Surgical therapy. The majority of ectopic pregnancies are treated surgically.
Laparoscopy is preferred for diagnosis and treatment of tubal pregnancy; however, laparotomy is indicated if the patient is hemodynamically unstable.
Conservative surgical therapy is recommended in patients who wish to preserve reproductive potential. Linear salpingostomy in the antimesosalpinx portion of the tube performed with fine-tip electrocautery is preferable when the ectopic pregnancy is unruptured and is located in the ampulla of the tube, although this may increase the risk of future ectopic pregnancies. After removal of the pregnancy from the tube, the base is irrigated, and hemostasis is achieved with cautery. The tube is left to heal by secondary intention. Segmental resection often is performed when the tube is ruptured, and the ectopic pregnancy is in the isthmic portion of the tube.
Nonconservative surgical therapy includes salpingectomy (removal of tube) for tubal rupture or severe hemorrhage and cornual resection for interstitial pregnancies. Pregnancy rates after salpingectomy have beenshown to be equivalent to those following linear salpingostomy, although the incidence of recurrent ectopic pregnancy may be slightly higher with salpingostomy.
Follow-up. Patients treated with conservative surgical management or after rupture or spillage of trophoblastic tissue have a 5% incidence of persistent viable trophoblastic tissue. Weekly quantitative hCG values should be followed until negative. If the levels plateau or increase, reevaluation is indicated.
Medical therapy with methotrexate, a folic acid antagonist, can be used in compliant outpatients who are hemodynamically stable. Indications for ectopic pregnancy treatable with methotrexate include size of ectopic pregnancy equal to or less than 3.5 cm in diameter, an intact tube, no fetal heart motion, no evidence of hemoperitoneum, and an hCG less than 10,000 mIU/mL. Baseline laboratory tests including hCG, Rh factor, CBC, and hepatic enzymes should be obtained. The most common side effects of therapy are bloating and flatulence. Transient rise in hepatic enzymes may be observed. Less frequent side effects include stomatitis, hair loss, and anemia. Repeat quantitative hCG levels should be drawn on days 4 and 7. If hCG levels fail to decline less than 15% between days 4 and 7, a second dose of methotrexate should be administered and a new day 1 assigned. Quantitative hCG values are followed until negative. Approximately 20% of patients have an inappropriate fall in hCG levels and require surgical intervention. Separation pain refers to the increase in abdominopelvic discomfort that is commonly experienced by patients undergoing treatment and is thought to be caused by tubal stretching during resolution of the pregnancy. Patients are counseled to rest and take oral analgesics but warned to seek immediate reevaluation to rule out rupture if pain does not resolve within 1 hour. They should also avoid alcohol and folic acid because these may interfere with methotrexate and avoid intercourse because this may increase the risk of rupture (Copeland LJ. Textbook of Gynecology, 2nd ed. Philadelphia:
