••• Chapter 29^ Ectopic Pregnancy^283
❍ If the hCG level is <3000 mIU/mL and rising abnormally, what diagnostic test(s) can be used to confirm the
diagnosis of ectopic pregnancy?
If the woman is not symptomatic, the options are as follows: continue to follow the hCG level until it reaches the
diagnostic level and repeat the transvaginal ultrasound or perform a diagnostic dilation and curettage (D & C) to
rule out an abnormal intrauterine pregnancy. If symptomatic, diagnostic laparoscopy can be performed.
❍ Does the presence of a thick endometrial stripe indicate an intrauterine pregnancy?
The endometrium can be thickened due to the hormonal stimulation associated with either an ectopic or
intrauterine pregnancy, so this is not a consistent sign of a normal pregnancy.
❍ Does the presence of a gestational sac always rule out an ectopic?
Up to 15% of women with an ectopic pregnancy can have a “pseudosac” or fluid area (representing blood and
mucus) within the cavity. Therefore, it is critical with women at high risk of an ectopic pregnancy to confirm an
intrauterine pregnancy with a follow-up ultrasound. This ultrasound will identify the yolk sac (“double ring sign”)
or fetal pole within the gestational sac.
❍ Is Doppler flow ultrasonography useful in the diagnosis of ectopic pregnancy?
Doppler flow may show variation in tubal blood flow in the case of a tubal pregnancy. It may also be useful in
identifying the presence and location of a cervical pregnancy.
❍ At what gestational age, does tubal rupture most commonly occur?
Rupture of an ampullary ectopic typically occurs at 8 to 12 weeks, allowing adequate time for early diagnosis and
treatment prior to rupture in most cases. Isthmic ectopics may rupture earlier at 6 to 8 weeks.
❍ What type of ectopic pregnancy has the highest mortality rate?
Although a rare site of an ectopic pregnancy, the highest mortality rate occurs with cornual pregnancies.
❍ Should women with ectopic pregnancies be given RhoGam?
Most authors recommend administration of RhoGam with any failed pregnancy in an Rh-negative patient. A
“mini” dose of RhoGam (50 mg) may be given up to 12 weeks or alternatively full-dose RhoGam (300 mg) may be
given at any time.
❍ What are the indications for laparotomy in the treatment of ectopic pregnancy?
Common indications for laparotomy include an unstable patient, large hemoperitoneum, and lack of appropriate
surgical tools for laparoscopy. An interstitial pregnancy can most often be treated laparoscopically but occasionally
will require laparotomy for resection. Some authors would also include a large ectopic (>6 cm) and fetal heart
tones in the adnexa as indications of laparotomy.
❍ Is there an advantage in removing the ipsilateral ovary when the tube must be removed?
In the past, the ovary was removed with the tube to promote fertility, but conception rates are not different if the
ovary is removed or retained. Fertility is theoretically delayed, as ovulation occurs half the time on the side without
a tube.