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MRCOG PART 2 SBAs and EMQs

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Essay 220 - Ectopic pregnancy

Posted by GBENGA O.
abdominal pain in gestational amenorrhea raises the suspicion of an ectopic gestation,therefore has to be ruled out or ruled in The patient should informed of the findings..At 8wks gestation,she needs to be admitted,even though she haemodynamically stable now,her clinical picture could change especially if it is an ectpic gestation.Other differential diagnosis are corpus leuteum accident,very early pregnancy loss.The nature of the pain and intensity is important as crampy abdominal pains are associated with miscarriage while constant pain are in keeping with ovarian pathology.
History of passage of clots or tissues PV prior presentation should be sought.Shoulder tip pain is associated with ectopic gestation.Her parity,history of contaception (especially mirenal IUS),history of pelvic inflammatory disease or pelvic surgery should be found out.Other medical condition and drug allergy must be ruled out.
Blood would be taken and sent urgently for serum BHCG,FBC,couagulation screening,group and save,in case she has to go theatre for diagnostic or therapeutic procedure.If BHCG level is more than 1000iu,then a repeat TVS should be performed,and if the uterus is still empty,a diagnostic laparoscopy may be performed.If the level is less than 1000iu,a repeat serum BHCG should be performed in 48hrs.If the level has risen more than 66%,a viable intra-uterine gestation is likely and a repeat ultrasound should be performed to confirm this..However,ectopic is more likely with the level\'s rise of less than 66%.A falling level would indicate a non-viable pregnany.
Ectpoic pregnancy can be managed expectantly,medically or surgically.Since she is haemodynamically stable,she is could opt for any of the three approaches.
For expectant management,she would be told of the need to stay in the hospital for serial BHCG nad ultarsould management and that there would be a recourse to surgical option should her clincal picture s become dramatic or BHCG are rising.
Medical approach involves use of methotrxate injection.Allergy to this drug is a contraindication.This also involve serial BHCG measurement and scanning.She would be warned of the potential side effects of the drug such as abdominal pain,rash,photosensitivity.She might require more than on dose of methotrexate and a recousre to surgical management is a possibility if this fails or she becomes unstable.
Surgical management is carried ou more often than not laparoscopically and this may be salpingectomy or salpingostomy.The procedure would be explained including the intended benefits,recurrent risks(anaesthetic,pains,DVT/PE,haemorrhage),serious risks(bladder or bowel injury,major vascular injury),recourse to laparotomy.Alternative options enumerated above would be discussed.Her views and wishes would be taken into consideration and documented befor taken her written consent.In her case,salpingostomy would be performed if at all possible,otherwise salpingectomy.The realtive risks of recurrence of salpingectomy and salpingostomy woul dbe discussed on one hand and compare this with recurrence in medical and expectant management.If she opted for surgical option,anti D should be offered if she is Rhesus negative and unsensitised.


Posted by Sarwat F.
Diagnostic approach includes urgent serum Beta HCG estimation. At a level of 1000 to 1500 iu/ml an intrauterine sac should be visible. As the patient is haemodynamically stable Beta HCG will be repeated 48 hrs later. She will be given options either to stay in or to be managed as outpatient depending on the severity of her symptoms. If she opts for outpatient management she should be given a 24 hour emergency number and should be educated about warning signs of ectopic pregnancy which includes severe abdominal pain, fainting, dizziness and shoulder tip pain. In a normal intrauterine pregnancy Beta HCG doubles in 48 hrs time. If there is less than 66% increase between the two samples then it is suggestive of ectopic pregnancy. ultrasound scan is repeated to check for any adnexal masses and fluid in pouch of Douglas. Definite diagnosis can only be made on laparoscopy if ultrasound does not show any definite ectopic pregnancy. patient will be counseled about pros and cons of laparoscopy versus medical treatment with methotrexate.
If an ectopic pregnancy is diagnosed on ultrasound scan, various factors need to be considered before counseling for tubal conservation versus salpingectomy. These include whether ectopic pregnancy is intact, state of contralateral tube, Beta HCG levels, presence of fetal heart beat, size of ectopic pregnancy and patients wishes. If Beta HCG is less than 3000 iu/mls, size of ectopic pregnancy is less than 2.5 cm, there is no fetal heart beat and patient is haemodynamically stable she will be explained that medical treatment with methotrexate with tubal conservation can be done. Patient?s past medical history is explored to exclude any medical diseases involving liver or erythropoietic system. This will include sending baseline investigations like full blood picture, urea and electrolytes, liver function tests. Methotrexate is administered in the dose of 50 mg/m2. she will be explained about the side effects which include skin rashes, gastrointestinal ulceration, leukocyte depression, depression of erythropoiesis, alopecia, hepatocellular damage and jaundice and skin photosensitivity. Beta HCG will then be repeated on day 4 and then day 7 there should be at least 15% decrease in the levels. Subsequently Beta HCG is repeated weekly until it falls to less than 20 iu/ml. success rate of medical treatment is 85%, subsequent intrauterine pregnancy rate is comparable to salpingectomy and recurrence rate of ectopic pregnancy is 12%.
Other methods of tubal conservation include milking of tube, salpingostomy and salpingotomy whereby ectopic pregnancy is removed by making an opening in the tube and tube is conserved. The recurrence rate of ectopic pregnancy is higher with this option as compared to salpingectomy.
She will be explained about pros and cons of salpingectomy which include complications associated with anaesthesia and surgery for example haemorrhage, bowel injury, injury to bladder and major blood vessels, need for laparotomy and repair of bowel injury. Recurrence rate of ectopic pregnancy is low with salpingectomy. Status of contralateral tube is also important as it will not be a favoured option in patients with unhealthy tubes.
Patient will be explained about the options preferably with the help of leaflets and informed consent for treatment is obtained.
Posted by Mary M.
In making diagnosis, it is important to do urgent serum beta HGG level.If HGG level is below 1000.It can be early pregnancy with wrong dates or pregnancy of unknown location or ertopic pregnancy serum HGG monitoring is done. If level doubles in 48 hours it can present early pregnancy.In this case review after a week for repeat scan is done.If level remain plateau or drop down. It represent ertopic or miscarriage .As patient is haemodynamically stable therefore admission is not necessary she is counselled about condition & follow up is done twice weekly HGG level & once vaginal ultrasound. If HGG level are increasing or patient condition becomes unstable then admission and close observation with intervention in form of laparoscopy or lapartomy is necessary at that stage It is counselled about compliance of follow up for making final diagnosis and further treatment.

