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Ectopic pregnancy

A pregnancy resulting from implantation and maturation of the concepts outside of the endometrial cavity , which eventually ends in death of the fetus.98 % implant within the Fallopian tubes hence often used term tubal pregnancy .Rest occur in the abdomen , ovary , cervix or in a C-section scar

Epidemiology- Estimated prevalence 1-2 % globally In UK nearly 12000 diagnosed each year ( ie prevalence of 1.1 % ) More common following assisted reproduction – incidence about 4 % Mortality 0.2 % per 1000 estimated ectopic pregnancies ( ie very low )

Death rates from ectopic pregnancy have fallen steadily in the last few decades in the developed world despite an increase in prevalence concomitant with increased STI rates and associated salpingitis

Risk factors – Previous ectopic pregnancy Previous tubal surgery
♦ sterilization
♦ reversal of sterilization
♦ tubal reconstruction or repair H/O PID , chlamydia or gonorrhoea Current use of Cu IUD or LNG-IUS
If a pregnancy occurs there is a high risk of ectopic particularly with LNG-IUS Known tubal infertility Assisted conception Endometriosis
 Smoking Increased maternal age Multiple sexual partners

Etiology –Current understanding of the cause is a combination of
 retention of the embryo within the Fallopian tube due to impaired embryo-tubal transport alterations in the tubal environment allowing early implantation to occur

Further studies are needed to understand the etiology to improve preventative measures , better diagnostic screening and development of novel treatments

Studies have identified several risk factors however most patients presenting with ectopic pregnancy have no 
identifiable risk factor

Amenorrhoea or missed period Abdominal or pelvic pain Vaginal bleeding with or without clots .Only about 50 % present with all 3 symptoms Often asymptomatic Breast tenderness Gastrointestinal symptoms Dizziness , fainting or syncope Shoulder tip pain Urinary symptoms Passage of tissue Rectal pressure or pain on defecation Typically presents
 6-8 weeks after LMP 
but can present 
earlier or late

Diagnosis can be difficult About 1/3rd of women experience some pain and/ or bleeding in early pregnancy Pain and vaginal bleeding between 6-10 weeks Typical history is an abnormal period where the bleeding is prolonged with brown prune juice spotting History is more important here as clinical signs may be equivocal Presentation may be subacute/chronic or acute ( dramatic ) About 5 % of women with EP present in hemorrhagic shock ( rupture of FT ) Pallor , tahcycardia and hypotension indicates major abdominal bleeding irrespective of the intensity of abdominal pain Shoulder tip /epigastric pain- referred pain Beware of atypical presentation and take into account that it remains difficult to diagnose an ectopic pregnancy from risk factors , history and clinical examination (10-20 % with EP have no bleeding , about 10 % do not report abdominal pain )

Differential diagnosis- Miscarriage
○ threatened – vaginal bleeding 1st 24 wks gestation
♦ inevitable – threatened + os open or products of conception seen
♦ completed Molar pregnancy Postabortion bleeding Retained products of abortion Ruptured ovarian corpus luteal cyst Pregnancy related degeneration of fibroid Ovarian torsion Salpingitis Ovarian tumour Endometrioma Non-pregnancy related causes of 
bleeding in early pregnancy. Musculoskeletal Urinary tract related Constipation Pelvic inflammatory disease Appendicitis Nephrolithiasis Bowel obstruction Adhesions Ovarian cyst
○ rupture
○ torsion
○ bleeding

Presentation – Pelvic tenderness Adnexal tenderness Abdominal tenderness.Cervical motion tenderness Rebound tenderness or peritoneal signs Pallor Abdominal distension Enlarged uterus Tachycardia or hypotension ( < 100/60 ) Shock or collapse Orthostatic hypotension.

NICE guidance –Women who are haemodynamically unstable or you have significant concern about degree of pain or bleeding -Refer directly 
to A & E

Beware that atypical presentation of ectopic pregnancy is common







Positive pregnancy test and 
 pain and abdominal tenderness OR pelvic tenderness OR cervical motion tenderness




-Refer immediately to an early pregnancy assessment service or OOH gynecology service.


During clinical assessment of women of reproductive age -
 consider that they may be pregnant and think about offering a pregnancy test even when symptoms are non-specific and the symptoms and signs of ectopic pregnancy can resemble the common symptoms and signs of other conditions – for e.g GI tract or urinary tract infection

Women with bleeding or other symptoms and signs of early pregnancy complications who have pain OR a pregnancy of 6 week’s gestation or more OR a pregnancy of uncertain gestation



-Refer to an early pregnancy assessment service or OOH Gynae- urgency based on clinical situation

Urine pregnancy test High resolution transvaginal US ( TVS ) Transabdominal US Serial blood hCG Serum progesterone Blood type , Rh type antibody screen FBC , Us&Es , LFT.

