Arch Gynecol Obstet (2000) 263:87–92 © Springer-Verlag 2000

R E V I E W A RT I C L E

Rainer Lehner · Elisabeth Kucera · Stefan Jirecek

Ectopic pregnancy

Received: December 1998 / Accepted: 25 May 1999

Abstract Ectopic pregnancy is a implantation occurring most effective prevention is to avoid tubal inflammation
elsewhere than in the cavity of the uterus, whereas ninty- or, in cases of preexisting inflammation, to administer
nine percent of extrauterine pregnancies occur in the effective therapy.
fallopian tube. The incidence of extrauterine pregnancy
has increased from 0.5% thirty years ago, to a present Key words Ectopic · Tubal · Pregnancy · Therapy
day 1–2%. The most frequent cause of tubal pregnancy
is previous salpingitis. Mortality rates for tubal pregnan-
cies used to be approximately 1.7% in the 1970 s but Introduction
dropped to 0.3% in 1980 s. Diagnosis: Using transvagi-
nal ultrasound it is possible to obtain positive evidence Ectopic pregnancy is defined as implantation occurring
of an ectopic pregnancy at a very early stage. In cases of elsewhere than in the cavity of the uterus. A distinction
hCG titers>2000 IU/l, intrauterine pregnancy can be dia- is made between this condition and ectopic intrauterine
gnosed with certainty. The most important differential pregnancies. The latter include cornual pregnancies in
diagnosis of ectopic pregnancy is early intrauterine pre- which the product of conception is located in the proxi-
gnancy. Clinical management and therapy: Regardless mal portion of the fallopian tube, and cervical pregnan-
of the therapeutic strategy selected by the physician, cies in which the product of conception is located in the
informing the patient is a major aspect of the manage- uterine cervix. In intramural pregnancies, which are rela-
ment of ectopic pregnancy. If surgery is considered ap- tively rare, the gestational product is entirely surrounded
propriate, the patient must be informed about the nature, by the myometrium and has no contact with the uterine
side effects and complications of the procedure. How- cavity. A further rare form of ectopic pregnancy is intra-
ever, it should be remembered that in some cases, the mural cervical pregnancy.
actual chances of cure first become apparent at surgery. All these forms of intrauterine pregnancy are distin-
In asymptomatic patients with a serum hCG titer guished from extrauterine types. Ninety-nine percent of
<1000 IU/l that is falling, it is appropriate to wait and extrauterine pregnancies occur in the fallopian tube. The
watch. In clinically stable patients with an unruptured pregnancy is most frequently located in the ampullary
tubal pregnancy and steady hCG levels, systemic treat- portion (47–70% of cases) and more rarely in the isth-
ment with methotrexate might also be considered. In mus (14–21%) or infundibulum (5%) [3]. Pregnancies in
unruptured tubal pregnancy with a hCG titer between the interstitial space, i.e., the fimbria, occur in no more
1000 and 2500, a further therapeutic alternative is intra- than 1–2% of cases. Non-tubal extrauterine oovarian or
tubal injection of prostaglandins, hyperosmolar glucose abdominal pregnancies, are very rare. In abdominal
of NaCl. Generally speaking, the currently widespread pregnancy, implantation occurs on the peritoneal surface
laparoscopic surgical treatment of the fallopian tube of the ovary, in the pouch of Douglas or the omentum (a
hardly influences the risk of recurrence. If the gestational rarity). An abdominal pregnancy may develop via prima-
mass is larger, the serum hCG titer higher than the ap- ry or secondary implantation. The latter is the case when
proximate limit of 2500 mU/ml and/or the tube already trophoblastic tissue falls out of the fallopian tube. Het-
ruptured, surgery is usually required. Prevention: The erotopic, i.e. simultaneous extra- and intrauterine preg-
nancy, occurs in only one of 30,000 cases [13]. However,
R. Lehner (✉) · E. Kucera · S. Jirecek · C. Egarter · P. Husslein with the increased use of in vitro fertilization, this phe-
Department of Obstetrics and Gynaecology, University of Vienna,
Währinger Gürtel 18-20, A-1090 Vienna, Austria nomenon is become more common.
