异位妊娠

当存在客观的缓解证据时——通常通过 hCG 水平维持平稳或降低来证明，其适用于低风险、血流动力学稳定的无症状患者（或伴极轻微的疼痛）。 [40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com 在英国，英国皇家妇产科医师学会 (RCOG) 推荐，一开始降低的 hCG 水平<1500 IU/L (1500 mIU/mL) 时，期待疗法是一种选择。[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com 在初始 hCG 水平< 200 IU/L (<200 mIU/mL) 的患者中，88% 将自发缓解，且 hCG 水平越高，预期缓解率越低。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[58]Korhonen J, Stenman UH, Ylöstalo P. Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy. Fertil Steril. 1994 Apr;61(4):632-6.http://www.ncbi.nlm.nih.gov/pubmed/8150103?tool=bestpractice.com

认为 71.2%-94.2% 有效。[59]van Mello NM, Mol F, Verhoeve HR, et al. Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison. Hum Reprod. 2013 Jan;28(1):60-7.https://academic.oup.com/humrep/article/28/1/60/596638http://www.ncbi.nlm.nih.gov/pubmed/23081873?tool=bestpractice.com

应连续测定 hCG 水平，直至达到不可测的水平。

期待疗法失败后，要进行药物（如果适用）或者手术治疗。如果患者疼痛加重，hCG 水平没有降低或有输卵管破裂的体征，则应停止期待治疗。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com

在临床上稳定且异位妊娠未破裂的患者中，腹腔镜手术和药物治疗都是合理的治疗选择，并且应该通过初始检查以及与患者的讨论来指导决策。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com

对于血流动力学稳定的患者可选择药物治疗，这些患者确诊或高度临床怀疑为异位妊娠、有未破裂的肿块，并且无甲氨蝶呤绝对禁忌证。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com 在英国，RCOG 还推荐适合该治疗的患者应为：hCG 值＜1500 IU/L (1500 mIU/mL)，但其最高可达 5000 IU/L (5000 mIU/mL)，且超声扫描无胎心活动，确定无宫内妊娠。[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com

已有证据表明，初始血清 hCG 水平＞5000 mIU/mL 预计药物治疗（特别是单次给药方案）的失败率增加，[49]Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril. 2008 Nov;90(5 Suppl):S206-12.http://www.fertstert.org/article/S0015-0282(08)03510-3/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/19007632?tool=bestpractice.com[60]Menon S, Colins J, Barnhart KT. Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review. Fertil Steril. 2007 Mar;87(3):481-4.http://www.ncbi.nlm.nih.gov/pubmed/17173905?tool=bestpractice.com 并且美国生殖医学学会 (American Society of Reproductive Medicine) 指出，初始 hCG 浓度高是甲氨蝶呤治疗的相对禁忌证。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[61]Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013 Sep;100(3):638-44.http://www.ncbi.nlm.nih.gov/pubmed/23849842?tool=bestpractice.com

异位妊娠大小＞4 cm 也被认为是药物治疗的相对禁忌证，但如果异位妊娠大小＜2 cm 且 hCG 水平＜1855 IU/L (1855 mIU/mL)，则不太可能发生输卵管破裂。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[49]Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril. 2008 Nov;90(5 Suppl):S206-12.http://www.fertstert.org/article/S0015-0282(08)03510-3/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/19007632?tool=bestpractice.com[62]Karadeniz RS, Tasci Y, Altay M, et al. Tubal rupture in ectopic pregnancy: is it predictable? Minerva Ginecol. 2015 Feb;67(1):13-9.http://www.ncbi.nlm.nih.gov/pubmed/25660430?tool=bestpractice.com

其他相对禁忌证包括经阴道超声扫描发现胎心活动以及拒绝接受输血。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[49]Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril. 2008 Nov;90(5 Suppl):S206-12.http://www.fertstert.org/article/S0015-0282(08)03510-3/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/19007632?tool=bestpractice.com[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com 大多数医生除了超声所见和 hCG 值之外，还会结合具体的临床情况来确定药物治疗是否适于个体患者。

某些疾病是患者接受甲氨蝶呤治疗的禁忌证，其中包括免疫缺陷证据、肝病（转氨酶水平超过正常值的两倍）、肾病（肌酐＞132.6 μmol/L [1.5 mg/dL]）、活动性消化性溃疡病、明显的肺部疾病或血液系统异常（例如，明显贫血、血小板减少或白细胞减少）。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[49]Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril. 2008 Nov;90(5 Suppl):S206-12.http://www.fertstert.org/article/S0015-0282(08)03510-3/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/19007632?tool=bestpractice.com[63]Barash JH, Buchanan EM, Hillson C. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2014 Jul 1;90(1):34-40.http://www.aafp.org/afp/2014/0701/p34.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/25077500?tool=bestpractice.com 其他禁忌证包括宫内妊娠、母乳喂养、对甲氨蝶呤敏感以及无法进行随访。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com 

