QuestionSBA
QuestionChoice
Mifepristone is an antiprogestogenic steroid used in medical termination of pregnancy. Whilst this woman wishes to proceed with termination of pregnancy, the location of the pregnancy must be confirmed as intrauterine first.
49834
c
Mifepristone
QuestionChoice
This woman currently has a pregnancy of unknown location. Methotrexate is used in the medical management of ectopic pregnancy. Medical management is offered where a woman has an ectopic pregnancy, but there are no indications for surgical management.
49833
b
Methotrexate
QuestionChoice
Misoprostol, a synthetic prostaglandin analogue, is used in a medical termination of pregnancy. Whilst this woman wishes to proceed with termination of pregnancy, the location of the pregnancy must be confirmed as intrauterine first.
49836
e
Misoprostol
QuestionChoice
This woman has a pregnancy of unknown location. As she is haemodynamically stable with mild pelvic pain, she can be managed conservatively.

Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.

- If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.
- If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy.
- A large increase in B-hCG suggests the foetus is growing normally intrauterine. In this case a repeat transvaginal scan may be performed, and if the pregnancy is confirmed as intrauterine, the woman may proceed with termination of pregnancy.
49832
a
Repeat serum B-hCG in 48 hours
QuestionChoice
Whilst this woman may have an ectopic pregnancy, she is haemodynamically stable, therefore there is no indication for surgery. It may well be an intrauterine pregnancy which is too small to see on a transvaginal ultrasound scan.
49835
d
Admit for an exploratory laparoscopy
QuestionComment
Surely wanting to proceed with termination of pregnancy implies that she wants either medical or surgical intervention and not manage it conservatively
24786
User
subscriber
WBC Zebras
QuestionComment
I assumed this was a question about ectopic pregnancies - but it's about pregnancy of unknown location. In this case, ectopic pregnancy cannot be diagnosed based on the USS, and so they will not treat it yet. The two hCG tests will be done to determine whether this is intrauterine (if it increases by >63%) or not, and then that will guide future management. The pregnancy may be intrauterine, but not yet seen. 
27309
User
subscriber
Axillary Gas
Concept
Chapter
# Summary
  
 
Ectopic pregnancy is a gynaecological emergency, referring to a fertilised ovum that has implanted anywhere outside the endometrial cavity. This may present with pelvic pain, shoulder tip pain, abnormal vaginal bleeding, and haemodynamic instability if ruptured. Diagnosis is confirmed by positive pregnancy test and a transvaginal ultrasound that has located the pregnancy outside the uterine cavity. Management strategies include conservative management, medical management with methotrexate, and surgical management, the choice of which depends on the patient's presentation and level of risk.
  
  
 
# Definition
  
An ectopic pregnancy refers to a fertilised ovum that has implanted outside the endometrial cavity, usually in the fallopian tubes. This is a gynaecological emergency. 
  
 
  
 
# Epidemiology

 
The estimated incidence of ectopic pregnancies in the UK is 1.1%. The risk is higher in women with a history of pelvic inflammatory disease, genital infection, pelvic surgery, an intrauterine device in situ, assisted reproduction, previous ectopic pregnancy, or endometriosis.
  
 
  
 
# Aetiology 
  
 
Ectopic pregnancy usually presents in the 6-8th week of pregnancy, but can occur earlier or later. They can occur anywhere outside the endometrial cavity, but most commonly in the fallopian tube. 

Risk of an ectopic increases with conditions that impair the passage of a fertilised egg into the uterine cavity, or with conditions that cause the fertilised egg to implant prematurely. However, most ectopics are not associated with any risk factor.  
  
Specific risk factors include: 
 
  - Pelvic inflammatory disease and previous STIs
  - Pelvic surgery
  - Having an intrauterine device e.g. copper coil or Levonorgestrel-releasing intrauterine system (e.g. Mirena) in situ
  - Assisted reproduction e.g. IVF
  - Previous ectopic pregnancy
  - Endometriosis
  
 
  
# Signs and Symptoms
 
Clinical features of ectopic pregnancy may include:
  
 
  - Pelvic pain, which may be unilateral to the side of the ectopic
  - Shoulder tip pain - If the ectopic pregnancy bleeds, the blood can irritate the diaphragm causing shoulder tip pain
  - Abnormal vaginal bleeding e.g. missed period or intermenstrual bleeding
  - Haemodynamic instability caused by blood loss if the ectopic ruptures, resulting in syncope/fainting
  - Abdominal examination may reveal unilateral tenderness
  - Cervical tenderness (chandelier sign) on bimanual examination
  
 
# Differential Diagnosis

1. **Miscarriage:** will also present with bleeding following a positive pregnancy test. However, less likely to have shoulder tip pain, beta-hCG levels will not be as high as in an ectopic (and will fall), and TV USS may show intrauterine pregnancy (if not yet completely expelled). 


