Ectopic pregnancy

EBM Guidelines

Last updated: 2012-02-23 © Duodecim Medical Publications Ltd

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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 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 (98%) 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
    • previous ectopic pregnancy
    • use of copper intrauterine device (IUD) – provides better contraception for intrauterine than for ectopic pregnancy [C] (the increased use of hormone-releasing IUDs has decreased the frequency of ectopic pregnancies related to IUD failure)
    • a history of infertility and treatment of infertility
    • smoking.

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 (serum 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 hCG concentration in the serum is 1 000–2 000 IU/l and no intrauterine pregnancy can be detected by ultrasound an ectopic pregnancy is approximately 95% certain.
    • 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.
    • Flowchart of the diagnostic process: see picture [1] .

Complications

  • The growing pregnancy mass ruptures (by week 10–12 of the pregnancy at the latest) 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

  • In some cases (18–33%) mere follow-up is sufficient (concentration of hCG low < 1 000–2 000 IU/l, pregnancy focus small < 4 cm). The decrease in hCG level must be confirmed by repeated measurements.
  • Medicines can induce resorption of the pregnancy tissue. Methotrexate treatment should be considered [B] if the patient has few symptoms, liver and kidney function tests are normal, the size of the ectopic pregnancy focus is < 4 cm, serum hCG concentration is < 5 000 IU/l and it is possible to arrange follow-up of the hCG concentration.
    • Methotrexate [B] is administered intramuscularly (50 mg/m2) or orally as one single treatment or in series. Folic acid supplementation is not necessary in single-dose treatment.
    • 70–90% of ectopic pregnancies have been managed successfully with a single i.m. injection of methotrexate.
    • The outcome is better if the serum hCG level is low [C] .
    • The most common adverse effect of the treatment is abdominal pain which occurs in about 75% of the treated patients.
  • Patients in poor condition and with low blood pressure (at risk of shock) are immediately put on an i.v. drip. The haemodynamics allowing, they are operated on as soon as possible. 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 treatments [C] 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 recommended for Rh-negative women.
  • The effect of conservative treatments is confirmed by monitoring the decrease of serum hCG concentration (down to less than 10 IU/l).
  • 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 (at pregnancy weeks 5 to 6) there is a need to confirm the location of the pregnancy by transvaginal ultrasound.
  • None of contraceptive methods is subsequently contraindicated.
  • The prognosis for further pregnancies is good after conservative surgical and/or medical treatment; the recurrence risk of an ectopic pregnancy is 5–15%.
  • A new pregnancy may be tried when the woman has had one normal menstruation after the treatment.
    • Serum hCG less than 10 after follow-up
    • An interval of 12 weeks is needed after methotrexate treatment.

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