Exclude the possibility of ectopic pregnancy even in absence of risk factors 
( for e.g previous ectopic ) as about a 3rd of women with an ectopic pregnancy will have no known risk factors







Pregnancy of less than 6 weeks gestation who are bleeding but not in pain and have no risk factors ( e.g a previous ectopic )







Expectant management-to return if bleeding continues or pain develops to repeat urine pregnancy test 7-10 days and to return if +ve a negative pregnancy test means that the pregnancy has miscarried.

Woman returns with worsening symptoms and signs that could suggest an ectopic pregnancy







-Refer to an early pregnancy assessment service or OOH Gynae

Beware that ectopic pregnancy can present with a variety of symptoms , even if a symptom is less common , it may still be significant . Symptoms include

Common symptoms –abdominal or pelvic pain amenorrhoea or missed period vaginal bleeding with or without clots

Other reported symptoms –breast tenderness gastro-intestinal symptoms dizziness , fainting or syncope shoulder tip pain urinary symptoms passage of urine rectal pressure or pain on defecation

Beware that ectopic pregnancy can present with a variety of signs of examination-pelvic tenderness adnexa; tenderness abdominal tenderness

Other reported signs –cervical motion tenderness rebound tenderness or peritoneal signs pallor abdominal distension enlarged uterus tachycardia shock or collapse orhostatic hypotension

Terms used to define management
 Expectant- spontaneous resolution Medical- methotrexate Surgical.

Diagnosis –Diagnosis is made by
- transvaginal ultrasound ( investigation of choice )
- beta HCG measurement TVG at 5.5 weeks should identify the IU gestation sac with almost 100 % accuracy ( it is also operator dependent ) Establishment of EPUs and use of above methods has led to an improvement in diagnosis of EP TV US would fail to identify the location of pregnancy in a number of women these are usually labeled as ‘ pregnancy of 
unknown location ‘ ( PUL ) -biochemical tests as HCG/ Progesterone are helpful in such cases.

Laparoscopic surgery is the main treatment , in some select group
 medical and expectant management may be used

References

  1. Ectopic pregnancy and miscarriage : diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage Guideline summary National Collaborating Centre for Women’s and Children’s Health 2013
  2. Diagnosis and management of ectopic pregnancy BMJ 2011 ; 342 ;d3397
  3. CKS NICE Ectopic Pregnancy July 2013 https://cks.nice.org.uk/ectopic-pregnancy
  4. Diagnosis and Management of Ectopic Pregnancy RCOG Green-top guideline No 21 Nov 2016 https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/
  5. BMJ Best Practice Ectopic Pregnancy Ectopic Pregnancy https://bestpractice.bmj.com/topics/en-gb/174
  6. Medscape Sep 2017 Emergencies in Obstetrics and Gynaecology- Edited by Stergios K Doumouschtsis
  7. Ectopic pregnancy and miscarriage : diagnosis and initial management Clinical guideline 154 NICE December 2012
  8. Early diagnosis of ectopic pregnancy is essential to reduce deaths , says guideline BMJ 2016 ;355 :i5954
  9. Oxford Handbook of Obstetrics and Gynaecology
  10. Sivalingam, Vanitha N et al. “Diagnosis and management of ectopic pregnancy.” The journal of family planning and reproductive health care vol. 37,4 (2011): 231-40. doi:10.1136/jfprhc-2011-0073 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213855/
  11. Ectopic pregnancy and miscarriage: diagnosis and initial management NICE guideline [NG126] Published date:

  12. Ectopic Pregnancy: Diagnosis, Prevention and Management By Talal Anwer Abdulkareem and Sajeda Mahdi Eidan  December 20th 2017 DOI: 10.5772/intechopen.71999 https://www.intechopen.com/books/obstetrics/ectopic-pregnancy-diagnosis-prevention-and-management

  13. CLINICAL PRACTICE GUIDELINE THE DIAGNOSIS AND MANAGEMENT OF ECTOPIC PREGNANCY
    Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and Directorate of Clinical Strategy and Programmes, Health Service Executive  Version: 1.0 Publication date: November 2014
    Guideline No: 33 Revision date: November 2017  https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/diagnosis-and-management-of-ectopic-pregnancy.pdf

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