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Ectopic Pregnancy

by Lynae Brayboy, MD
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    00:01 In this lecture, I’ll be reviewing ectopic pregnancy. This is important for you to listen to as you can see questions on your USLME. In addition, you can save a life by understanding the pathophysiology of an ectopic pregnancy. An ectopic pregnancy essentially is a pregnancy that is developing outside of the uterus. This can happen in several locations.

    00:27 Let’s review some of those locations now. An ectopic pregnancy is more likely to occur in the ampulla.

    00:35 Over 70% of ectopic pregnancies occur here. Do you know why? I’ll wait for you to answer that.

    00:47 If you guessed because fertilization occurs here then you are correct. There are other regions that an ectopic pregnancy can implant including the isthmus and the fimbria.

    01:04 3% of all ectopics occur on the ovary. Sometimes you can have an ectopic in the interstitium.

    01:11 This is the junction between the tube and the uterus. 1% of all ectopics are abdominal.

    01:18 This is extremely rare. However, we are seeing a surge in cervical ectopics.

    01:25 These ectopics can be life-threatening as sometimes they look like a miscarriage.

    01:31 If you try to extract them, the patient can lose her blood supply very quickly. This is very life threatening.

    01:38 An ectopic pregnancy looks like this upon laparoscopy. They account for 1% to 2% of all pregnancies.

    01:45 They account for 5% of all assisted reproductive technology pregnancies. For more information about ART, please refer to that lecture slide. There are some definitive risk factors for an ectopic pregnancy such as previous surgery on the tube. Any surgery but especially tubal ligation can cause ectopics to occur. Tubal pathology from pelvic infection such as PID can also lead to ectopic.

    02:15 DES exposure increases the risk five-fold. However, less patients exposed to DES are now in their perimenopause and menopausal stages. So, you're unlikely to see this but you may be tested on your exam. Also, patients who have infertility who have any type of ART are two-fold increased risks. They are more likely to have a heterotopic.

    02:39 That means one ectopic and one normal intrauterine pregnancy or IUP. Patients who smoke are more likely to have an ectopic. There’s a two-fold increased risk. So, you should encourage all of your patients to stop smoking for their own health benefit but of course, for the benefit of any pregnancy that may occur. Contraception, we think that taking contraception decreases the incidence or absolute risk of ectopic. However, there are some times when the contraceptive method may fail and there's an increased risk of ectopic if you conceived with an IUD in place. Again, if you’ve had permanent sterilization, these patients are more likely to have ectopic if they become pregnant after the sterilization.

    03:26 One third of pregnancies from sterilization are an ectopic. The diagnosis is easy.

    03:33 A beta positive hCG usually occurs eight to ten days after ovulation. There is some time that is required to determine what the character of the beta-hCG will be. Will it double normally every two to three days or will it plateau? Serial beta-hCG determinations are more difficult to interpret in the setting of ART possibly because there may be more than one gestation and therefore, the beta-hCG is elevated.

    04:02 Let’s now look at what a normal pregnancy looks like. With an IUP, you have a gestational sac usually at 38 days after the onset of menses. Then, you should see a fetal pole and a yolk sac.

    04:19 Perhaps, you'll see the yolk sac such as the one pictured here, which is an indication that there is an intrauterine pregnancy. However, you can't see a yolk sac in the adnexa.

    04:30 So, it’s important to look at the ultrasound pictures to determine where the yolk sac and therefore the IUP should be. An abnormal pregnancy would actually look like this.

    04:41 This is an observation of a gestational sac with a yolk sac, an embryo, and fetal cardiac activity outside of the uterus. This establishes the diagnosis of an ectopic. Typically, we don’t always see very well like the last image. So, sometimes if we suspect an abnormal pregnancy which could be an abnormal IUP, intrauterine pregnancy or an ectopic, we recommend doing some type of uterine curettage. This can be done with manual vacuum aspiration or a dilation and curettage. We typically do this when the beta-hCG is above the discriminatory zone but there is no IUP seen on ultrasound. Typically, if you recover villi, this will exclude ectopic and will tell you it was an abnormal IUP. However, it does not rule out the chance of a heterotopic.

    05:32 Let’s talk about the medical management of ectopic pregnancy. Methotrexate is an effective first-line medical therapy. It works by inactivating dihydrofolate reductase and inhibiting DNA and RNA synthesis. It is the preferred alternative to surgical treatment.

    05:48 However, the patient needs to meet some criteria. She needs to be hemodynamically stable.

    05:55 She must not have any evidence of acute or intra-abdominal bleeding. She must be compliant with the medication and is scheduled to come back to check her titers of beta-hCG.

    06:07 Methotrexate does have some contraindications. If the woman is currently breastfeeding, she cannot take Methotrexate. If she’s immunodeficient such as HIV positive or has AIDS, she is not a candidate for Methotrexate. If the patient has cirrhosis or hepatitis, she is not a candidate for Methotrexate. If she has renal failure, she should not receive Methotrexate.

    06:33 Any bleeding dyscrasias or blood dyscrasias are also a contraindication. Sometimes patients report a history of sensitivity to Methotrexate. They should also not receive Methotrexate.

    06:45 Any active pulmonary disease such as an ongoing asthma exacerbation should not permit the use of Methotrexate in these patients. Also, if a patient has active peptic ulcer disease, she should not receive Methotrexate to treat her ectopic. I’d now like to review the surgical treatment for ectopic pregnancy. We traditionally do this via laparoscopy and not laparotomy.

    07:10 I can either perform a salpingostomy or a salpingectomy. A salpingostomy allows me to make a linear antimesenteric incision on the fallopian tube. Then I remove the ectopic pregnancy through the incision sometimes with hydrodissection. The incision is then allowed to close by secondary intention. For a salpingectomy, the entire tube is removed. With salpingectomy, we try to avoid this so the patient can have access to both her tubes even after having an ectopic.

    07:44 About 65% of patients who’ve had an ectopic in a tube will go on to have an IUP or an intrauterine pregnancy.

    07:53 Thank you for listening and good luck on your exam.


    About the Lecture

    The lecture Ectopic Pregnancy by Lynae Brayboy, MD is from the course Female Pelvic Medicine. It contains the following chapters:

    • Ectopic Pregnancy: Definition and Risk Factors
    • Methotrexate (MTX): Indications and Contraindications

    Included Quiz Questions

    1. Ampulla
    2. Isthmus
    3. Fimbriae
    4. Ovary
    5. Interstitium
    1. Gestational sac with yolk sac, embryo, or fetal cardiac activity outside of the uterus.
    2. Positive pregnancy test after ART.
    3. Increasing serial beta-hCG levels.
    4. Absence of gestational sac in the uterus with an equivocal pregnancy test result.
    5. Lack of fetal cardiac activity at six weeks of gestation.
    1. Methotrexate
    2. Mifepristone
    3. Misoprostol
    4. Dinoprostone
    5. Oxytocin

    Author of lecture Ectopic Pregnancy

     Lynae Brayboy, MD

    Lynae Brayboy, MD


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