甲氨蝶呤给药后，应连续监测 hCG 水平，直至检测不到。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com 这通常需要 2-4 周，但可能长达 8 周。[66]Barnhart KT, Gosman G, Ashby R, et al. The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and "multidose" regimens. Obstet Gynecol. 2003 Apr;101(4):778-84.https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0020120/http://www.ncbi.nlm.nih.gov/pubmed/12681886?tool=bestpractice.com

在甲氨蝶呤治疗期间，应避免剧烈活动和性交，因为这可能导致异位妊娠破裂；应限制盆腔和超声扫描；并且患者应避免使用叶酸和非甾体抗炎药，因为这些会降低甲氨蝶呤的疗效。还应避免食用产气食物，因为它们可能产生与破裂症状相混淆的疼痛。日光暴露可能使发生甲氨蝶呤导致的皮炎风险增加。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com

在任何时间点，如果患者临床状况不稳定，则需要手术干预。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com 药物治疗不成功也需要手术治疗。然而，一项病例对照系列研究结果发现，对于治疗失败风险较高的病例（例如，hCG 水平较高或有胎心活动），在甲氨蝶呤全身用药之外，在超声引导下向异位妊娠注射甲氨蝶呤可安全地替代手术。[65]Wang M, Chen B, Wang J, et al. Nonsurgical management of live tubal ectopic pregnancy by ultrasound-guided local injection and systemic methotrexate. J Minim Invasive Gynecol. 2014 Jul-Aug;21(4):642-9.http://www.ncbi.nlm.nih.gov/pubmed/24462855?tool=bestpractice.com

在临床上稳定且异位妊娠未破裂的患者中，腹腔镜手术和药物治疗都是合理的治疗选择，并且应该通过初始检查和与患者的讨论来指导选择。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com

如果患者出现血流动力学不稳定的体征、异位包块破裂的症状或腹膜内出血的体征，则需要进行手术干预。如果患者对药物治疗有绝对禁忌证，也需要进行手术干预。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com

首选方法是腹腔镜输卵管造口术或腹腔镜输卵管切除术，这取决于对侧输卵管的情况和对将来生育的愿望。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com[67]Gao M-XG. Laparoscopy versus laparotomy for ectopic pregnancy: a systematic review. Chin J Evid Based Med. 2008 Jul-Aug;14(4):309-19.[68]Mol F, Mol BW, Ankum WM, et al. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update. 2008 Jul-Aug;14(4):309-19.http://humupd.oxfordjournals.org/content/14/4/309.fullhttp://www.ncbi.nlm.nih.gov/pubmed/18522946?tool=bestpractice.com[69]Hajenius PJ, Mol BW, Mol BWJ, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007;(1):CD000324.http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000324/frame.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/10796710?tool=bestpractice.com[70]Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet. 2014 Apr 26;383(9927):1483-9.http://www.ncbi.nlm.nih.gov/pubmed/24499812?tool=bestpractice.com

应在输卵管造口术后连续测定绒毛膜促性腺激素水平，直至达到不可测出的水平。输卵管切除术后，应确认妊娠试验呈阴性。

针对经选择患者组全部患者的治疗推荐

如果术后血清绒毛膜促性腺激素水平没有恢复到不可测出的水平，则给予甲氨蝶呤。

针对经选择患者组全部患者的治疗推荐

美国急救医师学会临床小组委员会 (American College of Emergency Physicians' Clinical Subcommittee) 的综述发现，无论支持还是反对在 Rh 阴性的异位妊娠女性中使用抗 D 免疫球蛋白进行治疗的证据均不足。[71]American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Early Pregnancy: Hahn SA, Promes SB, Brown MD. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2017 Feb;69(2):241-250.e20.http://www.annemergmed.com/article/S0196-0644(16)31344-0/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/28126120?tool=bestpractice.com 然而，英国国家卫生与临床优化研究所 (NICE) 推荐对所有因异位妊娠接受手术的 Rh 阴性女性患者使用抗 D 免疫球蛋白，但不推荐用于接受药物治疗的患者。[72]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. December 2012 [internet publication].http://www.nice.org.uk/guidance/CG154

