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子宮外孕的機率佔所有懷孕的 0.5~1%
位於輸卵管的子宮外孕 > 95 %
近年來因為人工受孕技術, 子宮外孕機率顯著上升
若是同時有子宮內懷孕以及子宮外孕
稱為合併妊娠 (Heterotopic pregnancy)
在一次子宮外孕後的下一次懷孕中
10~28% 機率為子宮外孕
50~80% 的機率為子宮內懷孕, 剩下的則為不孕
Triad :
- Abdominal pain
- Vaginal bleeding
- Delayed menstrual cycle (Typical : LMP 後 6-8 W)
(No missed menses are reported in 15% of ectopic pregnancy cases.)
* The majority of patients with ectopic pregnancy have no identifiable risk factors
* Pelvic, adnexal, cervical tenderness
Peritoneal sign, Shock sign if ruptured
Normal vital signs do not rule out ruptured ectopic pregnancy.
* Hemoperitoneum, Cullen' s sign
* Pregnancy test, Beta HCG
* TVS : Adnexal mass, Fluid accumulation
Qualitative tests in clinical use are typically reported as “positive”
when the β-hCG concentration is ≥20 mIU/mL in urine
and ≥10 mIU/mL in serum.
At this level of detection, the false-negative rate for detection of pregnancy
will not be >1% for urine or 0.5% for serum.
In clinical use, the performance of urine qualitative testing is 95% to 100% sensitive
and specific compared withserum tests.
Perform a quantitative serum test if ectopic pregnancy
is still considered after negative urine test
The sensitivity of quantitative serum testing
for the diagnosis of pregnancy is virtually 100%
when an assay capable of detecting ≥5 mIU/mL of β-hCG is used.
真正的懷孕日期和懷孕週數差了兩周
ex : 1/1 LMP, 1/14 受孕, 1/29 月經沒來
實際懷孕時間是兩周, 但 LMP 是 4 周了
所以驗 HCG 會是 2-3 weeks (100-5000)
1. 超音波 :
正常懷孕時, TVS 在懷孕 4 週 可看到妊娠囊
TAS 則要在懷孕 5 週 才看的到妊娠囊
以下的幾種情況可以懷疑是子宮外孕：
(1) 懷孕 6 週 仍無法從 TVS, TAS 看到子宮內的妊娠囊
(2) Blood β-hCG > 1500 mIU/mL, TVS 無法看到胚囊
可懷疑子宮外孕 (Discriminatory zone = 1500)
IUP should be detected at b-hCG of 1500mIU/ml (vaginal US);
6000mIU/ml (abdominal US)
6000mIU/ml (abdominal US)
(3) 可在子宮外部看到有妊娠囊或胚胎
(4) 驗孕呈現陽性反應, 但無法在子宮內找到妊娠囊並合併有子宮外積液
2. β-hCG :
正常懷孕血液中 β-hCG 每隔 2 天會呈倍數增長
(Doubles every 2 days early in a normal pregnancy)
若是隔2天抽血的結果 β-hCG 成長 < 66%
應懷疑有子宮外孕的可能, an increase of >53% does not rule out ectopic pregnancy.
Urine BhCG are unreliable (false negatives early in pregnancy).
Always obtain serum BhCG.
There is no BhCG level or series of BhCG levels at which ectopic can be ruled out.
Ectopic pregnancy may present with rising, falling or plateau, or even zero β-hCG levels.
3. 子宮擴刮術 (D&C) :
若病人驗孕呈陽性, 合併持續性出血, 超音波又找不到胚囊
可以 D&C 清除子宮內組織化驗
若在子宮內可找到殘餘絨毛或胚胎組織, 就代表這是早期流產而排除子宮外孕
若 D&C後, β-hCG 仍持續上升, 要懷疑是子宮外孕
MTX (Methorexate)
hemodynamic stability, minimal abdominal pain, the ability to follow up reliably,
and normal baseline liver and renal function tests.
抑制 DNA 合成而使胚胎死亡
MTX適應症包括
- 子宮外孕週數 < 6 週
- 胚胎囊 < 3.5公分
- β-hCG < 5000 mIU/L
治療子宮外孕時, 使用的劑量較低, 時效較短, 所以副作用不大
也不會造成自發性流產, 先天性畸形或腫瘤
使用到 β-hCG < 10 mIU/L 可停用
Lower abdominal pain lasting up to 12 hours is common 3 to 7 days after methotrexate treatment
and is thought to be secondary to methotrexate-induced tubal abortion
or tubal distention due to hematoma formation (“separation pain”).
Methotrexate
Unruptured ectopic pregnancy
Hemodynamic stability
No severe or persisting abdominal pain
Normal baseline liver and renal function test results
Absolute contraindications :
Existence of an IUP
Immunodeficiency
Moderate to severe anemia, leukopenia, or thrombocytopenia
Sensitivity to methotrexate
Active pulmonary or peptic ulcer disease
Clinically important hepatic or renal dysfunction
Breast feeding
Evidence of tubal rupture
* Medication Relative contraindications :
Sonogram findings of an ectopic gestational sac > 4cm in size
(or 3.5cm, if the ectopic pregnancy has fetal heart motion)
An initial β-HCG > 5000 mIU/Ml
Significant free fluid
Fetal cardiac activity
2. 手術：
分為保守性的輸卵管造口術 (Salpingostomy)
根除性的輸卵管切除術 (Salpingectomy)
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