Ectopic pregnancy can be a cause of serious morbidity or mortality if undiagnosed. This article looks at the diagnosis and management of this gynaecological emergency.
Emergency Gynaecological and Early Pregnancy Assessment services should be introduced especially to early diagnose and treat this potentially life-threatening condition with early recourse to medical and surgical treatment.
With an ectopic pregnancy, the pregnancy occurs in a place other than the uterus. It has an incidence of 11/1000, can occur in the fallopian tube, cornual (where tube meets uterus), ovary, abdomen, cervix and even in a caesarean section scar. Rarely can it be heterotopic where there is an intrauterine and tubal as well. This has an incidence of 1 in 30,000.
Risk factors include previous ectopic pregnancy, a history of pelvic inflammatory disease, tubal surgery, in vitro fertilisation and smoking.
Ectopic pregnancy is diagnosed by history, investigation, and examination.
The history will show a period of amenorrhea, with pain and sometimes bleeding. The pain is usually lower abdominal and occasionally shoulder tip, especially if the ectopic is ruptured. If the patient is haemodynamically compromised, there may be a history of a syncopal episode prior. Abdominal examination may reveal lower abdominal tenderness and an internal examination may show tenderness to one side and on movement of the cervix. Blood pressure may be normal or low and there may be an increase in pulse rate.
If the ectopic is early, then these symptoms may be absent.
The trans-vaginal scan should be offered to rule out ectopic, but one should realise the varying results one can get. This can range from seeing a live ectopic pregnancy, adnexal masses in the pelvis, or free fluid to nothing at all being seen in the uterus.
These are then correlated with serum beta-HCG blood tests (hormone of pregnancy); if one uses the threshold value of 1500 then one should see signs of an intrauterine pregnancy; if not then an ectopic pregnancy is strongly suspected. If it is less than 1500, then it is usually repeated in 48 hours and it should increase by 66%.
Once diagnosed, one must decide on treatment and the patient must be fully informed to make a valid consent. Current treatment options include medical management where the fallopian tube is conserved and surgical management where the tube is removed.
Medical management is best when there is no compromise of the patient and the HCG levels are less than 5000, there is no cardiac activity on ultrasound, a willingness for follow up and there are no associated medical problems like liver disease. This is because the drug used for medical management is Methotrexate, a folate antagonist which stops the rapidly dividing tissue of pregnancy from dividing and can affect other cells like the mucosal tissues.
Before it is given, a baseline of kidney and liver tests are done to make sure these are normal and once given, the Beta-HCG and the other bloods are repeated in a week and should be decreasing. Once treated the patient should be advised not to get pregnant for six months.
The HCG should decrease. However, there are instances where it can increase, and another dose of methotrexate is given.
Methotrexate shouldn’t be given unless the diagnosis of ectopic pregnancy is clear and there is no viable intrauterine pregnancy.
Surgical management is mainly by laparoscopic surgery. This has the advantages of less blood loss, less analgesia post operatively, and quicker recovery. Here, the fallopian tube is removed and this is called a salpingectomy. Rarely can one do a salpingostomy where an incision is made on the tube and the ectopic pregnancy is removed. This is sometimes done where the tube that is affected is the patient’s only tube. The disadvantage of this is that an ectopic pregnancy can reoccur in the tube and one has to do serial measurements of the Beta HCG to ensure that it is decreasing.
Complications that should be discussed include visceral injury, transfusion and possible laparotomy, where the surgery might be difficult and conversion to laparotomy is safer.
Contraception should be discussed afterward and the possibility of getting pregnant again is around 83 to 100%.
In summary, early presentation and diagnosis are essential to decrease morbidity of ectopic pregnancy. This can further be improved by the introduction of services like emergency gynaecology and early pregnancy Assessment whose purpose is to triage these patients, resulting in decreased waiting times in General Accident & Emergency and decreasing diagnosis to treatment intervals.
The article is done by Dr John Barker, Bsc MBBS DFSRH MRCOG BSCCP(cert), Dip (Risk Management). Consultant Obstetrician/Gynaecologist at JRB Medical Centre, 7th Avenue Belleville.
His special interests include Gynaecological Oncology, Emergency Gynaecology, Alternatives to Hysterectomy, Out-patient Hysteroscopy, High-Risk Obstetrics.