Ectopic Pregnancy

Last updated 20.09.12

 

Definition

-  Implantation of a fertilised ovum (pregnancy) outside the uterine cavity

 

Features

-  Obstetric emergency

-  1-2% of all pregnancies (increasing)

-  Mortality rate 0.2% of ectopics

-  Cause of 4% maternal deaths in pregnancy

-  As embryo enlarges risk of organ rupture

-  10% recurrence rate

 

Sites

-  Fallopian tubes >95%

-  55% in ampulla

-  25% in isthmus

-  17% in fimbria

-  2% in interstitial region

-  Cervix 0.2%

-  Ovaries 0.2%

-  Abdominal cavity 1.2%

-  Caesar scar

-  Heterotopic

  

Risk Factors

-  PID

-  Previous ectopics (10% risk)

-  Tubal/Pelvic Sx (10% risk)

-  ? chromosomal abnormalities

-  ART

-  IUD increased risk if fall pregnant

-  POP increased risk if fall pregnant

-  Age

-  Smoking

 

Associated S/S

-  Classic triad in 50% pts

-  Abdo pain/Pelvic pain

-  Worse with defecation

-  30% pain free

-  Vaginal bleeding 75% pts

-  Tissue to histology if passed to DDx intrauterine miscarriage

-  Amenorrhoea

-  Presentaion as per early pregnancy

-  Nausea, breast fullness, fatigue, cramping

-  +/- Shoulder pain (referred)

-  Dyspareunia

-  Dysuria

-  Abdo exam +/- VE

-  Pelvic tenderness 75%

-  Enlarged uterus

-  Adnexal mass/tenderness 50%

-  Cervical excitation

-  Rebounds, guarding: acute abdomen: rupture

-  Haemorrhage

-  20% pts haemodynamincally compromised at presentation

-  Shock: rupture

 

Complications

-  Infertility

-  Decreased fertility after 1 ectopic

-  Shock

-  Salipingectomy +/- oophorectomy

 

DDx

-  Appendicitis

-  Salpingitis

-  Pregnancy of uknown location

-  Ruptured corpus luteum cyst or ovarian follicle

-  Spontaneous/threatened miscarriage

-  Threatened miscarriage

-  APH

-  Ovarian torsion

-  UTI

 

Ix

-  Vitals

-  Tachycardia, hypotension: shock: rupture

-  Ultrasound

-  70% sens

-  + doppler = 87% sens

-  DDx normal pregnancy (intrauterine)

-  Beta hCG

-  If >1,500 should see intrauterine pregnancy

-  FBE: anaemia

-  Blood group

-  Rhesus factor: Anti-D

-  Blood transfusion

 

Mx

-  +/- BLS, ALS

-  Resuscitation

-  IV fluids +/- Blood transfusion

-  Medical

-  Anti-D 250 IU for all rhesus –ve mothers regardless of gestation

-  Methotrexate

-  Single IM injection at 50mg/m2

-  May cause increased abdominal pain 2-3 days later

-  Preferred option for cervical, ovarian or interstitial ectopics to preserve fertility

-  3-4% will still rupture despite decreasing Beta hCG

-  50% pts negative Beta hCG in 5 weeks

-  Patients should have easy access to 24hr medical R/V

-  Most suitable if Beta hCG < 3,000

-  Contraindications

-  Haemodynamically ustable (active bleeding or haemoperitoneum)

-  Beta hCG >5,000

-  Ultrasound

-  Gestation > 3.5cm on US

-  Fetal cardiac activity

-  Free fluid in pouch of Douglas (esp low level echoes &/or hetrogenous)

-  Intra-uterine pregnancy

-  Hepatic or renal disease

-  UC or PUD

-  Concurrent infection

-  Protocol

-  Day 1: Beta hCG, LFTs, U&E, FBE

-  Counsel patient

-  Return if increased pain or bleeding

-  Administer Methotrexate (90% require single dose)

-  Day 4: Beta hCG (expected to rise)

-  May experience pelvic pain

-  Day 7: Beta hCG, LFTs, FBE

-  Beta hCG should decrease by 15% or more from Day 4 to 7

-  If not consider second dose Methotrexate

-  Weekly Beta hCG until negative

-  US 1/12 & 3/12 post to confirm ectopic clear

-  Contraception for 3/12+

-  Sx

-  Laparoscopy

-  Standard for Dx

-  Preferred approach if stable

-  Salpingotomy w manual removal of ectopic

-  Considered if contralateral tube damaged or removed

-  Increased risk of repeat ectopic or residual tissue

-  Repeat Beta hCG to confirm declining & exclude presistant trophoblast

-  Segmental salpingectomy +/- anastamosis

-  Total salpingectomy

-  Completed childbearing

-  Previous ectopic in same tube

-  Severely damaged tubes

-  +/- Laparotomy

-  Haemodynamically unstable

-  Conversion from laparoscopy if technically difficult

- Expectant Mx

-  Asymptomatic

-  No evidence of haemodynaimc compromise or rupture

-  Declining Beta hCG levels

-  Observe over days for tubal reabsorption or spontaneous miscarriage

- Contraception

-  Higher rates of ectopic pregnancy on progesterone only methods (as ovulation not prevented)

-  Progesterone effects tubal motility

-  POP does have higher failure rate so best avoided

-  Implanon, Depo Provera, Mirena safe as very effective

-  COC & barrier, etc also safe

 

 

 

References

 

Peninsual Health CPG: Methotrexate for Ectopic Pregnancy, Feb 2011

RWH CPG: Pain & Bleeding in Early Pregnancy, 7/10/2010

RCOG: The Management of Tubal Pregnancy, May 2010