b) Patient is counselled about both methods.Information leaflets are given. Regarding pregnancy loss, relevant support group is contacted .If she is advised that if both tubes are healthy then salpingectomy is method of choice. Randomized trials have shown the equal chances of pregnancy after each method If the contralateral tube is blocked or absent the conservation of tube or salpingotomy is prefered.It is more economic than salpingectomy and IVF.However there are chances of residual trophoblastic tissues to be left & risk of future haemorrhage & needs of treatment by Methotrexate & long term follow up required. The chances of recrunt ectopic is more in salpingotomy than salpingectomy.Patient view is respected in any case after detailed discussion.


Posted by Srivas  P.
a)History should be asked about bleeding per vaginum and passing any products of conception -rule out complete miscarriage. History of passing grape like structures may suggest hydatiform mole. Any history of fainting attacks, shoulder tip pain, abdominal distension, tenderness could suggest ectopic pregnancy. Nature of abdominal pain should be asked?sudden sharp abdominal pain may suggest ruptured corpus luteum cyst. Her contraceptive history-use of IUCDs should be taken. Her sexual history, number of partners, any history of vaginal discharge, dyspareunia may suggest prior pelvic inflammation leading on to an ectopic pregnancy. This helps decide use of proper antibiotics and contact tracing. Her menstrual history and LMP should be taken to date her pregnancy.

Investigation should include FBC, blood grouping, and urine for pregnancy test, quantitative serum beta HCG levels and subsequently a repeat 48 hrs later. 85% of viable intrauterine pregnancies will show a 66% rise in hCG every 48hour, but 13% ectopic may also show same trend. A rise less than 50% is always associated with non?viable pregnancy. An USG normally shows an intra uterine gestational sac at discriminatory levels of serum HCG of 1500miu/ml and its absence at these levels may suggest an ectopic pregnancy. Serum progesterone level may be useful?a level of 25ng/ml suggests IU pregnancy while level less than 5ng/ml-a non viable pregnancy. A rising trend may suggest ongoing pregnancy and a search for location of IU gestational sac. Though Laproscopy is the gold standard in diagnosing an ectopic pregnancy, with 5% false +ve and 4% false ?ve rates, it is invasive and it maybe avoided if she is assessed to be haemodynamically stable ectopic pregnancy based on quantitative HCG levels and USG findings alone and she is agreeing for conservative or medical management and a regular follow up.

Clinical examination should include P, B.P, pallor per abdominal examination for abdominal distension, rigidity, direct and rebound tenderness. Pelvis examination for size of uterus, os open or closed, adnexal masses, fullness in pouch of Douglas, cervical excitation pain?can help differentiate between miscarriage and ectopic gestations.

b)The options in this haemodynamically stable woman with USG diagnosed ectopic pregnancy are medical or surgical options.

As surgical option since she is haemodynamically stable, laparoscopic approach is preferable to an open approach. Advantages are shorter operation times, less blood loss, shorter hospital stays and less analgesic need. Subsequent intrauterine pregnancy rates are similar in both methods with a lowered repeat ectopic pregnancy rate with laparoscopic approach. But laparoscopic approach is associated with increased chances of persistent fetal tissues which may necessite a treatment with methotrexate or even a laparotomy.

The other option I would need to discuss with her is option of conserving the tube by salpingotomy rather than remove the tube by salpingectomy. I would tell her that though Intra ut preg rate with salpingotomy is slightly higher, the ectopic pregnancy rate too is increased to 18% compared to 8% with salpingectomy. Hence I would offer her conservative procedure only if the contra-lateral tube is damaged.

Compared to the surgical option medical option with methotrexate is equally good as it avoids invasive procedures like laparoscopy/ laparotomy and risks of laparoscopic procedures-injury to blood vessels, bowel injury and rarely even death in 1: 12000 cases, and risks of anesthesia. She would require inpatient stay.

Methotrexate treatment can be done as OPD procedure and is 50% cheaper and is best offered with Beta HCG levels between 3000-5000 miu/ml. The subsequent intra uterine pregnancy rate is comparable to a surgical prodedure and a 10% recurrent pregnancy rate. She would need to have regular follow ups. The presence of cardiac activity is a contra indication.

There is 10% chance it may fail and she would need surgery and a 15% chance that she may need more than one dose of methotrexate with all the side effects- nausea, oral ulcers, loss of hair, lowered white blood cells and chest infection.She may have abdominal pain during treatment and admission for monitoring. She should also avoid sexual intercourse during treatment and avoid pregnancy for 3 months due to teratogenic effect of methotrexate.