e-mail: [email protected] The incidence of extrauterine pregnancy has in-
Tel.: +43-1-40400-2822, Fax: +43-1-40400-2861 creased in the last 30 years [22]. From 0.5% 30 years
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ago, to a present day 1–2%. The frequency rates are rela- dominal or ovarian pregnancy could result. Salpingitis
tive to pregnancies. isthmica nodosa, which thickens the proximal part of the
Possibly, a major reason for this increase is the avail- tube and hinders the transport of the oocyte, is also sug-
ability of improved procedures for the diagnosis of early gested as a cause of proximal tubal pregnancy.
stage extrauterine pregnancy. Nowadays, physicians can The role of the embryo in tubal pregnancy is not en-
detect extrauterine pregnancies that may have resolved tirely clear. Morphological genetic disorders are fairly
spontaneously in the past. A rising rate of tubal infection common and may be caused by faulty implantation.
may be another factor. Risk also correlates with age. Up However, chromosomal disorders such as a haploid, trip-
to the age of 20 the rate is 0.4%; from 20–30 years, loid or multiploid chromosome complement, were not
about 0.7% and from 30–40 years, 1.3–2% [22]. more frequent in ectopic pregnancies than in intrauterine
The most frequent cause of tubal pregnancy is previ- pregnancies.
ous salpingitis, especially recurrent forms of the disease. The trophoblast of the human embryo is known to pos-
Ascending pathogens such as chlamydia, staphylococcus sess a strong ability to invade maternal vessels. As the oc-
or gonococcus (more rarely tuberculosis) are liable to currence of pregnancy in vitro fertilization correlates with
trigger subclinical infections which damage the tubal the morphological “quality” of the pre-embryo, the enzy-
mucosa. The tubal mucosa may be destroyed, and the matic activity of blastocytes is likely to be more strongly
motility of the fallopian tube and the transport of oocytes involved in a successful implantation than is the activity
may be impaired. Rare congenital anomalies of the prox- of the endometrial surface. Secondary ectopic pregnancies
imal portion of the tube, e.g., rudimentary or extremely are explained by the fact that trophoblastic tissue might
elongated tubes may be associated with ectopic pregnan- open up new vessels at a later point in time.
cy. Intraluminal polyps could also influence the motility Intrauterine devices are an iatrogenic factor for ectop-
of the fallpian tube and thereby enhance the risk of ec- ic pregnancy, as the device may cause mechanical im-
topic pregnancy. Endometriotic may also damage or pairment of tubal motility. Subclinical infection follow-
compromise tubal epithelium and motility and thus cause ing the placement of a device may also play an
tubal pregnancy. aetiological role. Hormonal factors such as the use of a
The number of cilia, their beat frequency, as well as gestagen mini pill or post-coital contraceptives are also
the muscular motility of the tube and the complex tube potential causes of ectopic pregnancy. The effect of hor-
contractions change in the course of the menstrual cycle. mones on tubal motility might play a significant role. A
Motility is enhanced by estrogens, but is reduced in the prerequisite for this, however, is that the method of con-
luteal phase [3]. The exact processes governing motility traception fails to inhibit ovulution. In rare cases, ectopic
during ovulation are poorly understood. However, it is pregnancies have been reported after sterilization. One
more or less certain that the peristalsis of the isthmus is explanation is the formation of a fistula in the proximal
important for transporting the oocyte. Moreover, the isth- part of the tube. In rare cases, sperms pass over to the
mus is capable of transporting the sperms in the direction distal portion of the tube through such a fistula, with the
of the ampulla before fertilization, and the fertilized egg fertilized ovum migrating via the pouch of Douglas into
in the direction of the uterus. As tubal contractions are the contralateral tube or back through the fistula into the
influenced by various substances including prostaglan- proximal portion.
dins E2 and F2α, the muscular activity is also sensitive Mortality rates for tubal pregnancies used to be ap-
to pharmacological manipulation. For instance, the risk proximately 1.7% in the 1970s but dropped to 0.3% in
of ectopic pregnancy is significantly higher after ovarian 1980s. Nevertheless, ectopic pregnancies account for
stimulation with HMG or clomiphen, as well as after in- 0.004% of all pregnancies and continue to be a common
duction of follicular rupture with hCG. In addition, mi- cause of maternal mortality in the first trimester.
crovascularization, which is also subject to various influ-
ences, affects the transport of oocytes [18].
