Ectopic Pregnancy, Diagnosis and Management
Introduction:
The incidence of ectopic pregnancy is increasing due to various reasons like Pelvic infections, previous tubal surgery and assisted conception technology. Appropriate diagnosis and timely intervention is key management of better maternal outcome. Nearly 32,000 ectopic pregnancies are diagnosed in the UK within a three year period from 1997 to 1999.
Tubal pregnancy can be managed by laparotomy, operative laparoscopy, medically and occasionally by conservative management. Management must be tailored to the clinical condition and future fertility requirements of the woman.
Every institution at accident and emergency, should have a written protocol and a simple algorithm to diagnose and manage ectopic pregnancy.
Clinical Preseantation: Mostly atypical!
Detailed history is obtained if the patient is in stable condition. History of amenorrhoea, onset of pain, Vaginal bleeding , associated symptoms like giddiness, vomiting, dysurea, dyspareunia and past history of sexually transmitted disease, pelvic infection, assisted conceptions, contraception is essential and helps in diagnosis.
Clinical examination for pulse, blood pressure, general condition and pallor is undertaken. Abdominal examination for suprapubic tenderness, rigidity and guarding is mandatory. Vaginal examination for adnexial mass, cervical excitation pain, uterine size and tender uterine movements should be done.
Investigations:
- Sensitive Urine Pregnancy Test
- Serum Beta HCG
- Trans vaginal Scan.
- Complete Blood count, Blood group and Rh , Cross match.
- Random Blood Sugar, Sickling test.
A simple but sensitive pregnancy test is basic at an A & E. Negative pregnancy test does not rule out ectopic pregnancy !
Simple algorithm can be followed as stated below.
(attached to this lecture as an attachment of algorithm for diagnosis and management of ectopic pregnancy).
Management:
Many randomized controlled trials have shown that laparoscopic management of ectopic pregnancy has advantages over laparotomy. There is quick recovery, less requirement of analgesia, and less adhesions with laparoscopy. But many gynecologists avoid laparoscopic management in clinically unstable ectopic pregnancy. Facilities like laparoscopic equipments and expertise are essential and persistent trophoblastic tissues with slow regression of HCG levels are added disadvantages with laparoscopy.
Laprotomy still remains the main management option in unstable women with ectopic and where the facility and expertise are lacking.
If contralateral tube is unhealthy , salpingostomy is advised with the explanation of risk of future ectopic and subfertility. Salpingostomy can be again through laparoscopy or laparotomy.
Medical management is indicated in women who are clinically stable and available for follow up. Other criteria for medical management with Methotrexate are Pregnancy sac size of < 3 – 3.5 cms , Serum Beta HCG < 3500 IU, and no fetal heart activity. Some gynaecologists have given Methotrexate where BHCG levels are up 5000 IU.
Dilemma continues in pregnancy of unknown location where BHCG values are less than 1000 IU and no intra or extra-uterine sac is noticed. If the patient is stable and available for follow-up, either the medical management with Methotrexate or only observation can be considered. But, clear explanation and counseling of patient are of paramount importance.
Serial BHCG and Transvaginal scans are done till the BHCG values are declined to < 20 IU in medical management and in the observation group.
EVIDENCE-BASED: LAPAROSCOPIC MANAGEMENT IS THE PREFERRED METHOD OF MANAGEMENT OF ECTOPIC PREGNANCY IN CLINICALLY STABLE WOMEN WHERE EXPERTISE AND FACILITIES ARE AVAILABLE.
References:
- Lewis G, Drife J, editors.Why Mothers Die 1997-1999.The Fifth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press;2001.
- Royal College of Obstetricians and Gynaecologists. Searching for evidence. Clinical Governance Advice No 3. London: RCOG Press; 2001.
- Parker J, Bisits A. Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy? Aust N Z J4. Vermesh M,Silva P,Rosen G,Stein AL,Fossum GT,Sauer MV.
- Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 1989;73:400-4.
- Lindorff P, Thorburn J, Hahlin M, Kallfelt B, Lindblom B. Laparoscopic surgery in ectopic pregnancy: a randomized trial versus laparoscopy. Acta Obstet Gynecol Scand1991;70:343-8. Obstet Gynecol 1997;37:115-7
- Gray D,Thorburn J, Lundorff P, Strandell A, Lindblom B.A cost-effectiveness study of a randomized trial of laparoscopy versus laparotomy for ectopic pregnancy. Lancet 1995;345:1139-43.