首选方法是腹腔镜下输卵管造口术或腹腔镜下输卵管切除术，这取决于对侧输卵管的状态和对今后生育的愿望。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[52]Elson CJ, Salim R, Potdar N, et al; Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy: Green-top Guideline No. 21. BJOG. 2016 Dec;123(13):e15-e55.https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/http://www.ncbi.nlm.nih.gov/pubmed/27813249?tool=bestpractice.com[67]Gao M-XG. Laparoscopy versus laparotomy for ectopic pregnancy: a systematic review. Chin J Evid Based Med. 2008 Jul-Aug;14(4):309-19.[68]Mol F, Mol BW, Ankum WM, et al. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update. 2008 Jul-Aug;14(4):309-19.http://humupd.oxfordjournals.org/content/14/4/309.fullhttp://www.ncbi.nlm.nih.gov/pubmed/18522946?tool=bestpractice.com[69]Hajenius PJ, Mol BW, Mol BWJ, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007;(1):CD000324.http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000324/frame.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/10796710?tool=bestpractice.com[70]Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet. 2014 Apr 26;383(9927):1483-9.http://www.ncbi.nlm.nih.gov/pubmed/24499812?tool=bestpractice.com[Figure caption and citation for the preceding image starts]: 异位妊娠的手术摘除来自 Sina Haeri 医生收集的资料 [Citation ends].[Figure caption and citation for the preceding image starts]: 异位妊娠的手术摘除来自 Sina Haeri 医生收集的资料 [Citation ends].

在接受腹腔镜治疗的患者中，将来生育和输卵管通畅率与药物治疗患者组的近似。[40]ACOG practice bulletin no. 193: tubal ectopic pregnancy. Obstet Gynecol. 2018 Mar;131(3):e91-103.https://journals.lww.com/greenjournal/fulltext/2018/03000/ACOG_Practice_Bulletin_No__193___Tubal_Ectopic.46.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/29470343?tool=bestpractice.com[63]Barash JH, Buchanan EM, Hillson C. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2014 Jul 1;90(1):34-40.http://www.aafp.org/afp/2014/0701/p34.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/25077500?tool=bestpractice.com

应在输卵管造口术后连续测定绒毛膜促性腺激素水平，直至达到不可测出的水平。输卵管切除术后，应确认妊娠试验呈阴性。

针对经选择患者组全部患者的治疗推荐

如果术后血清绒毛膜促性腺激素水平没有恢复到不可测出的水平，则给予甲氨蝶呤。

针对经选择患者组全部患者的治疗推荐

美国急救医师学会临床小组委员会 (American College of Emergency Physicians' Clinical Subcommittee) 的综述发现，无论支持还是反对在 Rh 阴性的异位妊娠女性中使用抗 D 免疫球蛋白进行治疗的证据均不足。[71]American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Early Pregnancy: Hahn SA, Promes SB, Brown MD. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2017 Feb;69(2):241-250.e20.http://www.annemergmed.com/article/S0196-0644(16)31344-0/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/28126120?tool=bestpractice.com 然而，英国国家卫生与临床优化研究所 (NICE) 推荐对所有因异位妊娠接受手术的 Rh 阴性女性患者使用抗 D 免疫球蛋白，但不推荐用于接受药物治疗的患者。[72]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. December 2012 [internet publication].http://www.nice.org.uk/guidance/CG154

与异位妊娠破裂相关的血液动力学不稳定是由继发于失血的严重低血容量导致。

首要治疗是用等渗液和血液制品快速补充容量，避免缺血性损伤和多器官损害。

所采用的手术类型取决于外科医生的经验和判断，并要与麻醉师协商决定。

根据现有可用资源（包括经充分培训的人员）决定是否进行开腹手术是合理的，具体术式应根据出血部位而定。

针对经选择患者组全部患者的治疗推荐

美国急救医师学会临床小组委员会 (American College of Emergency Physicians' Clinical Subcommittee) 的综述发现，无论支持还是反对在 Rh 阴性的异位妊娠女性中使用抗 D 免疫球蛋白进行治疗的证据均不足。[71]American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Early Pregnancy: Hahn SA, Promes SB, Brown MD. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2017 Feb;69(2):241-250.e20.http://www.annemergmed.com/article/S0196-0644(16)31344-0/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/28126120?tool=bestpractice.com 然而，英国国家卫生与临床优化研究所 (NICE) 推荐对所有因异位妊娠接受手术的 Rh 阴性女性患者使用抗 D 免疫球蛋白，但不推荐用于接受药物治疗的患者。[72]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. December 2012 [internet publication].http://www.nice.org.uk/guidance/CG154