Ectopic Pregnancy

Dr Tom Leach

8 years ago

Contents

Introduction
Incidence
Classification
Risk Factors
Symptoms
Signs
Investigations
Management
References
Related Articles

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]