She should be given written handouts and information materials to read and come to informed decision.


Posted by Randa E.
The best approach to diagnosis is to be highly suspicious of an ectopic pregnancy in a women of child bearing age who presents with the above presentation. A detailed medical history needs to be obtained and should focus on the LMP to ascertain dates and try to exclude early gestation. The onset and localization of the pain must also be ascertained.Its duration and whether it was prior to or after the vaginal bleeding should also be known for it might help in the exclusion of complete miscarriage. Classically with ectopic pregnancy the pain preceeds the bleeding. Association of shoulder tip pain is suggestive of an ectopic. Contraceptive history is also important e.g IUCD or minipill use. Other risk factors like PID, previous tubal surgery , previous ectopic pregnancy and exposure to DES in utero should also be ascertained.
Thorough abdominal examination is important for it might reveal localization of pain to one or the other iliac fossa. Overt blood loss must be assessed and if minimal would suggest an ectopic pregnancy. Vaginal examination might reveal a closed cervix and tenderness in one iliac fossa which might also be suggestive of an ectopic.
Blood group should be determined and serum saved so that if vaginal bleeding increases blood can be transfused rapidly. Rhesus status should be ascertained and anti-D if rhesus -ive might be required in the case of surgical intervention.
Serial measurements of serum hCG levels can be used to assess patients with suspected ectopic pregnancy. Levels >1000 iu/l with the absence of an intrauterine sac on u/s is nearly always associated with ectopics. A single serum progesterone measurement might also exclude and ectopic(>25ng/ml). Laproscopy can be used to confirm the diagnosis if seen appropriate.
In order to properly council this patient she should know that ectopic pregnancy is a serious condition and a major cause of maternal death in the UK. She must Know that the best choice of management must be tailored to her clinical condition and her future fertility requirements. She should be aware that the conservation of the tubes (salpingotomy) is most suitable for unruptured ectopics <5cm in diameter. It is also considered as the primary treatment when managing tubal pregnancy in the presence of contralateral tubal disease and desire to maintain future fertility. She must be told that the risk of persistent trophoblastic tissue is higher after salpingotomy .Serum hCG levels should be followed after the operation using serial hCG measurements which normally fall after successful treatment. Methotrexate might be an alternative if levels fail to fall as expected. Salpingotomy also carries an increased risk of tubal bleeding in the immediate post-op period with the risk of further surgical intervention. It also carries a higher risk of a further ectopic pregnancy. In the prescence of a healthy contra-lateral tube it would be more appropriate to use salpingectomy for there does not appear to be a difference in subsequent intra-uterine pregnancy rate after removal of the affected tube. She must also be made aware of the risks of the surgery and anaesthesia. All that is discussed should be clearly documented and the womens wishes taken into account and recorded. Written information concerning her treatment options, follow-up and names of support groups should be provided.

Posted by Freha Z.
A thorough clinical history should be taken. Her Last menstrual period, menstrual cycle and its regularity, site and radiation of abdominal pain shuld beasked. A shoulder tip pain may be there in ruptured ectopic pregnancy. Abdominal pain out of proportion of vaginal bleeding is also an indicator of ectopic. Risk factors such as pelvic inflammatory disease, multiple sexual parteners and any abdominal surgery may be present in 25-50% ectopics. Her Pulse, Blood pressure should be taken as hypotension and tachycardia are early signs of bleeding/shock. Pelvic examination may not be helpful. Two most important examination tools are transvaginal scan and B hCG. In absence of intrauterine sac if B-hCG is more than >1500IU/l it indicates ectopic or recent abortion. But if B hCG is <1000 in presence of irregular cycle may indicate early intrauterine pregnancy or ectopic. Further diagnosis depends on serial quantitative assessment of B hCG. If B hCG rises by less than 66% in 48 hours an ectopic should be considered in 85% however 15% of ectopic show rise more than 66%. A plateau in hCG rise ( doubling time of 7days or more) is highly suggestive of ectopic. Falling levels of hCG indicate spontaneous miscarriage. Uterine curettage can be used as diagnostic tool which may show Arias Stella reaction in endometrial curettings but rarely performed because of presence of other effective non invasive methods.
Laparoscopy is a gold standard for diagnosis of tubal pregnancy which is seen as distention of tubal wall in unruptured ectopic. Free blood in peritoneal cavity suggests careful examination of fallopian tubes as in 3-4% of very small ectopics may be missed.
(b)She should be informed that the decision to perform salpingectomy depends on the status of other tube. If the other tube is healthy salpingectomy may be performed which reduces the risk of further ectopic in the same tube although the subsequent pregnancy rates might be a bit lower compared to salpingostomy. Conservative procedures are salpingotomy and Fimbrial evacuation. In salpingotomy products of conception are removed by giving a small incision on the tube while in fimbrial evacation the products of conception are milked out by fimbrial end. Both procedures increase the risk of subsequent ectopic in same tube. There is also risk of persistant trophoblast in conservative procedures which may need subsequent treatment. These procedures can be performed both by laparoscopy and laprotomy. Laproscpy has advantage of shorter duration of hospital stay, less analgesia requirement and less blood loss compared to laparoscopy.
She should also be informed that there in no clear evidence that salpingotomy is preferable to salpingectomy in presence of contralateral healthy tube. Therefore informed decision should be made on the basis of information provided which should be backed up by written information and should be clearly documented in notes.
Posted by Sreekala S.
The differential diagnosis includes ectopic pregnancy, pregnancy of unknown location, failing pregnancy and very early in pregnancy(<5weeks). An accurate menstrual history should be taken to confirm her period of amenorrhoea as a gestational sac may not be seen if she is very early in pregnancy although her pregnancy test is positive. She should be offered serum beta hCG estimation and repeated in 48hrs.Bloods should also be taken for FBC, group and save. Serial hCG estimation is more important than a single measurement. Usually, hCG levels double in 48hrs. Ideally the woman should be kept admitted until the diagnosis is confirmed due to the high mortality/morbidity assoiated with Ectopic pregnancy.
Serum hCG value of less than 1000iu/l in the absence of a gestation sac on TVS suggests a pregnancy of unknown location..
An ectopic pregnancy is very likely if the hCG values taken 48hrs apart have a sub optimal rise, fall or plateau.
If there is a gradual decline in hCG values there is a high probability of a failing pregnancy. hCG levels increasing by more than double in 48hrs is suggestive of an intra uterine pregnancy. A repeat scan is advisable in 7-10days to confirm the diagnosis. A diagnostic laparoscopy may be indicated if the woman becomes more symptomatic with pain or if the hCG values are inconclusive. She should be counselled with risks of diagnostic laparoscopy.

