Fact-sheet: Ectopic pregnancy


Updated on 09/15/2020 at 9:07 AM

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Definition

Embryonic implantation outside the endometrial cavity. Usually located in the ampulla of the fallopian tube but may be interstitial, abdominal, or ovarian.

Risk factors: history of genital infection, tubal surgery, active smoking, ART (IVF), presence of a copper IUD (debated)

Clinical features

  • Vaginal bleeding, dark blood
  • Lateralized pelvic pain
  • Palpable adnexal mass
  • Secondary amenorrhea

Signs of severity in case of rupture: shock, peritonitis.

Laboratory findings

Positive b-HCG

Ultrasound

Direct signs:

  • Painful, ovoid-shaped adnexal mass
  • Ring of fire pattern on Doppler
  • Extrauterine gestational sac (rarely visible)
  • Extrauterine fetal heart (pathognomonic)

Indirect signs:

  • Thickened, hyperechoic endometrium with empty uterine cavity (absence of intrauterine pregnancy after 6 weeks or Beta-HCG >1800 mIU/mL)
  • Visualization of hematosalpinx
  • Hemoperitoneum (effusion of variable echogenicity, with pelvic clot formation)
  • Tubal dilation

CT

Not indicated as first-line imaging.
May show a lateral uterine mass.
May show active bleeding.
Hemoperitoneum (look for pelvic sentinel clot, density > 40 HU)

MRI

  • Mass of intermediate signal intensity on T2
  • Post-laparoscopy, in the absence of postoperative HCG decline.

Management

Medical treatment in the absence of signs of severity and HCG < 5000:

  • simple clinical and biological monitoring if HCG < 1000 (HCG decline)
  • Methotrexate with monitoring of HCG decline

Surgical management if signs of severity or HCG > 5000

  • Radical treatment (salpingectomy) if massive hemoperitoneum > 2L, ectopic pregnancy > 6 cm in diameter, initial HCG > 20,000 mIU/mL
  • Conservative treatment (salpingostomy) in other cases
  • Rupture of interstitial ectopic pregnancy often results in hemodynamic instability, requiring emergency total hysterectomy

Classification

Fernandez score for surgical management (hemoperitoneum and hematosalpinx size being radiological criteria)

Differential diagnosis

  • Corpus luteum cyst
  • Tubo-ovarian abscess
  • Hydrosalpinx
  • Endometrioma
  • Ovarian cyst
  • Eccentric intrauterine gestational sac