Ectopic Pregnancy
Ectopic Pregnancy
Epidemiology
Clinical features
Risk factors for ectopic pregnancy
Diagnosis
EC care and disposition
Decision regarding medical vs. surgical management
Bereavement support
Epidemiology
- EP occurs in 2% of all pregnancies and is the leading cause of death in the 1st trimester.
- 20% are ruptured at presentation.
- The diagnosis must be considered in every woman of childbearing age with abdominal pain.
Clinical features
- The classic triad of abdominal pain, PV bleeding and amenorrhea may be present.
- Pain may vary from sudden and extreme to relatively minor and diffuse.
- The presence of haemo-peritoneum may cause referred pain to the shoulder.
- Vital signs may be entirely normal or may indicate advanced haemorrhagic shock.
- Physical exam findings are highly variable.
- The pelvic exam may be normal, but often reveals CET, adnexal tenderness with or without a mass.
Risk factors for ectopic pregnancy
- Women with previous ectopic pregnancy
- Previous pelvic infection or pelvic inflammatory disease
- IUCD in situ
- Previous pelvic surgery – including caesarean section, tubal surgery, appendicectomy
- History of fertility problems – including assisted conception
- Progesterone only pill.
Diagnosis
- Perform a urine BHCG.
- TV ultrasound is the test of choice to identify EP.
- Sonographic findings of an empty uterus with an adnexal mass with or without free fluid.
- A BHCG level of > 6000mIU/L with an empty uterus is suggestive of EP.
- If the BHCG is <1000 then the pregnancy may be either IUP or EP, a repeat BHCG quantitative test needs to be performed in 2 days.
- A normal IUP should increase at least 66% in 48 hrs.
Emergency Centre care and disposition
- For unstable patients, start 2 large –bore IV lines for rapid transfusion of fluids or packed RBC’s to maintain an adequate blood pressure.
- Notify gynae on call immediately.
- Draw labs, rhesus and blood typing.
- For stable patients, proceed with diagnostic workup including TV ultrasound including quantitative BHCG determination.
Decisions regarding medical vs. surgical management should take into account the following inclusion criteria:
| Management method | Inclusion criteria |
| Medical | Haemodynamically stable No pelvic pain and/or tenderness On TV ultrasound, have no fetal heart activity, an un-ruptured ectopic mass size <3.5cm and no fluid in the peritoneal cavity or P.O.D Agrees to use reliable contraceptive for 3-4 months post treatment Future fertility desired No pre-existing severe medical condition or disorder No liver, renal or bone marrow No known contraindications to methotrexate use Not currently taking NSAID’s, diuretics, penicillin and tetracycline No co-existing intrauterine pregnancy Not breastfeeding Will be compliant with regular follow-ups. |
| Surgical | Women who are NOT haemodynamically stable, or who cannot be managed medically, as per criteria above, should be directed to surgical management. |
Bereavement support
- Consider the following issues and refer for bereavement support as appropriate:
- The psychological impact of early pregnancy loss may seriously affect women and their partners
- Time should be given for women to make decisions and counselling should be made available.
- Evidence has shown that there may be little difference in psychological outcomes when comparing surgical and medical methods of managing ectopic pregnancy.
- In the situation where a woman and her partner are particularly distressed by their loss, referral to a social worker may be appropriate.
References:
1. Royal College of Obstetricians and Gynaecologists - RCOG (2004) Greentop Guideline number 21: The Management of Tubal Pregnancy, http://www.rcog.org.uk/index
2. www.ectopic.org.uk
3. Easily Missed? Ectopic pregnancy. BMJ 2010;341:c3770