An ectopic pregnancy occurs when a fertilised ovum implants outside of the uterus. The most common location is one of the fallopian tubes due to tubal dysfunction.
In the UK, there are approximately 11,000 ectopic pregnancies annually and the incidence is increasing.
Ectopic pregnancies are classified by the anatomical site of implantation of the pregnancy:
Ectopics can occur in the myometrium when a fertilised ovum implants in a Caesarean section scar. There have been isolated cases of ectopic pregnancies as far afield as the liver.
There is often no identifiable cause for ectopic pregnancy. However, the following risk factors are associated with an increased likelihood of developing the condition:
*Sterilisation and intrauterine contraception considerably decrease the chance of pregnancy. However, if pregnancy occurs, the risk of ectopic pregnancy is increased.
Patients with an ectopic pregnancy usually present with unilateral abdominal pain from 5 weeks of expected gestation onwards. Patients may be unaware of the pregnancy and using contraception.
In some cases, patients may present significantly shocked due to haemorrhage following the rupture of the ectopic pregnancy.
Typical symptoms of ectopic pregnancy include:
Other important areas to cover in the history include menstrual history, sexual history, past medical history, and medication history.
In the context of a suspected ectopic pregnancy, a pelvic examination is necessary.
Typical clinical findings in ectopic pregnancy include:
Any woman of reproductive potential who presents with abdominal or pelvic pain should always have a pregnancy test.
Relevant bedside investigations in the context of ectopic pregnancy include:
Relevant laboratory investigations in the context of ectopic pregnancy include:
Relevant imaging investigations in the context of ectopic pregnancy include:
An assessment of the patient should be undertaken if the pregnancy test is positive, as they may have an ectopic pregnancy until proven otherwise.
The ABCDE approach should be followed during the initial assessment and management of patients with suspected ectopic pregnancy. Ectopic pregnancy may present with significant haemodynamic instability requiring resuscitation and blood transfusion.
There are three management options for ectopic pregnancy, depending on the haemodynamic stability of the patient and investigation findings:
If the ectopic pregnancy has ruptured, surgical management is usually required. The decision between expectant and medical management, and medical and surgical management, depends on NICE guidelines and patient preference.
Expectant management includes monitoring serum bHCG and performing serial ultrasound scans to monitor the ectopic pregnancy until it spontaneously resolves (‘watch and wait’ approach). Expectant management is suitable for women who meet the following criteria:
Expectant management can also be considered for women who have a serum hCG between 1,000 -1,500 IU/L, providing they meet the other criteria.
Medical management involves using methotrexate to stop the growth of the ectopic pregnancy and allow resolution to occur. Medical management is suitable for women who meet the following criteria:
*Women with a serum hCG between 1500 -5000 may be considered for medical management. The serum hCG level is monitored to ensure it is declining and not continuing to rise. If serum hCG levels continue to rise, a re-assessment of the management plan should occur.
Surgical management involves the surgical removal of the ectopic pregnancy. Surgery should be offered to those women who meet any of the following criteria:
In cases of tubal ectopics, a laparoscopic salpingectomy is usually performed, removing both the ectopic pregnancy and the fallopian tube. Anti-D prophylaxis should be given to all rhesus-negative women who undergo surgical management of an ectopic pregnancy.
Salpingectomy is the removal of the ectopic pregnancy along with the fallopian tube. It is the preferred option in women with no other risks to their fertility, as it reduces the likelihood of a repeat ectopic pregnancy. It can affect future fertility, so women should be carefully counselled about the pros and cons of the procedure.
Salpingotomy is an alternative that seeks to remove the ectopic pregnancy whilst preserving the fallopian tube. It is usually offered to women with other fertility issues, such as damage to the other fallopian tube. It does carry a greater risk of a future ectopic pregnancy than a salpingectomy.
If an ectopic pregnancy is not diagnosed and treated promptly, potential complications can include fallopian tube or uterine rupture, secondary massive haemorrhage and death.
Complications of surgical management can include: bleeding, infection and damage to local structures (uterus, bladder, bowel, vasculature).
Whilst an ectopic pregnancy is a potentially life-threatening situation for a woman, it is also important to acknowledge the removal of an ectopic pregnancy as the loss of a much-longed-for pregnancy. Therefore, emotional support should be offered to the woman in the same way as anyone who has experienced early pregnancy loss.
Women who have undergone a salpingectomy may need additional emotional support to come to terms with the potential future fertility impact.
The Ectopic Pregnancy Trust website offers useful resources for patients and professionals.
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