I would tell that salpingectomy and tubal conservation with salpingotomy can be done laparoscopically or by laparotomy. I will tell her that laparoscopic approach has the advantage of shorter operation time, lesser intra-operative blood loss, shorter hospital stay and lesser analgesic requirement. It is the ideal approach if she is hemodynamically stable. If there is a suspicion of a ruptured ectopic and the woman is not hemodynamically stable, then laparotomy should be done as it is usually the most quickest route of entry into abdomen. I would tell her that if she wishes future fertility, the intra uterine pregnancy rates are equal with lapartomy and laparoscopic approaches, but laparocopic approach is associated with lesser future ectopics when compared to the open approach.
I will tell her that in the presence of a healthy contralateral tube, it is advisable to go for salpingectomy. In the presence of a diseased contralateral tube, salpingotomy should be strongly considered if fertility is desired. She should be counselled that with tubal consevation surgery, she will be at an increased risk of repeat ectopic pregnancy in the conserved tube, a small risk of postoperative tubal bleeding, increased risk of persistent trophoblastic tissue with a subsequent need for monitoring with serum hCG and treatment, usually with methotrexate. I would explain the possible complications like bleeding, injury to bowels/bladder and infection whatever surgical method she opts for.
I would also give her the option of medical management with methotrexate provided her hCG levels are < 3000iu/l and absence of fetal heart. She should be given information leaflets and made to take an informed choice. I would give her adequate time to decide and ask questions. I would inform her that she might need Anti-D if she is Rh negative. I will document the discussion in her notes.
Posted by Yasser S.
She should be considered as a case of ectopic pregnancy until proven otherwise. The immediate investigations that are required are serum beta HCG, full blood count and blood grouping. Though there\'s some controversy in the limit of beta HCG at which a gestational sac should be visualized, but a reading of 1500 IU with an empty uterus should alert for hospitalization for her. As long as she is hemodynamically stable, the gold standard for diagnosis is laproscopy. If the initial reading for Beta HCG is less than 1500, she should have another beta HCG repeated after 48 hrs. A rise less than double during this period is suggestive of ectopic pregnancy or a pregnancy of unknown origin. A fall in beta HCG suggests a complete abortion. During this period of 48 hrs, a stable patient could be discharged home with full instructions of symptoms of intraperitoneal bleed. She should be provided with 24 hrs emergency hotline numbers and written information of the symptoms. Careful documentation of her clinical status at discharge should be done. Another ultrasound should be repeated according to the rise or fall in beta HCG which might show the location of pregnancy or increase in the amount of fluid in the peritoneal cavity. When the diagnostic investigations are suggestive of ectopic pregnancy, the patient should be hospitalized and further management planned.

