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Ectopic pregnancy

Key sources
The following summarized guidelines for the evaluation and management of ectopic pregnancy are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021), the Royal College of Obstetricians and Gynaecologists (RCOG 2021; 2016), and the American College of Obstetricians and Gynecologists (ACOG 2018; 2017).
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Guidelines

1.Classification and risk stratification

Risk stratification: use risk models (such as M6 model) to stratify pregnancy of unknown location as either high or low risk for ectopic pregnancy to guide treatment decisions.
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2.Diagnostic investigations

Serum hCG levels
As per ACOG 2018 guidelines:
Do not use serum hCG values alone for the diagnosis of ectopic pregnancy, rather correlate it with the patient's history, symptoms, and ultrasound findings.
D
Use the conservatively high value (such as high as 3,500 mIU/mL), if the hCG discriminatory level is being used as a diagnostic aid in patients at risk of ectopic pregnancy, to avoid the potential for misdiagnosis and possible interruption of an intrauterine pregnancy that the patient hopes to continue.
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  • Serum progesterone

  • Other laboratory tests

  • Transvaginal ultrasound (general principles)

  • Transvaginal ultrasound (tubal pregnancy)

  • Transvaginal ultrasound (cervical pregnancy)

  • Transvaginal ultrasound (interstitial pregnancy)

  • Transvaginal ultrasound (cornual pregnancy)

  • Transvaginal ultrasound (ovarian pregnancy)

  • Transvaginal ultrasound (abdominal pregnancy)

  • Transvaginal ultrasound (heterotopic pregnancy)

  • MRI

3.Medical management

General principles: as per ACOG 2018 guidelines, decide on the choice of management (methotrexate versus surgery) of ectopic pregnancy guided by the initial clinical, laboratory, and radiologic data as well as patient-informed choice based on a discussion of the benefits and risks of each approach.
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  • Expectant management

  • Methotrexate

  • Anti-D immunoglobulin

4.Therapeutic procedures

Transvaginal targeted injection and aspiration: consider administering a local injection of potassium chloride or hyperosmolar glucose with the aspiration of the sac contents as an option in clinically stable patients with heterotopic pregnancy.
C

5.Surgical interventions

Surgical management, general indications
Recognize that both laparoscopic surgery and IM methotrexate are safe and effective treatment options in clinically stable patients with non-ruptured ectopic pregnancy. Decide between surgical and medical management based on the initial clinical, laboratory, and radiologic data as well as patient-informed choice based on a discussion of the benefits and risks of each approach.
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Perform surgery in patients with ectopic surgery exhibiting any of the following:
hemodynamic instability
symptoms of an ongoing ruptured ectopic mass (such as pelvic pain)
signs of intraperitoneal bleeding
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  • Surgical management (tubal pregnancy)

  • Surgical management (cervical pregnancy)

  • Surgical management (interstitial pregnancy)

  • Surgical management (cornual pregnancy)

  • Surgical management (Cesarean scar pregnancy)

  • Surgical management (ovarian pregnancy)

  • Surgical management (abdominal pregnancy)

  • Surgical management (heterotopic pregnancy)

6.Specific circumstances

Patients with molar pregnancy
Manage patients with ectopic pregnancy suspected to be molar in nature as any other case of ectopic pregnancy.
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Send a tissue specimen to a center with appropriate expertise for pathological review, if there is a local tissue diagnosis of ectopic molar pregnancy.
E

7.Patient education

General counseling: inform patients with tubal pregnancy undergoing salpingotomy about the risk of persistent trophoblast with the need for serum β-human chorionic gonadotrophin level follow-up and that there is a small risk that they may need further treatment in the form of systemic methotrexate or salpingectomy.
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  • Fertility counseling

  • Counseling on methotrexate treatment

8.Follow-up and surveillance

Serial hCG monitoring: obtain serial monitoring of hCG levels after administration of methotrexate treatment until a nonpregnancy level (based upon the reference laboratory assay) is reached.
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9.Quality improvement

Health professional training: ensure that clinicians undertaking ultrasound for the diagnosis of ectopic pregnancy have received appropriate training.
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  • Equipment and care availability