common site is the fallopian tube;rarely an ectopic pregnancy can befound in the ovary, a caesarean sectionscar, the abdomen or the cervix.
The most common risk factors are:• Previous ectopic pregnancy• Pelvic inflammatory disease• Endometriosis• Previous pelvic surgery• Presence of a coil9 Infertility
However, a third of women with anectopic pregnancy have no known riskfactors.
Ectopic pregnancy occurs in anaverage of 1 in 90 pregnancies in theUK. Although most cases are recognisedand treated appropriately, women stilldie as a result of late diagnosis andsuboptimal management of ectopicpregnancy. Six women died as a resultof ectopic pregnancy between 2006
jshoulddiagnosisbe confirmed?and 2008 in the UK.̂ The NICEguideline on ectopic pregnancy andmiscarriage, published in December2012, recommends a low threshold foroffering a pregnancy test to womenof childbearing age when they attendthe surgery.̂
Women should be referredto the most appropriate unit (A&E,gynaecology or early pregnancyassessment (EPA) service) if anectopic pregnancy is suspected. Theguideline also emphasises the need togive practical support and informationto patients and their partners.
SIGNS AND SYMPTOMSIn early pregnancy, all ectopicpregnancies will be asymptomatic;symptoms and signs appear when thetube starts to tear, see table 1, right.When the tube ruptures, the womanwill quickly become unwell andhaemodynamically unstable becauseof rapid intra-abdominal blood loss,see figure 1 above, »
managementoptions?
Symptoms of ectopic pregnancy
Common symptoms• Pelvic or abdominal pain• Amenorrhoea, missed period orabnormal period• Vaginal bleeding with or without clots
Other reported symptoms• Breast tenderness, nausea(related to pregnancy)• Diarrhoea and vomiting(related to intraperitoneai irritation)• Dizziness, fainting or syncope(related to significant haemorrhage)• Shoulder tip pain, shortness of breath,lower chest pain(related to irritation of the diaphragm)• Dysuria, urinary frequency(related to bladder irritation)• Pain on defecation or rectal pressure(related to deposit of blood in thepouch of Douglas)
Because of the range of symptomsa pregnancy test should be offered toall women of reproductive age.it is important to remember that apositive diagnosis of a urinary tractinfection or gastroenteritis does notexclude an ectopic pregnancy.
EXAMINATION ANDASSESSMENTA basic examination should includegeneral appearance (to look for pallor,shock, collapse), pulse (for tachycardia> 100 beats/minute) biood pressure(hypotension i.e. < 100/60 mmHg) andorthostatic hypotension.
The signs to look for in a case ofsuspected ectopic pregnancy areshown in table 2, above.
REFERRALThe urgency and location of thereferral depends on the clinicalsituation.
Women who are haemodynamicallyunstable, or in whom there issignificant concern about the degreeof pain or bleeding, should be referreddirectly to A&E, irrespective of theresult of the pregnancy test. Womenmay sometimes be unable to passurine If they are hypovoiaemic.
Stable patients with bleeding whohave pain or a pregnancy of six weeksgestation or more or a pregnancy ofuncertain gestation should be referredimmediately to an EPA service (orout-of-hours gynaecology service ifthe EPA service is not available) forfurther assessment. There are morethan 200 NHS EPA units throughoutthe UK with different working hours(see Useful information box on pl7).
If the EPA service is closed and youare concerned about the patient,contact the gynaecologist on call, witha view to avoiding delay in furtherassessment. It is important to explainto the patient, and her partner, whyshe is being referred and what toexpect when they arrive at thehospital.
GPs can use expectantmanagement for women with a
pregnancy of less than six weeksgestation who are bleeding but whoare not in pain. They should advisethese women to repeat a urinepregnancy test after 7-10 days and toreturn if it is positive or if theirsymptoms continue or worsen. Thepatient and her partner should begiven a phone number to cali in anemergency. The development of painshould prompt referral. An EPA serviceor out-of-hours gynaecology serviceshould be contacted immediatelywhen pain develops. If the pain issevere, the patient should be referredto A&E.
CONFIRMING DIAGNOSISAfter a positive pregnancy test at thesurgery, the diagnosis will beconfirmed, at the EPA service orout-of-hours gynaecology service,via a transvaginal ultrasound scan toidentify the location of the pregnancy.
If a transvaginal ultrasound scan isunacceptable to the woman, she wilibe offered a transabdominalultrasound scan, which has visuallimitations but has the advantage ofbeing able to detect fibroids, anenlarged uterus and ovarian cysts.
If the ultrasound is inconclusive andthe pregnancy cannot be located,human chorionic gonadotrophin(hCG) levels repeated after 48 hoursmay help to make a diagnosis andassist in planning the repeat scan.hCG is an indicator of trophoblastproliferation but not the location of thepregnancy, it should be noted thathCG can increase, decrease or plateauwith an ectopic pregnancy. Theultrasound scan and the woman'ssymptoms are the key to diagnosis.
if the diagnosis is still unclearand the woman is in significant pain,a laparoscopy may be offered.
MANAGEMENTThe management options depend onthe symptoms, the hCG level, theultrasound findings, the patient'sgeneral health and preferences, andthe facilities for follow-up.