The councelling on this subject needs a sensitive and sympathetic approach.She should be told that the procedure would mainly depend on the state of both tubes. If the other tube is healthy, then removal of the tube with the pregnancy is preferable as it can cause a further ectopic pregnancy. It would also depend on the location of pregnancy in that tube as if it is in the middle or the inner end, then it is difficult to preserve the tube. Another important factor is the state of the affected tube at the time of procedure. If it is about to rupture or affects a large area, then even the other tube is unhealthy, still it has to be removed. She must understand that tubal pregnancy in itself is an indication of unhealthy tube and the removal might be the best option. She must be reassured that whatever would be done, would be in the best of her interest. She might need a demonstration diagrammatically of the tuibal anatomy which would clear her concepts. She should be told that she would still have the option of invitro fertilization in the worst scenario of salpingectomy with other unhealthy tube. The consent should be fully informed. All the discussion with the patient should be fully documented and her wishes recorded.
Posted by Abi T.
There should be a high clinical suspicion of an ectopic pregnancy in this woman. However differentials would include very early intrauterine gestation ,pregnancy of unknown location and complete miscarriage. A good history should be obtained to ascertain LMP, any cycle irregularity and use of hormonal contraception as this may suggest possible very early gestation. Risk factors for ectopic pregnancy should be obtained eg, history of PID, multiple sexual partners, recent use of emergency contraception, use of IUCD or progesterone only pill. A history of heavy bleeding with clots and tissue passed may be more suggestive of a complete miscarriage. Useful clinical examination would be presence of localized tenderness in either iliac fossa and cervical excitaion may support a diagnosis of ectopic but not conclusive. She should be admitted if abdominal pain is severe and observed for symptomsand signs of ruptured ectopic which are shoulder tip pain,worsening abdominal pain, tachycardia, hypotension and rigid abdomen. FBC and group and save should be done in case she needs surgical treatment.
Serum BhCG and progesterone would be supportive in making a diagnosis but not conclusive, as they are more suggestive of viabilityand not location of pregnancy. They are also useful in deciding suitable treatment options. An initial level should be obtained and this should be repeated in 48 hours. A 66% rise in serum BhCG above baseline and a serum progesterone of more than 20nmol/l is more indicative of a viable intrauterine pregnancy, however 10% of ectopics may show this picture as well. If the serum BhCG is above 1000-1500iu/ml a repeat TVS should be done as an IUP should be detected at these discriminatory levels. A suboptimal rise in serum BhCG can also be suggestive of an ectopic. A rapidly falling BhCG and low progesterone levels are indicative of a failing pregnancy . These serial blood tests should be correlated with ongoing clinical assessment of the patient to reach a definitive diagnosis. Laparoscopy is the gold standard in diagnosing and treating an ectopic pregnancy and is indicated if patient\'s symptoms worsen and the above blood tests are highly suggestive of an ectopic or a repeat TVS confirms an ectopic gestation.
b) As the patient is hemodynamically stable she has the option of medical and surgical treatment options.Counselling as to tubal conservation or salpingectomy is suitable depends on wether the clinical criteria are met for the different treatment modalities, availability of rapid serum BhCG assays and TVS, patient\'s agreement for follow up , easy access to hospital and patient\'s wishes based on informed consent. She should be told that her overall risk of a future ectopic is higher than normal population and future IUP pregnancy rates are not significantly altered by whichever treatment option she chooses.
Expectant management is an option to conserve tubes if patient has minimal symptoms, fluid in POD less than 100ml, and BhCG is less than 1000iu/ml or rapidly falling levels. She should be warned that there is a 15% risk of recourse to surgery in case of ruptured ectopic as these can happen at low levels too. She should be compliant to follow up which may take several weeks involving serial BhCG measurements and have easy access to the hospital.
Medical management involves a single dose of IM methotrexate. A further dose may be needed if thesubsequent fall in BhCG is less than 15%. Criteria for medical management are minimal symptoms, serum BhCG less than 3000iu/ml, adnexal mass less than 4cm, absence of blood in POD or fluid less than 100ml and absence of fetal heart beat. Absolute contraindications are allergy to methotrexate and signs of a ruptured ectopic. failure of treatment is more likely if bhCG levels are higher than 5000iu/ml and presence of fetal heart beat. She should be informed of a 10% risk of failure of treatment requring surgery and the side effects of methotrexate ie, GI upset, photosensitivity and reversible liver damage. THis would also require compliance to several weeks of follow up with serial BhCG and possible admissions to hospital. She should avoid alcohol and sex till treatment is over and the need for contraception for 3 months following treatment as this drug is teratogenic.
LAparoscopic surgery is the mainstay of surgical treatment and indicated if criteria are not met for conservative/medical management or the above treatment failure. She should be told that salpingectomy is the recommended treatment in the presence of a healthy contralateral tube. Salpingotomy may have slightly higher future IUP rates but this is offset by the risks of tubal bleeding requiring salpingectomy and persistent trophoblastic tissue requiring repeat surgery or methotrexate. Salpingotomy is advocated if there is obvious disease in contralateral tube.The risks of laparoscopic surgery should also be discussed, ie, visceral injury, infection, recourse to laparotomy in case of visceral injury, failure to gain entry into abdomen and uncontrollable bleeding.The advantages are shorter operating times and shorter hospital stay and avoidance of prolonged follow up.
This verbal information should be supported by written information.
Posted by Shyamaly S.
A) A Full history should be taken, asking how severe the pain was , whether it was localised, with shoulder tip pain or associated with any episodes of loss of consciousness or collapse, which would be highly suspicious of an ectopic pregnancy pregnancy. A bowel and urinary history should be taken-a UTI may be responsible for pain, while constipation can also cause pain while diarrhoes may be associated with an ectopic. The heaviness of her bleeding should be determined- did she pass any clots or tissue suggestive of an incomplete miscarriage or was there light blood loss only. The date of her first positive pregnancy test as well as her LMP should be found as these will help in the interpretation of serum HCG levels. It should be asked if this was a planned pregnancy. Conception despited the use of the Progeterone only pill or intr uterine devices increases the risk of an ectopic pregnancy as does the use of emergency contraception. Fertility treatment is also important- IVF is associated with a higher ectopic rate especially because ectopic pregnancy is associated with tubal damage. Any history of previous pregnancies, in particular asking about previous ectopic pregnancies is pertinent as this would increase the risk of her having a further ectopic. History of previous pevic inflammatory disease or pelvic surgery would also raise the suspicion of ectopic pregnancy.
