Introduction

Ectopic pregnancy is defined as:

• Implantation of conceptious outside uterine cavity

When women of reproductive age present with pelvic pain and positive pregnancy test assume ectopic pregnancy until proven otherwise. The main differential is miscarriage, although any disorder that causes bleeding in early pregnancy can be suspected.

Incidence

20:1000 pregnancies

• Increasing from 11:1000 pregnancies
• May due to improved technology (US resolution), increased Assisted reproduction, increase PID
• Contribute to most significant death in 1st Trimester

Classification

Tubal (95% are in Fallopian tube)

• Ampullary – 55%
• Isthmic – 25%
• Fimbrial – 17%
• Interstitial – 2%

Others – <5%

• cervical, ovarian, scar

Heterotopic

• Ectopic pregnancy with combination of Intrauterine pregnancy

Risk Factors

• only evidence in 25-50% cases
• History of infertility
• Assisted conception
• History of PID (especially Chlamydia trachomatis)
• Endometriosis
• Prev Pelvic/ tubal surgery
• Previous ectopic (recurrent 10-20%)
• IUCD in situ
• Smoking
• Prior induced abortion

Symptoms

• Pain (unilateral/ generalised)
• amenorrhea (6-8 weeks)
• PV bleed (occur up to 75% cases)
• may be asymptomatic
• shoulder tip pain (from intra-abdominal irritation secondary to haemoperitonium)
• Collapse!

Signs

Acute abdomen

• Peritonism
• Guarding
• Tenderness @ adnexa
• Distension (in case of ruptured)

Cerical excitation

• During VE
• may indicate blood in pelvis
• Adnexa mass
• If ectopic large

Shock ! à This is emergency

• Hypotension
• tachycardia
• Tachypnoea
• GCS dropping
• Cold peripheries
• deteroriate end-organ perfusion

non specific signs

• normal size uterus

Investigations

Pregnancy test

• to confirm pregnancy

TVS

• pick up 90% case
• location
• adnexal mass
• presence of free fluid
• If hCG >1500IU à should see IUP (Intrauterine Pregnancy) /EP (ectopic pregnanacy)

Progesterone

• know whether pregnancy failing/ not
• <20 nmol/L – suggestive failing
• >60mmol/l – ongoing pregnancy

hCG

• repeat 48 hours later
• pattern ; doubling every 48 hours in normal pregnancy
• rise >66% indicate IUP
• suboptimal rise à suggest Ectopic Pregnancy
• If serum b-hCG <5 mIU/ml à ectopic is excluded
• if serum hCG >1500IU, US scan should visualise Intrauterine /Ectopic pregnancy

Laparoscopy

• gold standard

FBC

• To know degree of blood loss
• Look at Hct, Hb

Group& Save/ Crossmatch

Management

Expectant

• Need strict criteria for selection, also fulfilling Medical management criteria
• Patient understand consequences, complications
• Patient live close to hospital and can attend Hospital instantly during emergency
• patient can attend follow up
• Need to monitor serum hCG, initially and then every 48 hours until level fall, then weekly until <15IU
• Also moniotr using Transvaginal Ultrasound weekly
• serum progesterone <20mmol/l suggest ectopic that should resolve spontaneously
• More successful if initial serum hCG <1000IU

Medical

• Methotrexate (Folate antagonist) à destroys trophoblastic tissue
• Success rate : up to 90%
• Suitable for:
  • clinically stable
  • minimal symptoms
  • ectopic <3cm
  • no fetal cardiac activity
  • no evidence of haemoperitonium
  • hCG <3000IU
• Dose
  • 50mg/m2
  • Around 75-90 mg for most women
• Follow up hCG to check resolution
  • Should fall >15% between day 4 and 7 after treatment
  • If fall <15% à second dose Methotrexate will be given
  • At least 15% patiet treat medically need second dose Methotrexate
• Contraindicated in Liver disease, renal diseease
• Advise
  • Side Effect of Methotrexate
  • Avoid sexual intercourse during treatment
  • Keep ample fluid intake
  • Use contraception after treatment (for 3 months)

Surgical

Laparoscopy/ Laparatomy

• Gold standard
• Laparoscopy is preferable than laparotomy in haemodinamically stable patient

Salpingectomy

• lower rate persistent trophoblast
• Indicated when:
  • The tube is severely damaged
  • If contralateral tube healthy/ normal
  • No plan for future pregnancy/ complete family
  • Ectopic pregnancy >5cm size/ recurrent ectopic

Salpingotomy

• increase risk residual trophoblast/ residual bleeding
• Follow up hCG to ensure resolution
• Suitable for those with contralateral tube disease/ desire future pregnancy (preferably laparoscopic salpingotomy)

Anti-D immunoglobulin

• For rhesus negative mother with confirmed or suspected ectopic pregnancy
• Dose of 250IU (50 microgrammes)

Post-Ectopic

• 70% women will have intrauterine pregnancy
• risk recurrent around 10-20%
• If conceived, need to have early pregnancy scan to confirm the location of pregnancy

References

• Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and gynaecology. Oxford University Press. 2nd edition 2008.
• Sarris I, Bewley S, Agnihtori S. Training in Obstetrics And Gynaecology the essential curriculum. Oxford university Pres. 2009.
• Green Top Guideline No. 21. RCOG. May 2004.
• Dulay AT. Merk Manual: Ectopic Pregnancy. Feb 2010. [Online]

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