QuizMe 33

Unruptured Tubal Ectopic Pregnancy

A 29-year-old nulliparous woman presented to the outpatient clinic with a positive pregnancy test (B-HCG: 1200 IU/L) and a one-month delay in menstrual cycle. She had her menarche at the age of fourteen. She has a 28-day regular menstrual cycle with 4 days of menstrual bleeding. She used a levonorgestrel-releasing intrauterine device (Mirena) during the last 7 years for contraception. The IUD was removed 4 months ago as she desired to conceive. The patient was in a good general status and had no previous medical or surgical history. She had normal heart rate, arterial blood pressure, and respiration rate. Transvaginal ultrasonography revealed an empty uterine cavity and a mass over the left adnexa that measured 22 mm in its largest diameter. No fetal heart beat was observed. The right adnexa was unremarkable. No free intraperitoneal fluid was noticed in the posterior cul-de-sac.

Left tubal ectopic pregnancy

  • Expectant management,
  • Intramuscular methotrexate injection
  • Salpingectomy
  • Salpingostomy

A single dose Intramuscular methotrexate injection (50 mg/m2).

Serial serum B-HCG measurements

Anovulatory bleeding is the most common cause of noncyclic menstrual blood flow that may range in volume from spotty to excessive. It is attributed to anovulatory sex steroid production.

Medical treatment is the best management for anovulatory bleeding.

Estrogen-containing contraceptives, eg.Combined oral contraceptives, are contraindicated in women with a history of uncontrolled hypertension. They are considered to be UKMEC category 4.

Levonorgestrel IUD and the copper IUD are both UKMEC Category 1 for uncontrolled hypertension. However, on the levonorgestel IUD would be effective for this patients irregular bleeding and anemia.

On a different note, PCOS patients are found to be 3 times as likely as the general population to develop endometrial cancer. Conservative management via levonorgestrel IUD in cases of precancerous and early well differentiated endometrial neoplasia has displayed viability in patients concerned with preserving their fertility. (Keeping in mind Rotterdam Criteria for PCOS diagnosis.)

Tubal ectopic pregnancy is the most common type of ectopic pregnancy. It occurs when the blastocyst implants in the Fallopian tube instead of the endometrial cavity. Approximately 95% of ectopic pregnancies are tubal pregnancies. This condition is a serious obstetric emergency as it accounts for the highest first-trimester maternal mortality rate. The management of the tubal ectopic pregnancy depends on the patient’s case. In stable patients, conservative approaches are preferred over surgery.

The medical treatment with methotrexate is indicated for hemodynamically-stable patients with a gestational mass of less than 35 mm and a serum B-HCG concentration less than 1500 IU/L. A single dose intramuscular methotrexate injection is preferred over multiple doses of methotrexate because it was shown to be as effective with less side effects. Medical management of tubal pregnancy is a safe approach with less morbidity when compared to surgery. Moreover, it was found to carry better reproductive outcomes for patients who continue to seek fertility after a previous tubal ectopic pregnancy. However, methotrexate should not be administered in cases of heterotopic pregnancy, where a viable intrauterine pregnancy coexists with another ectopic pregnancy regardless of its location

 

1)  Baggio S, Garzon S, Russo A, Ianniciello CQ, Santi L, Laganà AS, Raffaelli R, Franchi M. Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management. Archives of Gynecology and Obstetrics. 2021 Jan;303(1):259-68.

2)  National Institute for Health and Care Excellence, 2019. Ectopic pregnancy and miscarriage: diagnosis and initial management. [online] Nice.org.uk. Available at: <https://www.nice.org.uk/guidance/ng126> [Accessed 18 October 2021].

3)  Guvendag Guven ES, Dilbaz S, Dilbaz B, Aykan Yildirim B, Akdag D, Haberal A. Comparison of single and multiple dose methotrexate therapy for unruptured tubal ectopic pregnancy: a prospective randomized study. Acta obstetricia et gynecologica Scandinavica. 2010 Jul;89(7):889-95.

4)Elson CJ, Salim R, Potdar N, Chetty M, Ross JA, Kirk EJ on behalf of the Royal College ofObstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy. BJOG 2016;.123:e15–e55

Author

Dr Antoine Naem & Dr Aya Al-Shati

Reviewer
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