Diagnosis and Management of Ectopic Pregnancy



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Am Fam Physician. 2014 Jul 1;90(1):34-40.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/ectopic-pregnancy.html.

Author disclosure: No relevant financial affiliations.

Ectopic pregnancy affects 1% to 2% of all pregnancies and is responsible for 9% of pregnancy-related deaths in the United States. When a pregnant patient presents with first-trimester bleeding or abdominal pain, physicians should consider ectopic pregnancy as a possible cause. The patient history, physical examination, and imaging with transvaginal ultrasonography can usually confirm the diagnosis. When ultrasonography does not clearly identify the pregnancy location, the physician must determine whether the pregnancy is intrauterine (either viable or failing) or ectopic. Use of the beta subunit of human chorionic gonadotropin (β-hCG) discriminatory level, the β-hCG value above which an intrauterine pregnancy should be visualized by transvaginal ultrasonography, may be helpful. Failure to visualize an intrauterine pregnancy when β-hCG is above the discriminatory level suggests ectopic pregnancy. In addition to single measurements of β-hCG levels, serial levels can be monitored to detect changes. β-hCG values in approximately 99% of viable intrauterine pregnancies increase by about 50% in 48 hours. The remaining 1% of patients have a slower rate of increase; these patients may have pregnancies that are misdiagnosed as nonviable intrauterine or ectopic. After an ectopic pregnancy has been confirmed, treatment options include medical, surgical, or expectant management. For patients who are medically unstable or experiencing life-threatening hemorrhage, a surgical approach is indicated. For others, management should be based on patient preference after discussion of the risks, benefits, and monitoring requirements of all approaches.

Ectopic pregnancy, a high-risk condition in which a fertilized ovum implants outside the uterine cavity, affects 1% to 2% of all pregnancies and poses a significant threat to women of reproductive age. It is the leading cause of maternal death during the first trimester of pregnancy and is responsible for 9% of pregnancy-related deaths in the United States.1,2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Serial measurements of β-hCG levels should be performed in patients with possible ectopic pregnancy. Most viable intrauterine pregnancies (99%) have β-hCG values that increase by about 50% in 48 hours.

C

18

When deciding between surgical and medical treatment of ectopic pregnancy, the choice should be based on the patient's preference after discussing the risks, benefits, and monitoring requirements of both approaches.

C

2, 3, 16, 19

The patient's absolute β-hCG level should be considered when deciding whether an ectopic pregnancy can be treated with methotrexate, because the success rate is lower with higher β-hCG levels.

C

16, 26

Treatment failure may be assumed if the patient's β-hCG level does not decrease by at least 15% from day 4 to day 7 after methotrexate injection, or if it plateaus or increases after the first week of treatment. In such cases, additional methotrexate administration or surgical intervention is required.

C

16

Expectant management should be considered for patients who have low and decreasing β-hCG levels, no evidence of an ectopic mass visualized by transvaginal ultrasonography, and minimal symptoms.

B

20, 34, 35


β-hCG = beta subunit of human chorionic gonadotropin.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Serial measurements of β-hCG levels should be performed in patients with possible ectopic pregnancy. Most viable intrauterine pregnancies (99%) have β-hCG values that increase by about 50% in 48 hours.

C

18

When deciding between surgical and medical treatment of ectopic pregnancy, the choice should be based on the patient's preference after discussing the risks, benefits, and monitoring requirements of both approaches.

C

2, 3, 16, 19

The patient's absolute β-hCG level should be considered when deciding whether an ectopic pregnancy can be treated with methotrexate, because the success rate is lower with higher β-hCG levels.

C

16, 26

Treatment failure may be assumed if the patient's β-hCG level does not decrease by at least 15% from day 4 to day 7 after methotrexate injection, or if it plateaus or increases after the first week of treatment. In such cases, additional methotrexate administration or surgical intervention is required.

C

16

Expectant management should be considered for patients who have low and decreasing β-hCG levels, no evidence of an ectopic mass visualized by transvaginal ultrasonography, and minimal symptoms.

The Authors

JOSHUA H. BARASH, MD, is an associate professor in the Department of Family and Community Medicine at Thomas Jefferson University, Philadelphia, Pa.

EDWARD M. BUCHANAN, MD, is an assistant professor in the Department of Family and Community Medicine at Thomas Jefferson University.

CHRISTINA HILLSON, MD, is a clinical instructor in the Department of Family and Community Medicine at Thomas Jefferson University.

Address correspondence to Joshua H. Barash, MD, Thomas Jefferson Hospital, 833 Chestnut St., Ste. 301, Philadelphia, PA 19107 (e-mail: joshua.barash@jefferson.edu). Reprints are not available from the authors.

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