Ectopic pregnancy occurs in about 1% of pregnant women. This early pregnancy complication may be life-threatening and adversely affect future fertility. The ability to diagnose this condition before it has deteriorated has changed it from a life-threatening disease into a more benign manageable one. This article reviews changes during the past century in the diagnostic and therapeutic management of ectopic pregnancies.
At the beginning of the 20th century, the first diagnostic tool was surgery, initially laparotomy. With the adoption of laparoscopy as a mainstream gynecology procedure decades later, the diagnosis became timelier and less morbid. In the 1970s, a nonsurgical diagnostic strategy was developed to manage ectopic pregnancies using a combination of high-resolution ultrasonography and sensitive serum human chorionic gonadotropin (hCG) assays. Advances in diagnostic ultrasonography have resulted in expansion of the diagnosis ectopic pregnancy into multiple categories related to their appearance on ultrasound; these include viable ectopic pregnancy, ectopic mass, and pregnancy of unknown location.
With respect to treatment, management in the beginning of the 20th century limited to mostly symptomatic women was salpingectomy by laparotomy. At present, laparoscopy is generally used in the surgical treatment of tubal ectopic pregnancies, either by salpingectomy or by salpingotomy. An alternative nonsurgical treatment option is use of systemic methotrexate for women with an ectopic pregnancy and no signs of active bleeding who present with low initial serum hCG concentrations.
Ectopic pregnancies in women with low and plateauing serum hCG concentrations may resolve spontaneously. Expectant management may be considered for such low-risk ectopic pregnancies. Obstetricians now follow national guidelines and local protocols for the diagnosis of ectopic pregnancy.
This review shows that the severity of ectopic pregnancies has not changed in the last 4 decades, but the use of new tools (transvaginal ultrasound and serial hCG measurement) has enabled earlier diagnosis and treatment, with substantially improved outcomes.
Department of Obstetrics and Gynecology (N.M.v.M., W.M.A., B.W.M., P.J.H.) and Centre for Reproductive Medicine, Academic Medical Centre (F.M., F.v.d.V.), University of Amsterdam, Amsterdam, the Netherlands