Written by The Royal Oldham Hospital. Revised March 2001.

In the 1994-96 triennium there were 12 deaths from ectopic pregnancy in the UK. Advanced information about the next three years' audit indicates that the number of deaths has not dropped. The key to reducing this mortality is vigilance.

Presentation

Classical Features: abdominal pain + vaginal bleeding + amenorrhoea.

There may be shoulder tip pain (from free blood irritating the abdomenal diaphragm), dizziness or spells of fainting.

The classical clinical presentation is not common so: the diagnosis of ectopic pregnancy should be considered in any woman of reproductive age who complains of abdominal pain (always suspect)

Gastrointestinal symptoms may be prominent in ectopic pregnancy, notably diarrhoea and painful defaecation.

The diagnosis should be strongly suspected in women with the following risk factors:

• previous PID (pelvic inflammatory disease)

• previous tubal surgery

• previous sterilisation

• previous ectopic pregnancy

• IUCD (coil) in situ

• IVF (in vitro fertilisation) treatment or assisted fertilisation

The diagnosis should be considered in women who present with hypovolaemic shock.

Diagnosis

(Blood) hCG* testing should be done in any young woman with unexplained abdominal pain whether or not she has missed a period or had abnormal vaginal bleeding.

*human chorionic gonadotrophin is the full name of the pregnancy hormone.

The algorithm in these guidelines should lead to early non-invasive diagnosis and minimise the occurrence of false negative laparoscopy.

Important: Serum hCG measurements should be interpreted not in isolation but in the context of clinical features

The figure below shows how the pregnancy hormone human chorionic gonadotrophin (hCG) levels change in normal pregnancy:

Mean (SE) serum concentrations of human chorionic gonadotrophin (adapted from Braunstein et al 1976)

SERUM hCG:

• Can be positive within 7-10 days of conception

• Doubles approximately every 48 hours in 85% of normal intrauterine pregnancies of 4-6 weeks

• In more than 80% of ectopic pregnancies the rise in serum hCG is <66% in 48 hrs (in about 13% of ectopics the doubling time is normal - false negatives)

• About 15% of normal pregnancies have subnormal doubling time

• At levels of 1000-1500 iu/1, an intrauterine sac should be normally be seen (endovaginal ultrasound imaging) previously called transvaginal, the probe is in the vagina

• Less than 10% of ectopic pregnancies have pseudogestational sac

Normal values of hCG:

At 5 weeks: 20-7000 iu/l

At 6 weeks: 1000-56000 iu/l

At 7-8 weeks: 7500-230000 iu/l

Algorithm for the management of early pregnancy bleeding

If the patient is bleeding PV (per vagina) +/- abdominal pain and has a positive pregnancy test* then this patient must have Ultrasound scan

- endovaginal scan (previously transvaginal) the probe is in the vagina.

* urine pregnancy test (hospital or over-the-counter kit) is usually positive when hCG in the body is greater than 25iu/l (international units per litre): blood test is more sensitive and positive when greater than 10iu/l. The test is enzyme linked with electro-luminescence detection, avoiding radioisotopes in the laboratory.

Further management

Will depend on the ultrasound findings: N.B. tvs ultrasound shows fetal heart action in normal pregnancy around 37 days from first day of last menstrual period on scanning in Oldham.

A. Viable intrauterine pregnancy confirmed by showing on scan

• Reassure and refer back to GP or arrange ANC booking appointment.

• Note: in IVF pregnancies the incidence of heterotopic pregnancy (both intrauterine and ectopic at once) is 1 in 33 -100

B. Empty uterus, no adnexal mass (no lump seen on either side of the womb at ultrasound examination)

• This could be an ectopic pregnancy, early intrauterine pregnancy or complete miscarriage

• If serum hCG value is greater than 1000 iu/l this patient needs diagnostic laparoscopy

• If serum hCG is less than 1000 iu/l and she is clinically stable then repeat hCG 48 hrs later.

