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Medical Management

Medical management is the treatment of choice for an ectopic pregnancy whenever the required criteria are fulfilled.

  1. Patient should be hemodynamically stable. Active intra-abdominal hemorrhage is an absolute contraindication to medical management.
  2. The size of the ectopic mass is also important (<4cm).
  3. Fetal cardiac activity is not present.
  4. Serum HCG level should be less than 3000 IU/L.
  5. There should be no intraabdominal hemorrhage.
  6. It is recommended that methotrexate should be avoided if the pregnancy is more than 4cm and Fetal cardiac activity is present. According to ACOG contraindications for methotrexate include: breast feeding, alcoholism, immunodeficiency, liver or renal disease, blood dyscrasias, active pulmonary disease and peptic ulcer.

Candidates for methotrexate therapy must be hemodynamically stable. They are instructed that:

  1. Medical therapy fails in at least 5-10% of cases.
  2. If tubal rupture occurs (a 5-10% chance), emergency surgery is necessary.
  3. If the woman is treated as an outpatient, rapid transportation must be reliably available.
  4. Signs and symptoms of tubal rupture such as vaginal bleeding, abdominal and pleuritic pain, weakness, dizziness, or syncope must be reported promptly.
  5. Until the ectopic pregnancy is resolved, sexual intercourse is prohibited, alcohol should be avoided, and folic acid supplements-including prenatal vitamins-should not be taken.

Methotrexate Therapy for Primary Treatment of Ectopic Pregnancy




Single dose: methotrexate, 50 mg/m2

Measure β-hCG at days 4 and 7


If difference is ≥ 15%, repeat weekly until undetectable


If difference <15%, repeat methotrexate dose and begin new day 1


If fetal cardiac activity present at day 7, repeat methotrexate dose,


begin new day


Surgical treatment if β-hCG levels not decreasing or fetal cardiac


activity persists after three doses of methotrexate

Variable dose


Methotrexate, 1 mg/kg i.m., days 1,3,5, and

Continue alternate day injection until β-hCG levels decreases to

7 plus leukovorin, 0.1 mg/kg i.m., days 2, 4,

6, and 8

> 15% in 48 h, or four does methotrexate given

Then, weekly β-hCG until undetectable

i.m. = intramuscular

Surgical Management

  1. Exploratory laparotomy with salpingectomy: In cases of ruptured ectopic pregnancy (shock and hemodynamic instability), blood transfusion and i.v fluids are to be given and simultaneously exploratory laparotomy with salpingectomy should be performed.
  2. Laparoscopic salpingectomy can be performed in cases of unruptured ectopic, chronic ectopic pregnancies, or in cases of early rupture (stable patient).
  3. Types of Surgery in Ectopic Pregnancy

Conservative surgery (Not done now a days)

Radical surgery





Segmental resection and anastomosis


Fimbrial expression of the ectopic pregnancy



Other sites of ectopic pregnancy beside tube


Site of ectopic pregnancy

Name of criteria

Detailed criteria

Primary abdominal pregnancy

Studdiford’s criteria

Both the tubes and ovaries should be normal (without evidence of recent pregnancy).

• Absence of utero-peritoneal fistula.

• The pregnancy must be related exclusively to the peritoneal surface.

Ovarian pregnancy

Spiegelberg’s criteria

• The tube on the affected site must be intact.

• The gestational sac must occupy the position of ovary.

• The gestational sac is connected to the uterus by ovarian ligament.

• Definite ovarian tissue must be found in the sac wall.

Cervical pregnancy

Rubin’s criteria

• The uterus is smaller than the surrounding distended cervix.

• The internal os is not dilated.

• Curettage of the endometrial cavity is non-productive of placental tissue.

• The external os opens earlier than in spontaneous abortion.

Ultrasound Criteria for Cervical Pregnancy (Paalman's)

1. Echo-free uterine cavity or the presence of a false gestational sac only

2. Hourglass uterine shape

3. Ballooned cervical canal

4. Gestational sac in the endocervix

5. Placental tissue in the cervical canal

6. Closed internal os

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