Ectopic Pregnancy Management - The Royal Women's Hospital

Guideline

Ectopic Pregnancy Management

1. Purpose

This guideline outlines the management of women who have a diagnosed ectopic pregnancy. An ectopic pregnancy occurs in about 1 in 60 pregnancies. Combined intra-uterine and extra-uterine pregnancy (heterotopic pregnancy) is rarely encountered (occurs in around 1:40,000 natural pregnancies and substantially more frequently in IVF pregnancies, depending on the number of embryos transferred).

This guideline is related to guideline `Pain and Bleeding in Early Pregnancy'.

2. Definitions

Ectopic pregnancy is a pregnancy that is not located in the uterus. The fertilized egg has settled in a location other than the endometrium. The large majority (95%) of ectopic pregnancies occur in the fallopian tube. Early Pregnancy Assessment Service (EPAS) is located in the Women's Emergency Care (WEC). EPAS sees women with and without scheduled appointments during business hours Monday to Friday.

3. Responsibilities

Gynaecology registrar is responsible for clinical assessment, determining and implementing appropriate management. WEC HMO/Registrar is responsible for providing acute/emergency care if required.

4. Guideline

4.1 Clinical presentation and diagnosis

(See guideline `Pain and Bleeding in Early Pregnancy')

Ectopic pregnancy is suspected when a woman presents with a combination of the following:

Clinical:

o History of amenorrhea o Pelvic pain and/or abnormal bleeding in the first trimester o Shoulder tip pain o Dizziness or spells of fainting o Other evidence of blood in the peritoneal cavity including haemodynamic compromise o Adnexal tenderness, cervical excitation, signs of peritonism.

Biochemical:

o Positive pregnancy test (urine or serum).

On transvaginal ultrasound:

o Intrauterine gestational sac not seen o Ovarian / fallopian mass may be seen (note: an adnexal mass will not be found in a small minority of

women with an ectopic pregnancy) o Blood in the Pouch of Douglas.

Where clinical and ultrasound findings are not conclusive, diagnostic laparoscopy may be indicated.

4.2 Risk factors for ectopic pregnancy

Women with previous ectopic pregnancy Previous pelvic infection or pelvic inflammatory disease IUCD in situ Previous pelvic surgery ? including caesarean section, tubal surgery, appendicectomy History of fertility problems ? including assisted conception

Uncontrolled document when printed

Published: 27/07/2020

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Guideline

Ectopic Pregnancy Management

Progestagen only contraception.

4.3 Selecting an appropriate management method

When ectopic pregnancy is diagnosed or considered likely the gynaecology registrar will:

Clinically assess the woman, including vaginal examination if planning non-surgical treatment. Discuss proposed management with the gynaecology consultant. Advise woman of safe treatment options, advantages and disadvantages. Ensure woman participates in the selection of the most appropriate treatment.

Treatment of interstitial and non-tubal ectopic pregnancies (such as ovarian, cervical and caesarean section scar ectopics) is not covered here as it needs to be individualized with consultant gynaecological and ultrasonological input. A helpful review was published in 2012 1. Treatment may include intrasac injection and/or multiple dose methotrexate (see appendix A for dosage schedule) or other interventions.

Plans for management and follow-up should be clearly recorded in the EPAS record and in any discharge letter from the EPAS.

Management Clinical criteria method

Surgical

Surgery is the default treatment for ectopic pregnancy, because of the risk of intraperitoneal haemorrhage and rupture of untreated ectopic pregnancy, with associated morbidity and mortality. Indicated if any of the following apply:

Not haemodynamically stable Intraperitoneal bleeding on the basis of clinical or ultrasound findings Fetal heart activity on ultrasound examination Adnexal mass measuring 3.5cm by ultrasound hCG level 3500IU/l Moderate to severe pelvic pain Any contraindication to medical management

Medical

Medical management with methotrexate may be considered if diagnostic parameters indicate haemorrhage and rupture are less likely and the woman clearly understands the risks and indicators for seeking urgent care and is willing to attend for regular follow up (usually 1-2 per week for 3 weeks)

All the following criteria must also be met:

Haemodynamically stable

No or mild pelvic pain; no significant pelvic tenderness on vaginal examination

?hCG ................
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