Treatment and Management of Ectopic Pregnancy

Dear Colleagues,

Ectopic pregnancy (EP) is defined as pregnancy that occurs outside the uterus. The fallopian tubes are the most common site of EP, with 80% located in the ampulla vs. 5% non-tubal. Cervical pregnancies account for <1% of EP and are hazardous due trophoblast penetration into the uterine vessels. Abdominal pregnancies are a rare form of EP; they usually have high morbidity and atypical presentation. Embryo transport relies on tube muscle contraction and ciliary beating, which are affected by toxic, infectious and hormonal factors. Smoking and infection decrease cilia density, while ciliary beat frequency follows hormones levels. Surgery and assisted reproduction techniques increase risk while contraceptives show protection against EP. 

Common EP symptoms include pelvic pain, vaginal bleeding, vomiting, and collapse, though some women are asymptomatic. Frequent EP ultrasound findings include a non-homogenous extrauterine mass with peripheric hypervascularization or even fetal pole. Similar hypervascularity can be found in corpus luteum; distinct diagnosis is generally challenging. Significant intrabdominal fluid raises suspicion for hemoperitoneum. This can be hypoechoic, evolving to become more hyperechoic as the clot organizes. Doppler can help distinguish between cervical pregnancy, showing intense peritrophoblastic flow, and abortion transiting in the cervix, with decreased flow. 

Regarding success rates and fertility, non-surgical management contemplates methotrexate use with single or multiple doses with good results. HCG levels should be serially monitored until a non-pregnancy level. Decision to manage an EP surgically will depend on the likelihood of success of non-surgical treatment. Surgery is the preferred approach when embryo shows cardiac activity, HCG concentrations are greater than 5,000 IU/L, adnexal mass is greater than 4 cm, and free pelvic fluid is found on ultrasound. In women with no shock signs, laparoscopic salpingectomy is preferred. Removing the tube seems to eliminate persistent trophoblast risk. 

This Special Issue will focus on evaluating surgical vs. conservative approaches as well as the optimal type and the time of medical therapy and surgical technique (e.g. sutures and knots).

Dr. Gianluca R. Damiani

Guest Editor

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