QuestionSBA
QuestionChoice
Methotrexate is utilised for medical management of ectopic pregnancy under specific circumstances where the patient is haemodynamically stable. This patient is unstable and would therefore not be suitable for medical management
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Methotrexate
QuestionChoice
Ectopic pregnancy may result in hypovolaemia secondary to blood loss. A blood transfusion may be considered if there is a large volume of blood loss with a significant drop in haemoglobin. Bloods should be sent off for group and save, and 2-4 units crossmatched. However, in the acute setting, the patient should be resuscitated with IV fluids first
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Blood transfusion
QuestionChoice
This patient is currently haemodynamically unstable and requires fluid resuscitation prior to the consideration of any surgery. Laparoscopy is usually the first-line diagnostic and therapeutic operation for ectopic pregnancy as it is less invasive and harbours a shorter recovery time than laparotomy. Emergency laparotomy would be indicated if the patient had an acute abdomen, or if other pathology e.g. bowel was suspected
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Emergency laparotomy
QuestionChoice
There is high suspicion for an ectopic pregnancy in a young sexually active female with signs of tachycardia and hypotension suggesting blood loss. Up to half of transvaginal US scans may be inconclusive. As she is haemodynamically unstable, she should be resuscitated with IV fluids as a first priority
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Intravenous (IV) fluid bolus
QuestionChoice
Whilst the next investigation and definitive management of suspected ectopic pregnancy would be an emergency laparoscopy, this patient is currently unstable and requires fluid resuscitation first
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Emergency laparoscopy
QuestionComment
surely give blood in preference to crystalloids (replace like for like) - your explanation says could transfuse if there is significant blood loss which this patient (SBP of 75) obviously has! I get in reality fluids more available but best theoretical answer is surely give O neg
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subscriber
Amnesia Wilsons
QuestionComment
laparoscopy no more definitive its tvus
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User
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Syndrome Neoplasia
QuestionComment
I understand that we still do fluid first, but how do we know that this isn't ruptured?
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Loose Tanoy
QuestionComment
Group and save and crossmatch takes timme, followed by setting up transfusion.  fluids are faster. (though in reality both would be done in clinical practice) 
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BeethovenVirus-ed
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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In suspected ectopic pregnancy, immediate intravenous fluid resuscitation is crucial for managing haemodynamic instability.
A 20 year old female has been brought into A&E by her partner with sudden onset right lower abdominal pain and vomiting for the past day. She had also briefly fainted just prior to arrival. In triage, she was afebrile, BP 75/50, HR 115, SpO<sub>2</sub> 98%. A urine pregnancy test was positive but transvaginal ultrasound scan (US) showed an empty uterus.

What is the next most appropriate course of action?
a