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LeenaLaitinen

Ectopic Pregnancy

Essentials

  • Always suspect an ectopic pregnancy in a woman of fertile age with pains in the lower part of the abdomen and/or abnormal bleeding.

Epidemiology

  • Of all pregnancies, approximately 1.5-2% are ectopic.
  • In recent years, the trend in the incidence of ectopic pregnancy has been clearly declining.
  • The incidence is highest among women aged 25-34 years.

Location

  • Most (95-97%) occur in the uterine tube. Abdominal, ovarian and cervical pregnancies are very rare.

Risk groups

  • In only a minority of the patients, some risk factor in the patient's history can be identified; these include
    • previous PID (chlamydia as the most common cause)
    • previous operations in the pelvic region (e.g. section)
    • previous ectopic pregnancy
    • a history of infertility and treatment of infertility
    • endometriosis
    • smoking
    • irritable bowel syndrome.
  • The risk of ectopic pregnancy is small in a user of an intrauterine device (IUD). If an IUD user becomes pregnant, however, an ectopic pregnancy should be suspected.

Symptoms

  • The clinical picture may vary from almost symptomless to very severe symptoms.
  • Abnormal vaginal bleeding and/or recurrent (unilateral) pains in the lower abdomen.
  • In some patients, the bleeding may resemble menstruation.
  • In severe cases with violent symptoms, abrupt intensive abdominal pain, stabbing shoulder pain and fainting are signs of tubal rupture and bleeding into the abdominal cavity.

Diagnosis

  • The primary investigation is a serum pregnancy test.
    • The most sensitive tests (plasma total hCG 10-20 IU/l) are positive as early as one week before the first missing period.
    • A urine pregnancy test is less sensitive: a positive result is significant, but a negative one does not exclude the possibility of an ectopic pregnancy.
  • In case of a positive pregnancy test the location of the pregnancy is determined by transvaginal ultrasonography.
  • Both quantitative concentration of hCG and vaginal ultrasonography help in the diagnosis.
    • When the total hCG concentration in the plasma is 1 500 IU/l and no pregnancy can be detected by ultrasound, 11% of the pregnancies are ectopic, 34% intrauterine and 55% will terminate itself.
      • Determining hCG two days apart will help in diagnostics. In intrauterine pregnancy the level of hCG usually doubles about every 2 days.
    • Transvaginal ultrasonography almost always confirms an intrauterine pregnancy (foetal heart beat) on the average 41 days after the last menstruation.
    • If ultrasonography does not confirm an intrauterine pregnancy but there is fluid in the pouch of Douglas, the finding is suggestive of an ectopic pregnancy.
    • For the purpose of differential diagnosis, examine basic blood count with platelet count, CRP, urinalysis and Chlamydia (nucleic acid test).

Complications

  • The growing pregnancy mass ruptures causing a haemorrhage into the abdominal cavity, which may in some cases be life-threatening.
  • A so-called persistent ectopic pregnancy begins to grow again spontaneously or after treatment.

Treatment

  • Mere follow-up is sufficient Expectant Management for Tubal Ectopic Pregnancy, when hCG concetration is low (< 1 500-2 000 IU/l) and the patient has only minor symptoms. The decrease in hCG level must be confirmed by repeated measurements.
    • About ⅔ of monitored patients will heal spontaneously; the lower the initial hCG value, the more likely this is.
  • Methotrexate can be used to induce resorption of the pregnancy material. Methotrexate treatment should be considered Methotrexate for Tubal Ectopic Pregnancy if the patient has few symptoms, liver and kidney function tests are normal, serum hCG concentration is < 5 000 IU/l and it is possible to arrange follow-up of the hCG concentration.
  • Patients in poor condition and with low blood pressure (at risk of shock) are immediately put on an i.v. drip. The haemodynamics allowing, a laparoscopy is carried out. Nowadays only about 5% of the patients need a laparotomy because of unstable haemodynamics or difficult haemoperitoneum.
    • Radical treatment (extirpation of the uterine tube) is advisable if the uterine tube is badly ruptured, the extrauterine pregnancy has recurred in the same place, the patient is not planning further pregnancies (it is possible to carry out sterilization at the same time), the pregnancy has started after sterilization, or IVF treatment is currently used or planned.
    • Conservative surgical treatmentsConservative Versus Radical Surgery for Tubal Pregnancy come into question if the patient wants to become pregnant in the future and a conservative operation is technically feasible. The most common of these is opening of the tuba (salpingostomy).
    • The severity of symptoms, the size and the nature of the ectopic pregnancy, serum hCG concentration as well as the patient's own wish affect the choice between surgical treatment and other treatment.

Further treatment and prognosis

  • Administration of anti-D immunoglobulin is always given to Rh-negative women.
  • The effect of conservative treatments is confirmed by monitoring the decrease of serum hCG concentration down to the normal level of a non-pregnant woman.
  • If hCG concentration decreases slowly or there is a suspicion that the primary treatment has failed, intramuscular or oral methotrexate can be given as a booster.
  • At the beginning of the next pregnancy, ultrasound examination should be considered to confirm the location of the pregnancy especially if the pregnant woman has unilateral lower abdominal pain.
  • None of contraceptive methods is subsequentlycontraindicated.
  • The prognosis for further pregnancies is good after conservative surgical and/or medical treatment. The probability of intrauterine pregnancy within 2 years' time is 80-90% after follow-up treatment, 55-70% after methotrexate treatment, 60-90% after salpingostomy and 40-65% after salpingectomy.
  • A new pregnancy may be tried when the woman has had one normal menstruation after the treatment.
    • After follow-up treatment, plasma total hCG at the normal level of a non-pregnant woman
    • After methotrexate treatment, the required pause is 1 month after single-dose therapy and 3 months after repeated-dose therapy.