2. **Pelvic inflammatory disease:** presents with abdominal pain and cervical tenderness, and may have bloody vaginal discharge. However, pregnancy test will be negative and inflammatory markers raised. Can be confirmed with positive swab. 


3. **Ovarian torsion:** also presents with abdominal pain, usually unilateral. Less likely to present with vaginal bleeding and will have negative pregnancy test. 

# Investigations
 
The investigations for ectopic pregnancy include:

**Bedside**

- Pregnancy test (to confirm pregnancy) 

  
**Bloods**

* FBC (check for anaemia)
* Serum beta-hCG (will help guide management)

**Imaging**

 - Transvaginal ultrasound (to locate the pregnancy)
  
 
# Management
   
 
There are three management options for ectopic pregnancy:
  
 
  **Conservative:**
  
 
  - This is an option for a small number of women with an ectopic pregnancy who have minimal or no symptoms, who are considered low risk (usually because there is a plateau or drop in beta-hCG levels indicating self-resolution of the ectopic). 
  - These patients require close follow-up with serial repeat b-hCG tests. If the levels do not decrease at a satisfactory rate, medical/surgical management is recommended.
  
 
**Medical:**
  
 
  - Involves administration of a one-off dose of methotrexate
  - Criteria for methotrexate treatment include: 
          - No significant pain
          - Low hCG level (below 1500 IU/L)
          - Unruptured ectopic pregnancy measuring below 35mm and with no visible heartbeat
          - Ability to attend follow-up
          - Adherence to avoiding pregnancy for a period following treatment
          - No intrauterine pregnancy (confirmed on an ultrasound scan). 
  - If the initial dose of methotrexate fails to treat the ectopic pregnancy, a second dose of methotrexate or surgical management may be indicated
  

**Surgical:**
  
  - Recommended as first-line option if: 
          - Patient is unable to attend follow-up
          - Serum hCG level of 5000 IU/L or higher 
          - Adnexal mass of 35mm or greater
          - Foetal heartbeat is visible on ultrasound scan
          - Patient is in significant pain
          - Patient is haemodynamically unstable
  - Also offered second line in cases where medical manamgement has failed 
  - The preferred surgical management is a **salpingectomy**, where the fallopian tube containing the ectopic pregnancy is removed. For patients with only one patent fallopian tube (e.g. due to previous PID or ectopic, or past removal of a fallopian tube), a **salpingotomy** may be performed instead, where only the ectopic pregnancy is removed and the ends of the fallopian tube are re-attached. 
  - There is a risk with salpingotomy that not all the tissue may have been removed, and so serial serum b-hCG measurements are performed to exclude any remaining trophoblastic tissue within the fallopian tube
  - Offer **anti-D immunoglobulin** to all rhesus-negative women who have had surgical management of ectopic pregnancy. 
 

**Borderline Cases: Choosing Between Medical and Surgical Management**

* There are some women who may be offered a choice of either methotrexate or surgical management as first-line.
* This applies to women who: 
    * Have a serum hCG level between 1500 IU/L and 5000 IU/L
    * Are able to return for follow up
    * Have no significant pain
    * Have an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
    * Have no intrauterine pregnancy (confirmed on an ultrasound scan). 
 

# NICE Guidelines 
 
   [Click here for NICE CKS on ectopic pregnancy ](https://cks.nice.org.uk/topics/ectopic-pregnancy/) 
 
# References


[NHS UK - Ectopic pregnancy](https://www.nhs.uk/conditions/ectopic-pregnancy/)
  
[Patient Info - Ectopic pregnancy](https://patient.info/doctor/ectopic-pregnancy-pro)
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A 22-year-old woman attends her general practitioner with a 1-week history of left sided pelvic pain.

On examination, there is mild tenderness in the left iliac fossa, with no peritonism or guarding. Her observations are normal.

Her last menstrual period was 4 weeks prior.

A urinary pregnancy test is positive, to her surprise.

She is referred to the early pregnancy assessment unit where a transvaginal ultrasound scan is performed. There is no pregnancy visible within the uterus, and there is no free fluid identified in the pelvis. A serum B-hCG is 315 mIU/mL.

She wishes to proceed with a termination of pregnancy.

What is the most appropriate management?
a