Salpingitis affects the cilia carrier cells of the mucosal Diagnosis
folds. The number of cilia, which appear to be important
for transporting the oocyte and, later, the pre-embryo, Secondary amenorrhea, irregular bleeding or persistent
may also be substantially reduced. Subsequently, fibrosis spotting with abdominal cramps should arouse suspicion
may cause synechiae in the tubal wall, which, in turn, of an ectopic pregnancy. Documentation of the previous
narrows the lumen and eventually leads to intraluminal gynecological diseases and operations, previous preg-
adhesions. All these factors impair the transport of oo- nancies and deliveries, is mandatory. Prior adnexitis and,
cytes. The oocyte does not reach the uterus from the am- of course, previous tubal pregnancies raise the level of
pulla but is implanted at the site of maximum cilial loss. suspicion. It is important to determine the cause of lower
As the ampulla is the more active and initial portion of abdominal pain. Even unruptured tubal pregnancies
the tube, irregular implantations occur more often at this might cause peritoneal pain due to distension of the tubal
site. This might explain the large proportion of ampulla- wall. However, the pain might also be caused by rupture.
ry pregnancies. If bleeding into the abdominal cavity has already oc-
If the macroscopic adhesions are such that the pre- curred, this could lead to peritonitis and, in particular,
embryo does not reach the ampulla at all, a primary ab- the symptoms of an acute abdomen.
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This is especially likely to occur in tubal pregnancies The basic diagnostic approach to ectopic pregnancy
with implantation in the mesosalpinx, as blood supply is has undergone a major change. Until a few years ago ul-
best in this area and bleeding after a preforation is usual- trasonography used to focus on excluding intrauterine
ly heaviest at this site. Perforation might be spontaneous, pregnancy. However, since the introduction of the trans-
but may occasionally be caused by a brusque clinical ex- vaginal scanner [1, 20], it is possible to obtain positive
amination. evidence of an ectopic pregnancy at a very early stage.
Tubal abortions are especially common in ampullarly The diagnostic reliability of transabdominal sonography
pregnancies, in which trophoblastic material is transport- is about 70% while that of transvaginal sonography, un-
ed into the abdomen, causing irritation of the peritone- der ideal conditions, is higher than 90%. If the hCG titer
um. Bleeding occurs at the site of implantation, resulting in the serum is higher than 800–1,000 IU/L, transvaginal
in a hematoma which causes secondary hemostasis. Oc- ultrasonography (with a scan frequency of 5 MHz) dem-
casionally, peritoneal irritation might cause fever. onstrates practically every normal intrauterine pregnan-
A tubal abortion or death of trophoblastic tissue is cy. Heartbeats should be visible from the sixth week of
usually followed by so-called terminal bleeding. Tropho- gestation and, in transabdominal ultrasonography, from
blast is responsible for the production of human chorion- the seventh week of gestation onwards. The amniotic sac
ic gonadotropin (hCG) and human placental lactogen. As is very rarely in the center of the uterine cavity. Howev-
these substances cease to be produced, the corpus luteum er, ectopic pregnancy might have a ring-like structure in
is also affected. the center of the cavity, also known as the „pseudo ge-
Thus, patients with a tubal pregnancy might be entire- stational sac“. This finding has also been reported before
ly asymptomatic or might present with massive hemor- menstruation and in patients with corpus luteum cysts.
rhagic shock following perforation. Pain used to be the The pseudo gestational sac may be up to 1 cm in diame-
most common symptom of tubal pregnancy but, as a re- ter. It is due to the stimulating effect of progesterone on
sult of improvements in the early diagnosis of this condi- the endometrium which becomes hyperechoic. In the ab-
tion, is no longer the most significant criterion. More- sence of an intrauterine gestational sac or pseudo gestat-
over, pain might be of various types. Lower abdominal ional sac and the presence of serum hCG values higher
pain alone is often experienced on the side in which the than 1,000 mU/L, an abnormal pregnancy is very likely.