On examination the patients haemodynamic status should be assessed using pulse, blood pressure and oxygen saturations. The temperature should be recorded as a pyrexia would raise the suspicion of inflammation secondary to appendicitis but also to an ectopic. On abdominal examination, signs of peritonism should be assessed for raising the possibiltiy of intra abdominal pathology. Tenderness may help to determine the location. Vaginal examination may reveal adnexal tenderness, swelling and cervical motion tenderness which are suspicios of an ectopic. Further investigations would be performed to distinguish between the differential diagnoses of ectopic pregnancy, threatened miscarriage, ovarian cyst accident, ruptured corpus luteum, appendicitis or UTI.
Blood tests should include full blood count to assess for anemia secondary to intra abdominal bleeding, and leucocytosis secondary to intra abdominal infection. A group and save should be performed- if she is Rhesus negative and surgery is required anti should be given. Blood should also be group and saved in case surgery is needed.
If the patient is haemodynamically unstable she should be taken to theatre for a laparotomy. If she is stable, a serum HCG should be performed. If it is more than 1000 a laparoscopy should be considered. If it is less than 1000 it should be repeated in 48 hours. If it has not doubled the risk of ectopic is elevated and a laposcopy should be considered bearing in mind that only 55% of intra uterine pregnancies show a doubloing in HCG.
B) Conservative, Medical and Surgical management is possible- these should be discussed with the patient and leaflets and information on ectopic pregnancy support groups should be given prior to a final decision being taken.
Conservartive
Inorder to manage an ectopic pregnant expectantly, the HCG should be less than 1000 and declining. The patient should be asymptomatic with minimal free fluid in the pouch of Douglas, available for weekly follow up and within easy reach of the hospital. The advantages are that major surgery is avoided in a situation where the tubal pregnancy is slowly miscarrying. The disadvantage is that the ectopic may rupture causing a lifethreatening situation and surgery may be required if HCG levels do not continue to fall. In this patients situation expectant management is not advisable given that she has had symptoms of pain and free fluid has been seen in th POD
Medical
A single dose of methotrexate, a folate antagonist at 50mg/kg can be given intramuscularly. She should be followed up as an outpatient on a twice weekly basis starting on day 4 post methotrexate to confirm that the HCG levels are falling. The advantages are that it is succesful in 85% of cases in resolving the pregnancy and avoids surgery. The disadvantages are that its use is recommended when the tubal mass is less than 3cm in size, the HCG is less than 2000, and there is no fetal cardiac activity, as these features reduce the efficacy. There is a risk that Medical management will fail and further methotrexate or surgery is needed. There is also a risk of scar rupture. Pt compliance is very important and pregnancy within the next 6 months is contra indicated.
Surgical
Surgical managemnt has the advantage of resolving the pregnancy immediately with minimal further follow up but it does carry anaesthetic risks, and risks of bleeding, needing a transfusion, infection, damage to bladder bowel and vessels.
This can be preformed laparoscopically or in an open procedure depending on the stability of the patient, the experience of the operator and the equipment available. Laproscopy is associated with a shorter hospital stay and faster post op recovery. The two surgical options are salpingostomy and salpingectomy.
Posted by Farzana N.
History and uss findings in this case are highly suggestive of ectopic preg,but a detailed history,examination and investigations would be required to confirm the diagnosis.
History regarding onset ,nature of painshould be taken.Associated shoulder tip pain or h/o fainting attack would be suggestive of ectopic pregnancy.h/o colicky pain and passage of clots /pocs taken to rule out complete abortion.
previous h/o PID or abdominal surgeries should be obtained,as damaged tubes and adhesions increase the risk of ectopic pregnancy.Mensttrual hist is taken to note any irregularity of periods and ascertain LMP,since empty uterus may be early pregnancy.
Examination would include general condition ,P,T,BP.Abdominal examination for any localised tenderness,rebound tenderness,guarding or rigidity,in case of ruptured ectopic preg with peritonitis.Pelvic examination done to note any cx excitation,size of the uterus and adnexae for any masses.
Investigations form the mainstay for confirmation of diagnosis of ectopic preg and deciding the mode of treatment.CBC done to note Hb level and if there is any fall.Blood is grouped and cross matched in case ectopic preg ruptures,and pt needs transfusion.serum beta HcG,quantitative is done.Levels >1500 would be suggestive of complete abortion.If the levels are less than this ,beta HcG should be repeated.USS is repeated in 2 days.In case of healthy preg,levels increase by 66% after 48hrs.If the levels increase by less than half or,are >1000,and TVS showing empty uterus,this is highly indicative of ectopic preg.Serum progesterone can be done and levels <15nmol/L is highly likely of nonviable preg.Repeat Scan may show adnexal mass.size of the mass is noted,as mass <3cm can be managed conservatively.Ifno adnexal mass is seen and the pt is symptomatic ,diagnostic laparatomy may have to be done.Liver and renal function tests should be done,which are required if methotrexate is to be given.
b)Pt would need good counselling,to decide abot thetreatment options,if the diagnosis of ectopic preg has been made.SIze of the adnexal mass,presense of free fluid in POD would influence the treatment options. She should be told about the pros and cons of different treatment options available .This can be expectant ,if the repeat beta HcG levels are falling and no definite mass is seen.If the mass is <3cm ,Beta Hcg levels<1000,and she is hemodynamically stable,medical treatment with methotrexate can be given.
Methotrexate therapy is given as a single dose 1mg/kg.success rates are80-90%.subsequent pregnancy rates are higher and repeat ectopic preg rates are lower than after surgery.Side effects include,vomiting ,diarrhea,photosensitivity.alopecia etc.she is advised to report if she has severe abdominal pain,heavy vaginal bleeding ,dizziness or syncope.She should be advised to avoid sunlight ,alcohol,NSAIDsand aspirin.She should also refrain from sex to avoid pregnancy as methotrexate is terratogenic.
If surgery is chosen she can have laparoscopy or laparotomy.Laparoscpy would be preferred since she is hemodynamically stable.advantages are shorte operation time,less intraoperative blood loss,shorter hospital stay and lower analgesic requirement.risk of bowel and visceral injury should be told ,also there is trend towartds increased rate of
repeat ectopic preg.
Salpingectomy or salpingotomy would be decided, based on the condition of the contralateral tube.if the other tube is healthy,RCOG recommends that salpingectomy should be done.If the other tube is damaged ,the tube should be conserved by doing salpingostomy.However this method has a risk of persistent trophoblastic disease.Although intrauterine pregnancy rates do not differ significantly ,ther is a higher of ectopic pregnancy with salpingostomy.
Written information should be given and informed consent obtained before any procedure is undertaken.
Posted by sailaja devi K.
Suspect ectopic pregnancy and differentiate from other causes of pain in early pregnancy.Causes of pain in early pregnancy are miscarriage , ruptured corpus luteal cyst ,appendicitis ,renal colic ,PID and endometriosis.
Review the history and identify any risk factors for ectopic pregnancy like PID ,IUCD.Clinical examination of the women helps to differentiate from other causes of pain.Women with ectopic may have few or no signs on examination. Per abdomen examination to identify tenderness ,guarding and rigidity.Pervaginal examination to elicit pain on cervical excitation, uterus may be soft and enlarged.

