Evaluating and managing ectopic pregnancy

While the incidence of ectopic pregnancy has increased dramatically over the past several decades, maternal mortality rates have steadily declined. Earlier detection and refinements in treatment account for most of this decline. Here, the authors outline current therapeutic options.

Dr. Givens is instructor and Dr. Lipscomb is professor and director, division of gynecologic specialties, department of OBG, at the University of Tennessee Health Science Center in Memphis.

Ectopic pregnancy is the leading cause of maternal death in the first trimester.¹ Fortunately, despite an almost 5-fold increase in the incidence of ectopic pregnancy in the United States since 1970, deaths have declined approximately 10-fold. The lower maternal mortality rates can be attributed to earlier diagnosis of the unruptured ectopic pregnancy, along with nonsurgical therapy and other alternatives to the traditional salpingectomy. On the other hand, the rising ectopic pregnancy rate is thought by many to be the result of an increased incidence of tubal disease due to gonorrhea and chlamydia infections, and tubal surgery.

The development of more sensitive and specific radioimmunoassays for progesterone and human chorionic gonadotropin (hCG), along with the widespread availability of laparoscopy and high-resolution transvaginal sonography, have made early diagnosis feasible. Diagnostic algorithms have been developed to simplify the management of suspected ectopic pregnancy. Initially, these algorithms relied on quantitative hCG titers and transabdominal ultrasound followed by diagnostic laparoscopy to confirm an ectopic pregnancy. But as the sensitivity and specificity of the diagnostic tests increased, the need for laparoscopy to confirm the diagnosis decreased. In a randomized clinical trial, Stovall and colleagues developed an algorithm that proved 100% accurate without the use of laparoscopy.² This algorithm was an extension of one then in use at the University of Tennessee, Memphis.