tubal pregnancy occurs. Pain mimicking labor is attribut- In cases of hCG titers >2,000 IU/L, intrauterine pregnan-
ed to tubal contractions. Approximately every tenth pa- cy can be diagnosed with certainty. On transabdominal
tient reports pain (indicative of a tubal pregnancy) even sonography, a pseudo gestational sac is occasionally mis-
before a missed period. In addition to strong lower ab- interpreted as a genuine gestational sac. However, this
dominal pain, perforations are also associated with a rarely happens on transvaginal sonography which has a
characteristic pain in the shoulder, the latter being caused higher resolution. The diagnostic reliability of vaginal
by irritation of the phrenic nerve. Generally speaking, sonography is reported to be around 95% [4].
pain in ectopic pregnancy is not very informative in The hCG titer is the most important laboratory param-
terms of differential diagnosis. eter. In a normal intrauterine pregnancy, the hCG titer
The first step is to confirm pregnancy, by testing for should rise by at least 60% in 48 h, until a titer of
human chorionic gonadotropin (hCG) in the urine. The 50,000 IU/L serum is achieved. Although a 50–60% in-
quick tests detect the presence of 10–25 mU/mL in the crease with 2 days was observed in normal pregnancy, a
serum and may therefore be regarded as fairly reliable. less than 60% increase is very likely to be a sign of ab-
Subsequent management is decided on the basis of pain. normal pregnancy (either an abnormal intrauterine preg-
As mentioned earlier, the clinical symptoms of ectopic nancy or a tubal pregnancy). A falling hCG is a definite
pregnancy vary. A routine gynecological examination sign of an abnormal pregnancy, regardless of whether it
with a speculum and bimanual palpation are obligatory. is ectopic or intrauterine.
Speculum examination demonstrates bleeding from the The second important parameter is progesterone. A
cervical canal as well as changes in the opening of the progesterone level <5 ng/mL is a fairly definite sign of
uterus indicative of abortions. Bimanual palpation is of an abnormal pregnancy. Values >25 ng/mL indicate a
significant importance to clarify any regidity in the normal pregnancy, while values between these limits are
lower abdomen. equal [7].
Tubal pregnancy may be characterized by a tender ad- Previously, laparotomy was indicated when an aspi-
nexal mass measuring 3–7 cm in diameter. Tenderness ration of the pouch of Douglas was positive. However,
may also be present on the contralateral side. aspiration of the pouch of Douglas has been largely re-
A typical sign of ectopic pregnancy is cervical excita- placed by never diagnostic procedures such as vaginal
tion which is also present with inflammatory diseases, ultrasonography. If the absence of an intact intrauterine
amenorrhea, or abdominal bleeding with pain should pregnancy has already been established by other diag-
arouse suspicion of an ectopic pregnancy. The same is nostic criteria, a potential ectopic pregnancy might be
true for tender or non tender adnexal tumors for women detected by curettage. If chorionic villi are found at the
referred to the gynecologist in a state of shock. The em- histological examination, the patient has an abnormal
phases must be in blood pressure, heart rate, temperature intrauterine pregnancy or may even have suffered an
and hematocrit count. abortion. Only in the very rare case of a heterotopic
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pregnancy does an intrauterine pregnancy occur in con- life, salphingectomy being the most commonly used pro-
junction with a tubal pregnancy. Although heterotopic cedure. Since the 1950’s, salpingotomy and salpingosto-
pregnancies are rare, they should be considered even in my have been used to preserve of tubal function. In both
the presence of histologically proven chorionic villi, al- procedures, an incision is made over the bulging anti-
though such cases may be very difficult to diagnose. In mesenteric surface, directly above the pregnancy, and the
rare cases, ultrasonography might demonstrate an intact latter is removed. While the wound is closed in salpin-
intrauterine pregnancy in conjunction with a painful ec- gotomy, it is left to heal by secondary intention in salpin-
topic pregnancy in the adnexal region. Such heterotopic gostomy. Following either technique, the tube may retain
pregnancies are very rare (1–30,000). Only in patients its normal function.
