Management Of Ectopic Pregnancy

Management Of Hypertension In Pregnancy

Acute Uterine Inversion

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MANAGEMENT OF ECTOPIC PREGNANCY

Dr Judith Kundodyiwa MRCOG

Table of content

5. Management flow chart-For the chart

6. Inclusion criteria for medical treatment

7. Exclusion criteria for medical treatment

9. Reference

DEFINITION

Incidence – 11 per 1000 pregnancies.
Incidence attending early pregnancy unit is 2-3%
11000 ectopic pregnancy diagnosed each year in the United Kingdom
Accounted for 6 direct maternal deaths between 2006 and 2008.
Risk: Previous tubal damage, previous ectopic, smoking, IVF
(ALWAYS consider ectopic pregnancy as a cause for abdominal or pelvic pain, with or without vaginal bleeding, or of unexplained symptoms of hypovolaemia in any woman of childbearing age)
Occasionally ectopic pregnancy can also present as diarrhoea and vomiting.

INITIAL ASSESSMENT

HAEMODYNAMICALLY UNSTABLE
- High-flow oxygen.
- 2 large bore cannulae + IV fluids
- Bloods for FBC, cross-match 4units and β-hCG (Urgent)
- Contact on call gynae team immediately including consultant gyaecologist
- Consider for direct transfer to theatre.
HAEMODYNAMICALLY STABLE
- History and examination.
- Arrange Transvaginal Ultrasound.

MANAGEMENT

Management is either conservative or expectant management, medical or surgical
Expectant management of ectopic pregnancies is rarely successful if β-hCG levels have ever risen above 1000IU/L. Success rate increases with decreasing βHCG levels
If serum βHCG concentration is rising or there is pelvic pain then most women will be best treated by medical or surgical intervention.
Overall success rate of single dose methotrexate for tubal ectopic pregnancy is 65-95% with 3-27% requiring a 2nd dose
Women must be made aware of the need for follow-up and repeat hospital visits.
7% of women will experience tubal rupture during follow-up.
Tubal patency rates and reproductive outcomes after medical therapy seem to be similar to those after laparoscopic salpingotomy

Flow chart

See below for suggested surgical management.

INCLUSION CRITERIA FOR MEDICAL TREATMENT:

Clinical symptoms: None or mild adnexal pain only
Haemodynamically stable
Serum βHCG level: <3000IU/L
Transvaginal Scan findings: Ectopic size (adnexal mass) <3.5cm in diameter

No cardiac activity

Minimal (<50ml) fluid in pelvis

No contraindications to Methotrexate (see below in excluding criteria)
Woman prepared to accept treatment and subsequent follow up
Persistent ectopic pregnancy following salpingotomy with the following:
A rise or a fall of < 15% of βHCG 7days after surgery
The same other criteria as above

A good candidate for methotrexate has the following characteristics:

haemodynamic stability
low serum β-hCG, ideally less than 1500 iu/l but can be up to 5000 iu/l
no fetal cardiac activity seen on ultrasound scan
certainty that there is no intrauterine pregnancy
willingness to attend for follow-up
no known sensitivity to methotrexate.

EXCLUSION CRITERIA FOR MEDICAL TREATMENT:

Haemodynamically unstable
Generalised peritonism on abdominal palpation
Diagnostic uncertainty requiring laparoscopy
Medical contraindication to Methotrexate (Leukopaenia, thrombocytopaenia, elevated serum liver enzymes or creatinine)

PLEASE NOTE

There are many well-documented cases of women with intrauterine pregnancies treated for suspected ectopic pregnancy with methotrexate. Methotrexate should, therefore, never be given at the first visit, unless the diagnosis of ectopic pregnancy is absolutely clear and a viable intrauterine pregnancy has been excluded.

MEDICAL MANAGEMENT PLAN

Day 0:

Pre-treatment Tests: Serum βHCG Level, FBC, LFTs and U&Es.
Ensure woman fulfils criteria for treatment, understands the implications and accepts the limitations
Give information leaflet to woman
Give mifepristone 600mg
Methotrexate must only be prescribed by consultant on yellow cytotoxic prescription sheet (rounded to nearest 5mg).
The woman can be discharged after receiving the Methotrexate.
METHOTREXATE DOSE – single IM injection of 50mg/m² of body surface area (see cytotoxic prescription sheets).
Offer anti-D to rhesus negative women

Follow-up of patient

Day 4: Clinical review

Serum βHCG level

Day 7: Clinical review

Repeat FBC, LFTs, U&Es.

Repeat serum βHCG level: If levels fall from by >15% between

continue weekly measurements.

If the fall was < 15% then repeat another dose of Methotrexate if not contraindicated

Weekly review:

Clinical review
Weekly serum βHCG till < 20IU/L
Arrange Transvaginalultrasound if abdominal pain develops (avoid bimanual vaginal examination)
A third dose of Methotrexate may be considered in exceptional circumstances (consultant decision only) if the serum βHCG level plateauing or rising after day 7 and no contraindication to Methotrexate have developed. However, surgery in this case may be a safer option

Note: Transient increase in serum βHCG level may occur between day 1-4 after treatment. The mean time for serum βHCG resolution is 23-35 days

ADVERSE EFFECTS OF METHOTREXATE

Stomatitis, gastritis and enteritis (nausea, vomiting, diarrhoea and sore and dry mouth)
Transient Impaired liver function test (elevated serum liver enzymes)
Bone marrow suppression (Leukopaenia, thrombocytopaenia)
Alopecia (extremely rare)
Abdominal pain usually 3-7 days after treatment (separation pain, haematosalpinx, pelvic haematocele or tubal rupture)

Patients must be advised to avoid pregnancy for 3 months following Methotrexate administration.

INDICATIONS FOR SURGICAL INTERVENTION

May be required if during follow-up clinical signs or ultrasound scan suggests tubal rupture. Also, if further medical therapy is required but a contraindication to further Methotrexate has developed.

Wherever possible surgical intervention should be performed laparoscopically as this is associated with shorter hospital stay, less intraoperative blood loss, reduced pain ,less adhesion formation and lower repeat ectopic pregnancies.

When performing surgical treatment for ectopic pregnancy, if the contralateral tube appears normal then salpingectomy is the procedure of choice.

If salpingotomy is performed then the woman must be informed of the need for follow up βHCG to exclude persistent trophoblastic disease.

Administer anti-D to rhesus negative women and surgical management

HETEROTOPIC PREGNANCY

Diagnosed when ultrasound findings demonstrates and intrauterine pregnancy and a coexisting ectopic pregnancy

Should be considered in women presenting after assited reproductive technologies (IVF), women with intrauterine pregnancy complaining ofpersistent pelvic pain and in those with persistently raised βHCG levels following miscarriage or termination of pregnancy