|Obstetric definitions
|Diabetes and Pregnancy
|Caesarean Section (CS)
|Epilepsy in Pregnancy
|Resuscitation - Obstetric Cardiac Arrest
|Normal Labour
|Premature Labour
|Ectopic Pregnancy
|Acute Fatty Liver of Pregnancy
|Multiple Pregnancy
|Prescribing in Pregnancy
|Termination of Pregnancy (Abortion)
|VTE DVT PE in Pregnancy
An ectopic pregnancy must be suspected in any woman with a positive pregnancy test, amenorrhoea, abdominal or pelvic pain, or PV bleeding, as delayed or misdiagnosis can be fatal.
About
- Ectopic pregnancy is the most common cause of maternal death in the first trimester./li>
- Suspect ectopic pregnancy in any woman with a positive pregnancy test
- Amenorrhoea, pelvic pain, or PV bleeding.
- Classic signs include a positive β-HCG, an empty uterus, adnexal mass on ultrasound.
- Digital vaginal examination should be deferred until resuscitation facilities are available, as it may provoke rupture.
- In normal pregnancies, serum β-HCG doubles approximately every 48 hours.
Aetiology
- Ectopic pregnancy occurs when the embryo implants outside the uterine cavity, with 90% of cases in the fallopian tubes.
- Incidence is approximately 1 in 200 pregnancies and increases with maternal age.
- The ampullary region of the fallopian tube is the most common implantation site.
Physiology
- Fertilization normally occurs in the fallopian tubes, with the fertilized egg traveling down to implant in the uterine cavity.
- Factors like scarring or infection can prevent this process, resulting in implantation outside the uterus.
Risk Factors
- Previous ectopic pregnancy
- Pelvic inflammatory disease (PID), intrauterine contraceptive device (IUCD) use, or endometriosis
- Previous abdominal or pelvic surgery
- Reversal of sterilization or in vitro fertilization (IVF) procedures
- Presence of ovarian or uterine cysts or tumours
Clinical Features (Pre-Rupture)
- Amenorrhoea, usually 5-8 weeks post-last menstrual period (LMP)
- Symptoms may mimic a normal early pregnancy (missed periods, breast tenderness, nausea).
- Unilateral lower abdominal pain
- Sharp, stabbing pelvic or abdominal pain
- Vaginal bleeding with a “prune juice” appearance in the first trimester
- Vasovagal episodes and potential haemorrhagic shock or syncope if ruptured
- Peritonitis or shoulder pain if ruptured, which constitutes a medical emergency.
Investigations
- Serum β-HCG: Monitors levels. In a normal pregnancy, levels double every 48 hours, while ectopic pregnancy may show a failure to rise.
- Ultrasound: Confirms extrauterine pregnancy or may show free fluid in the pouch of Douglas.
- Transvaginal Ultrasound: Shows an empty uterus, adnexal tubal sac, and free fluid in ectopic cases.
- Rhesus Status: Should be checked as anti-D immunoglobulin may be required.
- Laparoscopy: The definitive diagnostic procedure if non-invasive tests are inconclusive.
Differential Diagnosis
- Acute appendicitis
- Acute pelvic inflammatory disease (PID)
Management
- Medical Management (Early Ectopic Pregnancy):
- Methotrexate and Misoprostol may be used if the sac is < 4 cm and β-HCG < 1500 IU/L.
- Close monitoring of β-HCG is necessary, with follow-up visits to confirm resolution.
- Methotrexate is a cytotoxic agent, with side effects such as nausea, vomiting, hair loss, and fatigue.
- Surgical Management:
- Laparoscopic Salpingotomy: Often preferred in stable patients.
- Immediate Intervention: For unstable patients, involving ABCs, resuscitation, blood cross-matching, and immediate surgical intervention (laparotomy and salpingectomy).
- Conservative Management: Suitable for asymptomatic patients with hCG < 1000 IU/L and a small adnexal mass (<2 cm). Regular monitoring of serum hCG to confirm a 15% reduction at each follow-up.
- Follow-up: Patients managed medically or conservatively should attend Early Pregnancy Assessment Unit (EPAU) visits until serum hCG levels return to negative.
- Rhesus Prophylaxis: Anti-D immunoglobulin (250 IU) should be offered to all Rh-negative women undergoing a surgical procedure for ectopic pregnancy.
References