undergoing in vitro fertilization do heterotopic pregnan- Tubal pregnancy was first managed by laparoscopy in
cies occur at a higher rate, more so in recent years (ap- 1973 [17]. The trophoblast was expelled from the tube
proximately 30 out of 2,500). Attempts have been made by milking and then aspirated. This technique is relative-
to evaluate tubal pregnancy by using other serum pa- ly simple, as it require no incision [11, 12]. However, the
rameters such as Ca 125, Ca 19-9 or creatinine kinase as incidence of subsequent tubal pregnancy appears to be
a marker of destroyed muscle cells. However, experi- higher, as squeezing nearly always injures the tubal mu-
ence has shown that these parameters are not clinically cosa and the procedure is also liable to cause hemor-
useful. rhage. Moreover, especially advanced pregnancies are
The most important differential diagnosis of ectopic not confined to the lumen but also develop involve the
pregnancy is early intrauterine pregnancy. Secondary endosalpinx and the serosa, which makes it difficult to
amenorrhea, the absence of an intrauterine gestational achieve complete evacuation of the products of concep-
sac and the presence of a cyst in the adnexal region, e.g., tion.
a corpus luteum of pregnancy, might make it difficult to For the first time in 1982 [14], a tubal pregnancy was
diagnose an ectopic pregnancy. In some cases, abortion managed by medication alone (local instillation of meth-
or abnormal intrauterine pregnancy cause symptoms otrexate) [15]. Subsequently, prostaglandins, hyperosmo-
similar to those of tubal pregnancy. Free fluid in the lar glucose solution and NaCl were used for medical
pouch of Douglas has been observed in abortions as well treatment of tubal pregnancies. In all cases, the aim is lo-
as tubal pregnancies. Falling serum hCG titers occur in cal destruction of the products of conception and their
abnormal pregnancy as well as in inactive or spontane- absorption. A transition from radical surgery (tubecto-
ously resolving tubal pregnancies. Only the presence of my) to preservation of the tube was made during this
chorionic villi in the curettings suggests an abortion with time. Improved diagnostic procedures make it possible to
heterotopic pregnancy as a remove possibility. detect and treat unruptured tubal pregnancies before
Acute appendicitis in early pregnancy is rare. Typical hemorrhage into the abdominal cavity occurs [9].
clinical symptoms are tenderness over MacBurney’s Regardless of the therapeutic strategy selected by the
point and a normal hCG and/or progesterone level on the physician, informing the patient is a major aspect of the
one hand, or leukocytosis and high fever on the other. In management of ectopic pregnancy. Except for acute situ-
this setting, free fluid in the abdomen could also be due ations, which do occasionally occur even today, in most
to strong peritoneal irritation. Ultrasonography is used to cases there is enough time to discuss future pregnancy
differentiate between this condition and an early ectopic and the proposed mode of treatment with the patient. If
pregnancy. surgery is considered appropriate, the patient must be in-
Atypical breeding from the cervical canal in cervical formed about the nature, side effects and complications
pregnancy, and a palpable mass in the adnexal region in of the procedure. However, it should be remembered that
cornual pregnancy, might be signs of atypical location of in some cases, the actual chances of cure first become
an ectopic pregnancy. As a rule, the rare condition of an apparent at surgery.
interstitial pregnancy can be accurately located by ultra- In asymptomatic patients with a serum hCG titer
sonography. <1,000 IU/L that is falling, it is appropriate to wait and
The diagnosis of heterotopic pregnancies is a true watch. As mentioned earlier, tubal pregnancy used to re-
challenge. The patient usually comes to the physician solve spontaneously in the past, but are diagnosed more
with lower abdominal pain. Laboratory studies reveal often today. The patient should be monitored both clini-
normal, steadily increasing hCG and progesterone titers. cally as well as by ultrasonography. However, 4–6 weeks
The only unusual finding might be an atpyical course of may lapse before no hCG is detectable in serum. This
the hCG titer in the first weeks – an initial strong in- option is relatively laborious, as it involves intensive
crease following by a fall to normal values. monitoring and regular measurements of the serum hCG
titer. Approximately one third of cases so managed even-
tually do require surgery.
