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1. Purpose
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To support clinicians in the management of women who have a diagnosed ectopic pregnancy.
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2. Definition of terms
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EPAS: Early Pregnancy Assessment Service. This service runs Monday - Friday mornings, in Women's Emergency Care.
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Ectopic: a pregnancy that is not in the uterus. The fertilized egg has settled in a location other than the inner lining of the uterus. The large majority (95%) of ectopic pregnancies occur in the Fallopian tube. However, they can occur in other locations, such as the ovary, cervix, and abdominal cavity. An ectopic pregnancy occurs in about 1 in 60 pregnancies.
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Early pregnancy: all gestations up to 16 completed weeks. (Note: women with pregnancy of gestation >16 completed weeks should be referred to the obstetric unit).
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WEC: Women's Emergency Care
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POD: Pouch of Douglas.
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3. Clinical presentation
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Ectopic pregnancy is suspected when a woman presents with a combination of the following:
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Clinical:
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 | | - pelvic pain and/or abnormal bleeding in the first trimester
| | - dizziness or spells of fainting
| - other evidence of blood in the peritoneum
| - adnexal tenderness, cervical excitation, signs of peritonism.
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Bio-chemical:
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| - positive pregnancy test (urine or serum).
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On transvaginal ultrasound:
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| - intrauterine gestational sac not seen
| - ovarian / fallopian mass may be seen (note: an adnexal mass will not be found in 15-35% of women with an ectopic pregnancy)
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4. Risk factors for ectopic pregnancy
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- women with previous ectopic pregnancy
- previous pelvic infection or pelvic inflammatory disease
- IUD in situ
- previous pelvic surgery – including caesarean section, tubal surgery, appendicectomy
- history of fertility problems – including assisted conception
- progestagen only pill.
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Combined intra-uterine and extra-uterine pregnancy (heterotopic pregnancy) is rarely encountered (i.e. occurs in 1:40,000 natural pregnancies and 1:1,000 IVF pregnancies).
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5. Selecting an appropriate management method
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Once an ectopic pregnancy has been diagnosed, the gynaecology registrar will clinically assess the woman, including vaginal examination if planning conservative treatment.
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The Women's Emergency Care HMO/Registrar will provide acute/emergency care if required.
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Refer to: Appendix C: MEMO (29/07/2008) - changes to CPG plus clarification of referral process.
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Routinely discuss management with consultant.
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Two options for ongoing management are most used commonly:
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| - medical management (methotrexate)
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Women should participate fully in the selection of the most appropriate treatment.
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Provide written information concerning treatment options plus carefully advise advantages and disadvantages associated with each approach.
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Decisions regarding management should take into account the following inclusion criteria:
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| | | Medical management is most suitable for women who:
| - are haemodynamically stable
- do not have pelvic pain and/or tenderness
- have ßhCG <3500 IU/L (NB: may bleed or rupture at much lower HCG levels, even <200)
- on transvaginal ultrasound, have no fetal heart activity, an un-ruptured ectopic mass size <3.5cm and no fluid in the peritoneal cavity or Pouch of Douglas
- agree to use reliable contraceptive for 3-4 months post treatment
- desire future fertility
- have no pre-existing severe medical condition or disorder
- have no abnormality of LFT, U&E or FBC (liver, renal or bone marrow impairment)
- have no known contraindications to methotrexate
- are not currently taking non steroidal anti-inflammatory drugs(NSAID), diuretics, penicillin and tetracycline group drugs (not so critical for the single dose methotrexate regime)
- do not have a co-existing intrauterine pregnancy
- are not breastfeeding
- will be compliant with regular follow-ups.
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| | Women who are NOT haemodynamically stable, or who cannot be managed medically, as per criteria above, should be directed to surgical management.
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Plans for management and follow-up should be clearly recorded in the EPAS record and in any discharge letter from the EPAS.
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5.1 Bereavement support
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Consider the following issues and refer for bereavement support as appropriate:
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| - the psychological impact of early pregnancy loss may seriously affect women and their partners
- time should be given for women to make decisions and counseling should be made available
- evidence has shown that there may be little difference in psychological outcomes when comparing surgical and medical methods of managing ectopic pregnancy
- in the situation where a woman and her partner are particularly distressed by their loss, referral to a bereavement support worker may be appropriate; provide contact details for Women's Social Support Services or Pastoral Care and Spirituality Services.
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5.2 Medical management (methotrexate)
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The gynaecology registrar must complete the printed form: Methotrexate Treatment Record for Women with Ectopic Pregnancy (MR/53), then file the form in the woman's medical record.
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Treatment schedule:
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- explain treatment to the woman (and partner) and provide written information, including EPAS and WEC contact details
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- collect pre-treatment bloods (i.e. ßhCG, U&E, LFT, FBC).
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- administer Anti-D to Rhesus negative women according to the Women's CPG: Rh D Immunoglobulin in Obstetrics
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- obtain woman’s weight and height and calculate body surface area (refer to Appendix A)
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- obtain written informed consent
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- arrange admission onto the ward for administration of methotrexate
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- medical officer to prescribe a single dose of methotrexate (written up as the total dose of methotrexate in mg). Calculate the dose based on 50mg/m2 body surface area.
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- consider a multi-dose regime of methotrexate for women with cervical or cornual ectopic pregnancies, after discussion with gynaecology consultant - for multi-dose regime, refer to Appendix B.