Medical managementMedical management with methotrexateis offered to women who are able toreturn for follow-up and who fulfill allthe following criteria;• No significant pain• An unruptured ectopic pregnancywith an adnexal mass smaller than35 mm with no visible heartbeat• A serum hCG < 1,500 lU/L• No intrauterine pregnancy (as
confirmed on an ultrasound scan).Methotrexate is an antimetabolite
and antifolate drug, it is teratogenicand effective contraception should beused for three months followingadministration. Patients should avoidalcohol and NSAIDs. Approximatelyone in six women will experience sideeffects of nausea, sickness, diarrhoea,mouth ulcers and feelings of fatigue.These symptoms usually only last afew days.
Monitoring is hospital based.Women are asked to attend regularlyfor blood tests (including liver andrenal function) and hCG follow-up untillevels are < 25 lU/L. A Rhesus-negativewoman will not need to receive anti D.
An ectopic pregnancy may rupturedespite apparently successfultreatment and declining hCG levels.Significant pain during medicaltreatment with methotrexate wouldindicate a ruptured ectopic pregnancyand should prompt emergencyassessment and hospital admission.
'An ectopicpregnancy mayrupture despiteapparentlysuccessfultreatment anddeclininghCG levels'SurgerySurgical management usuallylaparoscopic salpingectomy (unlessthere is an abnormal contralateral tubeor the patient is haemodynamicallyunstable), will be offered to womenwho are unable to return for follow-upafter methotrexate treatment or whohave an ectopic pregnancy plus any ofthe following;• Significant pain• An adnexal mass of 35 mm or larger• A fetal heartbeat visible on anultrasound scan• A serum hCG > 5,000 lU/L
Rhesus-negative womenundergoing surgery for ectopicpregnancy should be offered250 lU anti D.
Expectant managementThis is outside the remit of the NICEguidance, but could be considered for
thepractitioner.co.uk
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key pointsDr Peter SaulGR Wrexham and Associate GP Dean for North Wales
The most common site of localisation of an ectopicpregnancy is the fallopian tube. Rarely an ectopic pregnancycan be found in the ovary, a caesarean section scar, theabdomen or the cervix. Risk factors are previous ectopicpregnancy, pelvic inflammatory disease, endometriosis,previous pelvic surgery, the presence of a coil and infertility.However, a third of women with an ectopic pregnancyhave no known risk factors.
NICE recommends a low threshold for offering apregnancy test to women of childbearing age when theyattend the surgery. Symptoms and signs appear whenthe tube starts to tear. When the tube ruptures, the womanwill quickly become unwell and haemodynamicallyunstable because of rapid intra-abdominal blood loss.The most common symptoms of ectopic pregnancy arepelvic or abdominal pain, amenorrhoea, missed period orabnormal period anci vaginal bleeding. A positivediagnosis of a urinary tract infection or gastroenteritisdoes not exclude an ectopic pregnancy Signs ofsuspected ectopic pregnancy include pelvic, abdominal,adnexal or cervical motion tenderness, reboundtenderness and abdominal distension.
Women who are haemodynamically unstable, or inwhom there is significant concern about the degree of painor bleeding, should be referred directly to A&E, irrespectiveof the result of the pregnancy test. Stable patients withbleeding who have pain or a pregnancy of six weeksgestation or more or a pregnancy of uncertain gestationshould be referred immediately to an early pregnancyassessment (EPA) service, or out-of-hours gynaecologyservice if the EPA service is not available. GPs can useexpectant management for women with a pregnancy of lessthan six weeks gestation who are bleeding but who are notin pain. Diagnosis is confirmed by transvaginal ultrasoundscan to identify the location of the pregnancy.
Medical management with methotrexate is offeredto women who are able to return for follow-up andwho have no significant pain, an unruptured ectopicpregnancy smaller than 35 mm with no visible heartbeat,serum hCG less than 1,500 lU/L and no intrauterinepregnancy. Surgical management, usually laparoscopicsalpingectomy, will be offered to women (where theseconditions are not met). NICE recommends that EPAservices should be available seven days a week and thatwomen who have had a previous ectopic pregnancy mayself-refer.
a pain-free woman with a smallectopic pregnancy, able to return forfollow-up, with low and falling hCGlevels. The protocols vary at eachhospital. A third of these women willrequire additional medical or surgicalmanagement.
CONCLUSIONNICE recommends pregnancy testingof women of reproductive agepresenting with both common andless common symptoms and signs ofectopic pregnancy and a lowthreshold for referral to the EPA,out-of-hours gynaecology service orA&E. There is a strong emphasis oncommunication and supportthroughout the whole process.
NICE has made a priorityrecommendation that EPA servicesshould be available seven days a weekfacilitating access to ultrasoundscanning. Women who have hada previous ectopic pregnancy mayself-refer to an EPA service.
The guidance also promotesmedical management of ectopicpregnancy for suitable patients andlaparoscopy (rather than laparotomy)for women who require surgery.
REFERENCES1 Centre for Maternal and Child Enquiries (CMACE),Saving Mothers' Lives: reviewing maternal deaths tomake motherhood safer: 2006-08. The Eighth Reporton Confidential Enquiries into Maternal Deaths in theUnited Kingdom. BJOG 2011:118 (Suppl. l):l-2032 National Institute for Heaith and Clinical Exceilence.CG154. Ectopic pregnancy and miscarriage: diagnosisand initial management in early pregnancy of ectopicpregnancy and miscarriage. NICE. London. 20123 Royal College of Obstetricians and Gynaecologists.The management of tubai pregnancy. RCOG GuidelineNo 21. RCOG. London. 2010
Useful information
Early Pregnancy Assessment UnitsTo find your local EPA unit go tohttp:/yearlypregnancy.org.uk/FindUsMap.asp
