Ectopic Pregnancy

Well patients

• Diagnosis
• Investigations
• Management

Unwell patient

• Diagnosis
• Management

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Ectopic pregnancy – well patients

Some patients with ectopics walk calmly into the clinic & appear to be well. The ectopic may be unruptured, or ruptured but not bleeding actively.

Diagnosis

• There should be at least some mild lower abdominal discomfort
• There may or may not be abnormal vaginal bleeding – it is small in volume
• Last menstrual period usually > 4 weeks
• Possible history of prolonged unprotected intercourse without conception (subfertility – tubal factor, possible history of previous PID or STI, pelvic or tubal surgery, or a previous ectopic pregnancy)
• There should be some lower abdominal tenderness
• Cervical tenderness & adnexal tenderness should be present
• An adnexal mass is often not felt

Investigations

• Urine pregnancy test will be positive. If not test is available the diagnosis may be obvious
• Ultrasound will show an empty uterus, with or without an adnexal mass, & free fluid (blood) in the Pouch of Douglas
• Culdocentesis & paracentesis are not usually done, but withdrawal of blood is suggestive of ectopic pregnancy. Failure to obtain blood does not exclude an ectopic
• A low Hb level may assist with the diagnosis

Management

Many are managed surgically

1. Insert an IV line (14, 16 gauge)
2. FBC, U&E & Group & Hold or Cross-match (according to ward/formal Hb)
3. Ensure the blood results are received before proceeding with surgery
4. Book for laparotomy or laparoscopy. Salpingectomy/salpingostomy
5. Laparoscopy if not contraindicated is (1) to confirm the diagnosis, (2) for surgical treatment, (3) appropriate if the surgeon is confident with the equipment, & (4) NOT contraindicated if there is fluid in the POD but the patient is stable patient is stable
6. Laparoscopy the following day - if the patient is stable it is possible to admit for observation and book for lap’scope a.m..

OR….Consider medical management with methotrexate (see below)

True conservative management (observation) is an option if there is uncertainty of the diagnosis & the patient is well:

1. Take blood for beta-hCG level
2. Explain the problem to the patient, & the necessity for follow-up
3. Advise the patient to return to hospital without delay if she feels unwell
4. Follow up in two days (24-48 hours). Ectopic pregnancy is likely if:
   • The pain has increased with marked excitation tenderness
   • There is free fluid or an adnexal mass on repeat ultrasound scan
   • The hCG level is >5000 U/L on transabdominal scan with an empty uterus
   • The hCG level is >1000 U/L on transvaginal scan with an empty uterus (& no history of heavy vaginal bleeding) 

Ectopic pregnancy – unwell patient, collapsed patient

The pregnancy is likely to have ruptured & be bleeding actively

Diagnosis

• Obtain as good a history as possible, from the patient, or those accompanying her (if semi-conscious). Ask about amenorrhoea & syncope or dizziness. Read the referral letter, if there is one, ask the paramedics
• Specifically inquire about known medical conditions affecting anaesthesia/ surgery
• Localize the problem on examination by looking for guarding, rebound, distension, & cervical excitation tenderness.
• An acute abdomen in a shocked patient, with a history of amenorrhoea is an ectopic until proven otherwise
• Look for evidence of systemic infection, or septic abortion, that may present with symptoms & signs similar to ectopic pregnancy
• A catheter specimen of urine can be used for pregnancy testing
• An ultrasound scan is useful, once the patient has been stabilized although ultrasound will rarely add to the clinical picture. The typical finding is an empty uterus with free fluid and a complex adnexal mass.
• Culdocentesis may occasionally be helpful to distinguish blood from peritoneal fluid 

Management

• Resuscitate as required – BAC. Give O₂ if necessary & use two IV lines if needed (large bore 14 or 16 gauge cannulas)
• Take blood for cross-match & order red-label packed cells – up to 4 units (a ward Hb – if available, will guide the cross match)
• Urgent U&E & FBC
• Book theatre for urgent laparotomy & discuss with the anaesthetist