Ectopic pregnancy

Disease Description (Causes and Symptoms)

• Definition summary: A condition in which a fertilized egg implants somewhere other than inside the uterine cavity. Approximately 95% implant in the fallopian tube (tubal pregnancy), and rarely in the ovary, abdominal cavity, cervix, or other locations.
• Causes/risk factors: Pelvic inflammatory disease (PID), previous tubal or abdominal surgery, history of ectopic pregnancy, increased proportion of ectopic pregnancies when pregnancy occurs while using an intrauterine device (IUD), assisted reproductive technology (ART), smoking, endometriosis, and anatomical abnormalities of the uterus or fallopian tubes, among others.
• Pathophysiology: As the fertilized egg implants in the fallopian tube or elsewhere, tissue proliferates. Because the fallopian tube cannot stretch easily, this can gradually cause vascular invasion and bleeding and eventually lead to tubal rupture and intra-abdominal bleeding (hemoperitoneum).
• Main symptoms: Lower abdominal pain (dull or acute), abnormal vaginal bleeding (persistent light bleeding or acute bleeding), dizziness, tachycardia, pallor, cold sweats, and rapid breathing (signs of hemorrhagic shock). In the early stage, it can be difficult to distinguish from a normal pregnancy or miscarriage because of a delayed period, persistent abdominal pain, and light bleeding.
• Diagnostic clues: Blood β-hCG increases more slowly or plateaus compared with a normal intrauterine pregnancy (for example, failure to double within 48–72 hours raises suspicion). If a gestational sac is not visible in the uterus on transvaginal ultrasound despite β-hCG being approximately 2,000 mIU/mL or higher, ectopic pregnancy is suspected.

Treatment Methods

• Classification according to stability: (1) Stable (no tubal rupture, slight bleeding, small lesion, low or slowly rising β-hCG) — medical treatment may be considered (2) Unstable or suspected rupture — emergency surgery is required.
• Medication treatment:
  • A single-dose or multidose regimen of methotrexate (MTX) is standard. Indications: the patient is stable, criteria such as lesion size and cardiac activity are met, and the β-hCG level can be monitored. Immediate and follow-up β-hCG tests are needed to assess effectiveness. When pregnancy is recommended to be attempted again, contraception is advised for a certain period (usually 3 months).
  • Precautions: Contraindications such as liver or kidney disease, bone marrow suppression, and current folic acid use should be reviewed.
• Surgical treatment:
  • Laparoscopic surgery (preferred): The choice between salpingectomy and salpingostomy is made depending on the lesion and whether fertility preservation is desired.
  • Laparotomy: Used in cases of massive bleeding, intra-abdominal hematoma, complex lesions, or when laparoscopy is not possible.
  • In the event of rupture, emergency salpingectomy and bleeding control are required.
• Emergency treatment:
  • In hemorrhagic shock, IV fluids, blood transfusion, and emergency surgery are required.
  • Administration of Rh immune globulin (RhoGAM) is recommended for Rh-negative mothers in the event of bleeding or a procedure.
• Follow-up care:
  • After treatment, serially measure β-hCG until it is negative (at an undetectable level) to confirm complete resolution.
  • Counseling on future pregnancy plans (risk of recurrence and recommendation for early ultrasound).
• Lifestyle management:
  • If severe abdominal pain, fever, heavy bleeding, or other symptoms occur after treatment, visit the emergency room immediately.
  • When using methotrexate, follow instructions such as avoiding alcohol, folic acid supplements, and pregnancy.

Checklist Before an Outpatient Visit (Items to Bring and Sample Questions)

• Items to bring:
  • A list of all medications and supplements currently being taken
  • Past medical history (especially pelvic surgery, tubal surgery, and intrauterine device history) and pregnancy history (previous ectopic pregnancy, miscarriage, or infertility treatment)
  • Recent test results, if available (pregnancy tests, blood tests, ultrasound images/reports)
  • The first day of the last menstrual period (LMP) and notes on when symptoms began (amount of bleeding and nature of pain)
• Self-recording recommended before the outpatient visit:
  • Location and intensity of pain (pain scale), amount and color of bleeding, presence or absence of dizziness or fainting, changes in urination, etc.
• Sample questions (prepared questions a patient may ask the doctor):
  • Do the medications I am currently taking affect the choice of treatment?
  • When are tests needed, and at what intervals?

General Sample Questions to Ask the Doctor

• What treatment options are available to me for this condition? (Medication vs. surgery)
• What side effects and precautions should I expect when using methotrexate?
• How will β-hCG follow-up be conducted after treatment, and how long will it take?
• What preparation and preventive measures are needed when I want to become pregnant in the future?

Disease-Specific Sample Questions

• Based on my case (β-hCG level · ultrasound findings · condition of the fallopian tubes), is methotrexate appropriate, or is surgery recommended?
• From the perspective of fertility (future pregnancy), which is more advantageous: fallopian tube-conserving surgery (salpingostomy) or salpingectomy?

(Summary for reference: Ectopic pregnancy occurs in approximately 1–2% of pregnancies, with implantation occurring in the fallopian tube in most cases. Because early symptoms are nonspecific, rapid diagnosis using β-hCG and transvaginal ultrasound and appropriate treatment improve the prognosis. Sudden severe abdominal pain, hypotension, fainting, and similar symptoms suggest tubal rupture and require emergency treatment.)