At 48 hrs:

• If a normal increase in hCG (greater than 66%) then repeat ultrasound in 1 week

• If a subnormal increase in hCG (less than <66%) or if the patient has had clinical deterioration in her condition then this patient needs diagnostic laparoscopy

If a fall in hCG occurs either:

• if bleeding proceed to ERPC (evacuation of retained products of conception or send to lab for confirmation of miscarriage or;
• if not bleeding then review in 3 days.

C. Intrauterine sac, but no fetal pole/FH (on ultrasound, no obvious fetal parts identified or heart action); no adnexal mass: (on ultrasound)

• If serum hCG is greater than 1000 and the patient is clinically stable, repeat hCG in 48hrs and rescan in 1 week (may be an early intrauterine pregnancy);

• If serum hCG is less than 1000 and no clinical symptoms or signs of ectopic pregnancy, treat as failure of pregnancy previously known as blighted ovum (ERPC or conservative management); (the sac on scan being greater than 20 mm with no embryo or yolk sac is suggestive of this, with some placental cells still surviving);

• If clinical signs are present regard this as a pseudogestational sac and proceed to laparoscopy.

D. Empty uterus, or intrauterine sac without fetal pole, with adnexal mass (+/- free fluid) (endovaginal ultrasound) this is an ectopic pregnancy until proven otherwise:- Book operating theatre for urgent laparoscopy

Treatment

Patients in haemorrhagic shock should be transferred promptly to theatre. Transfer should not be delayed by attempts to establish a normal circulating plasma volume.

Salpingectomy by laparoscopy or open surgery is the standard treatment.

Laparoscopic treatment should be performed only by surgeons trained in this procedure.

Laparoscopic surgery should not be performed in haemodynamically compromised women or those with extensive pelvic adhesions or haemoperitoneum.

Conservative surgery (salpingotomy) carries higher rates of recurrent ectopic pregnancy and persistent trophoblast, so should only be performed if the contralateral tube is damaged.

Expectant management (i.e. awaiting spontaneous resolution) of confirmed ectopic pregnancy is not acceptable in routine clinical practice in Oldham.

Non-surgical management (with methotrexate) may be offered with the approval of a consultant and strictly in line with the 2001 protocol for medical management of ectopic pregnancy.

ALL PATIENTS SHOULD HAVE THEIR RHESUS GROUP RECORDED.

Follow up

All rhesus negative patients must have anti-D immunoglobulin within 72 hours of initial assessment.

All patients investigated for possible ectopic pregnancy should be advised to return ASAP (or see their GP) if symptoms change.

Negative laparoscopies should be followed up with serial serum hCG.

Following ERPC for 'missed' miscarriage, the histology should be followed up. If histology shows no chorionic villi or fetal tissue, the case should be reviewed by the consultant, and the patient recalled immediately if indicated.

All women treated for ectopic pregnancy should be counselled regarding the risk of recurrence.

Following conservative surgery, hCG should be monitored weekly (this may take up to 10 weeks to return to normal). If hCG is rising, request ultrasound scan and consider further treatment (either laparotomy or methotrexate).

References

Symons I M. Ectopic pregnancy: modern management. Current Obstetrics and Gynaecology 1998:27-31

Department of Health. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-1996."Why Mothers Die" London:HMSO 1998

Speroff L, Glass R H, Kase N G. Ectopic pregnancy. In: Speroff L, Glass R H, Kase N G. (eds) Clinical gynecologic endocrinology and infertility. Baltimore: Williams and Wilkins 1994; 947-964

Sadek A L, Sciotz H A. Transvaginal sonography in the management of ectopic pregnancy. Acta Obstet Gynecol Scand 1995,74:293-296

Edozien L C, Pandiarajan T, Ali S W. False negative laparoscopy: a pitfall in the diagnosis of early ectopic pregnancy. Br J Clinical Practice 1995; 49:326-327

Royal College of Obstetricians and Gynaecologists. The management of tubal pregnancies. 'Green top' Guideline No. 21, October 1999 RCOG Green Top Guideline No. 21

Figure of hCG versus time in normal pregnancy from Ectopic Pregnancy. Tay J I, Moore J, Walker J J British Medical Journal 2000; 320:916-919 www.bmj.com/cgi/content/full/320/7239/916/DC1

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