Explain to the women the need to do blood test and repeat ultrasound to rule out ectopic pregnancy.Women needs admission in view of pain abdomen .

Full blood count , group and typing, save sera for cross matching.Serum beta hCG to be done and ask for urgent report.Levels of 1500iu/l or 2000 iu /l are used as discriminatory zone.In suspected ectopic pregnancy there is serum beta hCG level at which it is assumed that all viable intrauterine pregnancy will be visualized by transvaginal ultrasound.When serum beta hCG is below discriminatory and there is no pregnancy on scan, then the pregnancy is of unknown location.Repeat transvaginal scan and serum beta hCG after 2 days.If beta hCG increase by 66 % in 48 hours it indicate viable intrauterine pregnancy.If the rate of increase is less than 66% or if doubling time is more than 2.7 days then suspect ectopic pregnancy.If beta hCG decreases by more than one half with in 48 hours,it suggest pregnancy is resolving.

If serum beta hCG is raising do diagnostic laproscopy to detect ectopic .If beta hCG is falling option is expectant management.
During the diagnostic work up monitor the vitals and assess the severity of pain.


Women should know treatment option for ectopic pregnancy .Salpingectomy is resection of the tube.The option of resection or conservation of tube depend on status of contralateral tube and whether ectopic is ruptured or not .Salpingectomy is treatment option for ruptured ectopic .

RCOG recommends salpingectomy is preferred method of treatment for ectopic pregnancy when tube on other side is normal.Salpingectomy is safest ,most clinically effective and most cost effective treatment.If the both tubes are present there is no difference in subsequent intrauterine pregnancy rate with resection or conservation of tube.

Tubal conservation is considered as the primary treatment for tubal pregnancy if contralateral tube is diseased and the desire for future fertility.If the tube is conserved there is 8 ? 19 % risk of persistent trophoblastic tissue and the need to monitor with hCG.There is risk of tubal bleeding postoperatively.If tube is conserved there is 15 -20 % recurrence rate of ectopic .This should be discussed and documented if tube is conserved.Tubal conservation is associated with 54 % intrauterine pregnancy rate.Tubal conservation is cost effective when requirement for IVF is considered.Short term cost of tubal conservation surgery is more than that of salpingectomy.
Posted by M M A.
A] According to the ultrasound scan findings, the initial diagnosis could be pregnancy of unknown location or pregnancy of unknown viability(failed pregnancy). Subsequently the patient will require monitoring for development of any new symptoms like abdominal pain, headache, lethargy, fainting, etc. with monitoring of vital signs; pulse, blood pressure, temperature and fluid input and output . This will allow early diagnosis and management of rupture ectopic pregnancy.
A base line quantitative assessment of serum β-HCG will be requested followed by serial measurements every 48 hours, it will assists in the diagnosis of ectopic pregnancy if the β-HCG level is less than 1000 iu/L or the rise is less than 50% per 48 hours, this may indicate failing pregnancy if it is declining and the condition may resolve spontaneously in 88 % of cases, however, monitoring will be required until the β-HCG level is less than 20 iu l/L
Repetitions of trans-vaginal scanning will be required after one week or more frequent if the patient develop sudden unexpected signs and symptoms, or there is a marked increment in β-HCG level, it will help to detect any adnexal mass and the presence of cardiac activity inside it, also it can show the presence of intrauterine gestational sac, however, it is unlikely in this patient as she has 8 weeks amenorrhea, also it can assess the amount of free fluid in pouch of Douglas.
Colour Doppler can also be used as it gives an idea about endometrial blood flow and help differentiation of ectopic pregnancy from incomplete pregnancy, also vascularity of adnexal masses can be assessed.
Serum progesterone measurement alone is of limited value but if used in conjunction with β-HCG assessment and TV Us finding can be highly specific and sensitive using a cut off point of 6 ng/ml( 20 n mol /L), any level below this ;it can be reassuring and spontaneous resolution can occur.
A base line Hb level can be helpful also as declining level can reflect internal bleeding.
Usually the clinical feature with the quantitative measurement of β-HCG with the use of high resolutions TV US, all together can reach an accurate diagnosis.
If β-HCG level continue to rise to 2000 iu/ml or more and still there is no evidence of gestational sac whether intra uterine or extra uterine, laparoscopy will be indicated, it is the definitive diagnostic test in suspected ectopic pregnancy despite that it carries 3-4% of false negative and 5% false positive.
If the initial level of β-HCG is 5000 iu/L and more, an immediate laparoscopy is mandatory and we should progress to laparotomy if haemoperitonium is found.