Clinical management and therapy In clinically stable patients with an unruptured tubal
pregnancy and steady hCG levels, systemic treatment
The clinical management of ectopic pregnancy has un- with methotrexate might also be considered. The dose is
dergone significant change in the last 30 years. Open usually 1 mg methotrexate per kilogram body weight,
surgery used to be the only means of saving the mother’s administered as intramuscular injections on day 1 and 2.
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If a single dose is used, 50 mg are used per m2 of body although some (Feichtinger and Kemeter [6]) have de-
surface. Methotrexate is easier to handle than other sub- scribed guided aspiration of the pregnancy with the aid
stances such as etoposide, RU 486 and anti-hCG anti- of vaginal sonography in selected patients. This strategy
bodies. Although RU 486 (mifepristone) was initially is also suitable for the management of rare heterotopic
promising, subsequent experience did not fulfil expecta- pregnancy.
tions, so that its use in ectopic pregnancy was no longer Generally speaeking, the currently widespread lapar-
studied. Methotrexate is a folic acid antagonist. It inhib- oscopic surgical treatment of the fallopian tube hardly
its the spontaneous synthesis of purines and pyrami- influences the risk of recurrence. If the gestational mass
dines, thus interfering with DNA synthesis and cell mul- is larger, the serum hCG titer higher than the approxi-
tiplication. Highly active trophoblasts were shown to be mately limit of 2,500 mU/mL and/or the tube already
vulnerable to methotrexate many years ago. If the preg- ruptured, surgery is usually required. In women who de-
nancy is advanced, the embryo already has a diameter of sire further children and require surgery for ectopic preg-
3–4 cm and abdominal hemorrhage is evident, or an ex- nancy, care should be taken to ensure preservation of the
trauterine heart beat detectable, methotrexate should not tube – a goal that can be achieved even after rupture of
be used. In cases of a demonstrable heartbeat, systemic the tube. [16]
therapy is generally regarded as being inappropriate. In unruptured tubal pregnancy, linear tubostomy (sal-
Chemotherapy is also contraindicated in women in pingostomy) has been established as the appropriate
whom laparoscopy is required for the diagnosis. treatment. In some cases, a tubostomy may be performed
Methotrexate is toxic and precautions should be taken even after a rupture, provided the tubal wall is not exces-
against this of side effect. The patient must be informed sively damaged. Alternatively, in order to avoid further
in detail, as she may experience pain in the course of intraoperative bleeding, a diluted vascular astringent
treatment, usually between the third and seventh day. In- (e.g. Por8) may be injected into the tubal pregnancy.
deed, even a tubal rupture cannot be ruled out. However, it should be borne in mind that the effect is
Methotrexate may be supplemented by of 0.1 mg/kg markedly reduced after approximately 2 h and bleeding
intramuscular leucovorin [19]. Regular monitoring of se- may start again. In linear tubostomy, a longitudinal inci-
rum hCG is absolutely necessary, until no hCG is detect- sion (up to 2 cm) by microscissors or laser is made over
able in serum. It might be repeat the methotrexate or to the bulging antimesenteric surface above the gestational
switch to surgical therapy. Regarding systemic side ef- mass. Thereafter, the trophoblastic material is removed.
