of cases. Some of these will ultimately require methotrexate or surgery to resolve. Expectant management can be considered in other cases, but the success rate will be less. The overall successful resolution without surgery or methotrexate for ectopic pregnancies managed expectantly with initial HCG of <2000 is 60%.
Subsequent fertility has been shown to be about the same, regardless of whether the ectopic is managed expectantly, with methotrexate, or surgically.
Rh sensitization can occur following ectopic pregnancy treatment and Rh immune globulin is administered to Rh negative women to prevent such an event.
OB-GYN 101: Introductory
Obstetrics & Gynecology
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