B] The patient should be given written and verbal informations to enable her making an informed consent with a clear documentation of her wishes.
We tell her that tubal conservation or salpingotomy will involve incising the tube and removing of the ectopic pregnancy .
She should be told that there is no significant difference in subsequent intrauterine pregnancy in both options but there will be higher recurrence rate of future ectopic pregnancy if the tube is conserved, however, this option depend on the state of other tube, if the contralateral tube is unhealthy we should conserve the affected tube and this on the other hand can be associated with post-operative bleeding.
Tubal conservation is also associated with a risk of persistent trophoplastic tissue and she will need frequent monitoring of β-HCG to diagnose it early to prevent future rupture of the tube.
She should know also that both management options can be done laparoscopically as far as she is haemodynamically stable and the tube is not rupture, this approach is preferable to laparotomy because it gets rid from large abdominal incision with it\'s subsequent complications, it offers rapid recovery with shorter stay in hospital, it also associated with less blood loss and lower analgesic requirement and it will be cosmetically acceptable.
On the other hand laparoscopy can not deal with all cases of ectopic pregnancy and laparotomy may be anticipated in some cases.
Laparoscopy also carries risks of visceral injury and major blood vessel injury.
Over all, salpingotomy will be more cost effective because of less need for future IVF.
Diagnostic methods and subsequent management should follow the recommended protocols of our unit.






Posted by Sreekala S.
Dear Paul,
We would greatly appreciate if you could kindly give us the right diagnostic approach to Ectopic pregnancy as none of us has written that part of the answer well.
Posted by Parveen  Q.
This patient may be not pregnant, that is it could be1. false positive results 2. early intrauterine pregnancy, 3. pregnancy of unknown location, or 4. ectopic pregnacy. Her further approach should be based on examination, futher investigation and taking a detail history .Since she is haemodynamically stable, she should be followed up in EPAU . Abdominational examination if inconclusive, should be followed by vaginal examination to feel for bulky uterus, any adnexal mass, tenderness, cervical excitation.Triple swab test for vaginal discharge will point towards pelvic infection , as explaind by abdominal pain, and minimal fluid in POD. Quantitative B Hcg should be performed, this could guide us to come to a diagnosis and help us in further mangement. TV- Us can detect intrauterine pregnancy by 5 weeks andalso if the level of b hcg is 1500iu/l. If level is below 1000iu/l it should alert us about pregnancy of unknown location, but every unit has different protocol and it be adhered to.Expectant management is the option here as she is clinically stable, and has minimal symptoms. She should be advised to repeat it after 48 hours and can be ressured if the level is falling . This should continue till the level comes to 20iu/ml. She should be advised verbally or given written information about keeping up the follow up and report to emergency if the pain increases or feels unwell. If the level increases by 66% in 48 hours, it could be intrauterine preganacy and repeat trans vaginal ultrasound performed to confirm the foetal viability. If her menstrual cycles are regular, by this time,( 8 weeks) fetal heart should be detected by TV USS, so it could be an anembryonic preganancy. She should be counselled for termination, as growing gestational sac can be seen in the USS, but no foetal pole. Her blood group, and FBC taken . If she is Rh negative, anti- D given. FBC is taken as a basic investigation , as there is an increased chance of rupture if she has an ectopic pregnancy and will guide us subsequently, if she remains clinically stable.
Her further management depends on the size of the ectopic, site, her haemodynamic status and patient\'s choice after explaing the risk and benefit of each option. USS report reviewed for the size of ectopic and the amount of fluid in POD. She should be given an option of expectant management, medical and surgical treatment. As, she is clincally stable, with minimal symptoms can be managed expectantly provided she understands the need for follow up . Before embarking on the mediacl management she should be given a verbal and written information about the side effect of methtrexate- that she will have abdominal pain due the drug itself, or the ectopic can rupture and subsequently needs surgical mangement. If the b hcg is less than 3000iu/ml and if the ectopic is less than 3cm, she can be given a single course of methotrexate, calculated from her body surface area and b hcg measured on 4th day, if the level falls by 15%between 4- 7days, can be asuured of the response to methotrexate. Followup by bhcg till the level falls to 20iu/l. there is no risk of anasthesia or operative risk in this group.
Surgical management can be laprocopically or by laprotomy. The benefit of laproscopy is short hospital stay, less analgesia requirement, less blood loss ,but if failed needs further laprotomy. Laproscopically she has 2 choice- either salpingotomy or salpingectomy. Salpingotomy is undertaken if the other tube is damaged, or removed before,or if there is a desire for future fertilityand the diseased tube is intact not ruptured. If the other tube is healthy, there is no clear evidence that salpingotomy is better than salpingectomy. The subsequent intrauterine preganacy rate is similar in both groups, but there is increase in subsequent ectopic rate in the salpingotomy group. Salpingotomy group needs further follow up with b hcg and treatment as there is chance of persistent trophoblast . Laprotomy , is the management of choice in an haemodynamically unstable patient. The anasthetic and operative risk remains more or less the same in both group., though the duration of operation time is more in laprocopic, followed immediately by laprotomy. Leaf lets can be given to reinforce the discussion and should be allowed to take an informed choice.