fects, high doses of methotrexate are known to cause alo- The procedure is similar to that used for the removal of
pecia, photosensitivity, bone marrow suppression, stoma- cysts. Once hemostasis is achieved, the wound is either
titis, pulmonary fibrosis and acute hepatotoxicity. Col- closed with sutures (large incision) or left to heal by sec-
icky pain may occur in the first 2–3 days of methotrexate ondary intention (smaller incision). The wound usually
therapy. The patient must be informed about these side heals within a few weeks and without complications
effects. However, these side effects are rare during the such as fistulas or adhesions. More than 95% of cases re-
relatively short treatment schedule used in ectopic preg- quire no further treatment. Subsequent patency of the
nancy. Moreover, they can be attenuated by the adminis- tubes is ensured in approximately 75% of cases, as sub-
tration of leucovorin. The success rates of methotrexate sequent hysterosalpingographies have shown. In case the
therapy are approximately 94%. Patency of the fallopian patient develops a further tubal pregnancy, the procedure
tubes is restored in about 80% of patients. Approximate- may be repeated. Even in tubal pregnancies located in
ly 60% of patients who desire a further pregnancy to be- the infundibulum (about 5%) an incision can be made
come pregnant. However, a further ectopic pregnancy through the fimbria and the infundibulum, and the prod-
may be expected in 7–8%. ucts of conception removed. Again, the incision may be
Hajenius et al. [8] compared systemic methotrexate closed or left to heal. Ampullary pregnancy may be man-
therapy with laparoscopic salpingostomy and showed aged by performing an oblique wedge-shaped incision
that, both methods produce comparable and good results which can be used to anastomose the tube in one or two
(primary success of treatment, 72–82%). layers. Thus, subsequent passage of oocytes is ensured.
In unruptured tubal pregnancy with an hCG titer be- If the gestational mass is located in the proximal isth-
tween 1,000 and 2,500 [7, 8, 11], a further therapeutic al- mus, as is the case in 10–15% of ectopic pregnancies, a
ternative is intratubal injection of prostaglandins, hyper- tubostomy is difficult to perform and also less prudent,
osmolar glucose or NaCl [2, 5, 21]. Prostaglandins cause as hemorrhage in this location is more difficult to con-
strong contractions of the tubal wall and, with a high de- trol. The narrowness of the tubal lumen favors subse-
gree of probability, damage and even expel the products quent scars as well as distortion and obstruction of the
of conception. The dose of prostaglandins is 5–10 mg tube. In such cases, partial tubectomy followed by a sin-
(PGF2), with a success rate of approximately 80% [3]. gle-layer end-to end-anastomosis is usually the method
Side effects are cardiac arrhythmia and pulmonary ede- of choice. However, if the function of tube is damaged to
ma [20]. Lang et al. [10] showed that the instillation of start with, or the size and location of the tubal pregnancy
up to 20 mL of hyperosmolar glucose causes local necro- do not permit preservation of the complete organ, a tu-
sis and destruction of the product of conception. When bectomy may be performed. However, this is unfavor-
these methods are used, access is usually by laparoscopy, able to the extent that the function of the contralateral
92

tube is also impaired in 50% of patients with a tubal 3. Carson S, Buster J (1993) Ectopic pregnancy. N Engl J Med 329:
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4. Chambers SE, Muir BB, Haddat NG (1990) Ultrasound evalu-
precedes a tubal pregnancy, usually affects both tubes. ation of ectopic pregnancy including correlation with human
Therefore, tubectomy is generally not effective in reduc- chorionic gonadotropin level. Br J Radiol 63:246–250
ing the risk of recurrent ectopic pregency. In tubectomy, 5. Egarter Ch, Husslein P (1988) Treatment of tubal pregnancy
the tube and the gestational mass are removed. The sur- by prostaglandins. Lancet II:1104–1105
6. Feichtinger W, Kemeter P (1987) Conservative treatment of
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10 mm). Very large specimens are removed by morcella- ic control and methotrexate injection. Lancet 1:381–382
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comparative study of the treatment of tubal pregnancy by
Postoperative management consists of general con- pelviscopic surgery or prostglandin injection. Geburtshilfe
trols such as blood tests and hCG monitoring until no Frauenheilkd 52:536–538
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mation or, in cases of preexisting inflammation, to ad- ment of ectopic pregnancy. A preliminary report. J Reprod
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tibiotics such as tetracycline or cephalosporins. The Cen- Langer R, Arieli S, Caspi E (1989) Tubal patency after local
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this regard (200 mg 3×1, orally, /or up to 3×2 g i.v.). The 16. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA (1986)
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