A Study of Ruptured Tubal Ectopic Pregnancy DANNY SAXON, MD, TOMMASO FALCONE, MD, EDWARD 1. MASCHA, MS, TERESA MARINO, MD, MYLENE YAO, MD, Objective: Ectopic pregnancy continues to be a leading cause of maternal morbidity and of reduced childbearing potential among women of reproductive age. Because of tubal rupture, it is still the main cause of pregnancy-related death during the first trimester. The purpose of our study was to evaluate factors that may predispose a woman to rupture of a tubal ectopic pregnancy. Methods: In this retrospective study of 693 ectopic preg- nancies from three McGill University teaching hospitals, we compared risk factors, preoperative ultrasound, and serum hCG levels between cases with ruptured and unruptured tubal ectopic pregnancy. Results: The age and the number of pregnancies among the two groups of women were similar. The gestational age of women with an unruptured tube was 6.9 2 1.9 weeks, and of those with a ruptured tube, the gestational age was 7.2 f 2.2 weeks. Tubal rupture was encountered more often in women with at least one child than in childless women. History of ectopic pregnancy was found in 35% of women with an unruptured tubal pregnancy and in 26% of those with a ruptured tube. Serum hCG levels at the time of treatment were not significantly different among the two groups of women. Eleven percent of women with a ruptured tube had serum B-hCG levels of less than 100 II-J/L. Conclusion: Tubal rupture is encountered more often in women with no history of ectopic pregnancy and in those with at least one child. This suggests that ectopic pregnancy is less suspected in these women. Tubal rupture is encoun- tered less often in ampullary pregnancy and in small ectopic pregnancies. There is no correlation between serum B-hCG levels and tubal rupture, and rupture can occur even when serum B-hCG levels are very low. (Obstet Gynecol 1997;90: 46-9. 0 1997 by The American College of Obstetricians and Gynecologists.) The Centers for Disease Control and Prevention esti- mated a rate of 19.7 ectopic pregnancies per 1000 reported pregnancies.’ In 1992, ectopic pregnancy- From the Department qf Obstetrics and Gynecology, McGil/ Univer- sity, Mantreaf, Quebec, Canada; and the Departments oJGynecology and Obstetrics and Biostatisfics and Epidemiology, Cleveland CIinic Foun- dation, Cleveland, Ohio. Funded in part with a grant from Ethicon Endosurgery. 46 0029-7844/97/$17.00 PI1 SOO29-7844(97)00180-4 AND TOGAS TULANDI, MD related deaths made up 9% of all maternal deaths,’ and most of these deaths were due to tubal rupture. Accord- ingly, prevention of tubal rupture would have a great impact on gynecologic morbidity and mortality and on decreasing the costs associated with surgery and hos- pitalization. If tubal rupture could be predicted, a system of surveillance could be effected especially for those at highest risk. One study3 showed that absolute serum /3-hCGlevels were not helpful in predicting tubal rupture. The purposes of our study were to examine the association between rupture of tubal ectopic pregnancy and demographic risk factors and to evaluate tests that might aid in predicting tubal rupture. Materials and Methods A chart review of all tubal ectopic pregnancies diag- nosed and treated at McGill University’s three teaching hospitals (Royal Victoria Hospital, Sir Mortimer B. Davis Jewish General Hospital, and Montreal General Hospital) from 1984to 1994was conducted. All hospital record admission and discharge forms were in the same format, designated by the provincial regulatory board. A total of 716 reports of ectopic pregnancies were available. Rupture status was known for 693 pregnan- cies from 642 women. Multiple admissionsfor the same ectopic pregnancy were treated as one episode and the data recorded at the time of treatment were abstracted. Six hundred six women had only one ectopic pregnancy treated during the study period, 26 women had two, seven women had three, two women had four, and one woman had six. A total of 234 ruptured ectopic preg- nancies were reported, leaving 459 women with unrup- tured tubal pregnancies. The diagnosis of a ruptured tube was based on clinical and ultrasound examination and confirmed at the time of surgery. The following information was recorded: age, gravid- ity, parity, number of abortions, gestational age, serum quantitative p-hCG concentration, preoperative and postoperative hemoglobin concentrations, previous risk Obstetrics & Gynecology