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Make discharge arrangements:
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- arrange follow up with gynaecology registrar on day 4 and day 7, in conjunction with EPAS
- notify EPAS of treatment and next follow up to ensure patient is entered on the ectopic register (call ext 3643 - leave message, including UR number, if no answer)
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- provide contact numbers / appointments for Women's Social Support Services / Pastoral Care & Spirituality Services (as appropriate - refer to section: 5.1 Bereavement support)
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- advise woman of the following:
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| - she may experience some pain in the abdomen as the pregnancy resolves. She may take simple analgesia for this – if ineffective, contact EPAS (during hours) / WEC (after hours).
| - to avoid vaginal intercourse until satisfied that there is minimal risk of rupture of the ectopic; contraception should be recommended for 3 months
| - to avoid alcohol for 7 days
| - to avoid herbal remedies and vitamin preparations containing folate
| - if simple analgesia is ineffective or she has any concerns regarding pain or bleeding, to contact EPAS (during hours) / WEC (after hours).
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- complete discharge summary and GP notified.
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Follow up and monitoring:
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- Day 1: day on which methotrexate is given.
- Day 4: Clinical review by gynaecology registrar, ßhCG (expected to rise), discuss with consultant gynaecologist if necessary.
- Day 7: Clinical review by gynaecology registrar, FBC, ßhCG, LFTs, U&E.
- Day 14: FBC, ßhCG in EPAS, clinical review by gynaecology registrar if indicated by symptoms or blood results.
- weekly follow up in EPAS until ßhCG is <5 IU/L - ßhCG (can take several weeks to fall), clinical review by gynaecology registrar if indicated by symptoms or blood results
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- if ßhCG does not fall by >15% between days 4 – 7:
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| - discuss with consultant gynaecologist; consider whether surgery is indicated
- administer second dose (required in ~15% of cases)
- Management should be guided by clinical findings such as peritoneal irritation and vital signs in association with the BHCG. Women with evidence of rupture or significant pelvic/abdominal tenderness should be discussed with a consultant gynaecologist and are likely to require surgical treatment. Repeat ultrasound examination is usually unhelpful in these circumstances (the ectopic mass and some free fluid will probably be seen). Some pain is to be expected and is not in itself an indication for ultrasound examination: referral for ultrasound examination in these circumstances should be discussed with a consultant ultrasonologist.
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If second dose is administered:
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- Day 7: confirm normal LFT. Injection should be given in opposite gluteal
- Day 11: ßhCG and clinical review by gynaecology registrar
- Day 14: FBC, ßhCG, LFTs, U&E and clinical review by gynaecology registrar
- Women with evidence of rupture or significant pelvic/abdominal tenderness should be discussed with a consultant gynaecologist and are likely to require surgical treatment
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On completion of treatment
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- ensure contraceptive plan is in place
- ensure clinical review is planned to discuss relevant issues regarding future fertility and pregnancy care; offer appointment to gynae post-operative clinic
- send a letter to the woman's GP.
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5.3 Surgical management
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Treatment schedule
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Gynaecology registrar to:
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- arrange date and time for surgical management including booking of Operating Theatre and inpatient bed
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- explain treatment to the woman (and partner) and provide written information
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- obtain written informed consent
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- collect pre-treatment bloods (i.e. ßhCG, group and hold, FBC).
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- administer Anti-D to Rhesus negative women according to the CPG: Rh D Immunoglobulin in Obstetrics
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- if the woman is haemodynamically stable, a laparoscopic approach is preferable to an open approach
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- if the woman is not haemodynamically stable, the most expedient method of surgical management should be chosen – in most cases this will be laparotomy.
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For women who are not haemodynamically stable:
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| | - secure immediate IV access
| - send blood for FBC and cross match 4 units
| - inform: Operating Suite, anaesthetist and on-call gynaecology consultant.
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NOTE: the urgency of the situation must be stressed to all concerned. Surgery should be performed even before blood and fluid losses have been replaced.
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Salpingectomy is often performed, particularly if:
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- the tube is severely damaged
| - there is uncontrolled bleeding
| - there is a recurrent ectopic pregnancy in the same tube
| - there is a large tubal pregnancy of >5cm
| - the woman has completed her family.
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Laparoscopic salpingotomy should be considered as the primary treatment if the woman has contralateral tube disease and desires future fertility.
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In exceptional circumstances a family may want to bury the products at home. In this instance, ensure the remains are not placed in formalin, consult a bereavement worker and discuss with Anatomical Pathology staff. For details refer to the Bereavement Response Manual (available as a pdf) which can be found in the Women's Intranet-only Policy and Procedure Manual: linked to any of the Reproductive Loss procedures.
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On discharge after surgery:
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- notify EPAS of treatment and next follow up to ensure patient details are entered onto ectopic register. Call ext 3643 and leave a message (including UR number) if no answer.
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- provide contact numbers / appointments for Women's Social Support Services / Pastoral Care & Spirituality Services (as appropriate - refer to section: 5.1 Bereavement support)
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- advise woman of the following:
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| - to see GP in one week for removal of sutures
| - what to expect (in terms of pain, bleeding etc)
| - she may take simple analgesia for pain
| - to contact EPAS (during hours) / WEC (after hours) if concerns regarding pain or bleeding
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- ensure contraceptive plan is in place
- ensure clinical review is planned to discuss relevant issues regarding future fertility and pregnancy care; offer appointment to gynae post-operative clinic
- complete discharge summary and ensure that woman's GP is informed.
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Follow up and monitoring in special circumstances
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For women undergoing salpingotomy:
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- Day 3 ßhCG and clinical review by gynaecology registrar if symptoms or results indicate
- Day 7 ßhCG and clinical review by gynaecology registrar if symptoms or results indicate
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- if ßhCG plateaus or rises, consider medical treatment.
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Where a sub-optimal fall precedes a negative laparoscopy, consider managing expectantly.
An ultrasound examination may be helpful if the laparoscopy is negative but usually not for a week or two; this should be done in the Ultrasound Department, not in EPAS and preferably be discussed first with the Ultrasound consultant.
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6. Appendices
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Appendix A: Calculating body surface area (BSA) in m2
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