Case 4.4 – Ectopic Pregnancy

ABCDE Approach - Haemodynamically Unstable Patient with Suspected Ruptured Ectopic:

Airway & Breathing

• Patient is breathing but may need airway support
• Oxygen by mask or nasal prongs

Circulation - Critical Priority

BP 50/- indicates no perfusion and requires urgent attention:

• IV access - large bore cannulae (14 or 16 gauge) in both arms
• Warmed IV fluids - crystalloid 1-2L stat
• Blood cross match - 2 units urgently (FBC and group & hold/cross match)
• Urgent bHCG
• Urinary catheter - monitor urine output

Assessment of Bleeding Source

• Check for heavy vaginal bleeding
• Speculum examination - ensure no products of conception (POC) in cervical os (this can cause low BP and severe bradycardia)
• Abdominal examination - expect tender, rigid abdomen with rebound and guarding (surgical abdomen)

Definitive Management

• If haemodynamically unstable - immediate laparotomy
• If haemodynamically stable - proceed with laparoscopy

This is a surgical emergency requiring immediate intervention.

Obstetric & Gynaecological Causes

• Ectopic pregnancy (ruptured or unruptured)
• Ruptured right ovarian cyst (functional or pathological)
• Ovarian torsion (of enlarged ovary with cyst) - usually accompanied by vomiting
• Incomplete miscarriage
• Salpingitis/Pelvic inflammatory disease - usually febrile and bilateral
• Endometriosis
• Ovulatory pain (Mittelschmerz)

Non-Gynaecological Causes

• Appendicitis
• Meckel's diverticulum
• Inflammatory bowel disease (e.g., Crohn's disease)
• Ureteric colic/renal stones
• Constipation
• Urinary tract infection/pyelonephritis

Management Options: Medical vs Surgical

Medical Management - Methotrexate

Mechanism: Anti-folate drug that destroys rapidly dividing tissue

Characteristics:

• Takes time (a few weeks)
• Pain can increase in the first few days
• Requires regular third-daily bHCG monitoring until levels drop appropriately
• Patient cannot live far from medical help - ectopic can still rupture during treatment causing massive blood loss/haemoperitoneum

Criteria for Medical Management (generally):

• Haemodynamically stable
• Unruptured ectopic
• Mass < 3.5-4cm
• bHCG typically < 5000 IU (some protocols allow up to 5000)
• No fetal cardiac activity
• Patient able to comply with follow-up

Surgical Management - Laparoscopic Options

1. Salpingostomy (Conservative):

• Linear incision in tube with removal of ectopic pregnancy
• Preserves the fallopian tube
• Risk: Incomplete removal of trophoblastic tissue
• Requires third-daily bHCG monitoring until < 20 IU
• Risk of persistent ectopic (5-20%)

2. Salpingectomy (Radical):

• Removal of entire affected fallopian tube
• Lower risk of persistent trophoblastic tissue
• Definitive treatment
• May be preferred if tube is severely damaged or contralateral tube is healthy

Considerations for This Case

With bHCG 2500 IU, 3cm mass, and asymptomatic presentation:

• Medical management is a reasonable option if criteria met and patient can comply
• Surgical management may be preferred given the mass is at the upper limit for medical treatment
• Decision should be individualized based on patient preference, fertility desires, and ability to follow-up

Management Algorithm for Suspected Ectopic Pregnancy

Clinical Scenario	bHCG Level	Ultrasound Findings	Management
Haemodynamically Unstable	Any level	Not required for immediate management	Emergency laparoscopy/laparotomy
Haemodynamically Stable, bHCG Low	< 1000-1500 IU/mL	Transvaginal ultrasound - no clear findings	Repeat bHCG in 48 hours: - Normal rise >60% (remains clinically stable) → Repeat scan when bHCG >1000-1500 IU/mL - Falling levels → Observe (possible miscarriage) - Abnormal rise or plateau → Likely ectopic
Haemodynamically Stable, bHCG Elevated	> 1000-1500 IU/mL	Ectopic identified on transvaginal ultrasound	Medical or Surgical: - Consider methotrexate if criteria met - Laparoscopy (salpingostomy or salpingectomy)
Haemodynamically Stable, bHCG Elevated	> 1000-1500 IU/mL	Intrauterine pregnancy confirmed	No ectopic - manage intrauterine pregnancy as appropriate
Haemodynamically Stable, bHCG Elevated	> 1000-1500 IU/mL	No intrauterine pregnancy seen	Laparoscopy - likely ectopic or pregnancy of unknown location

Criteria for Medical Management (Methotrexate)

Parameter	Criteria
Clinical Status	Haemodynamically stable, minimal symptoms
bHCG Level	Generally < 5000 IU/mL (protocols vary)
Mass Size	< 3.5-4 cm diameter
Fetal Cardiac Activity	Absent
Patient Factors	Able to comply with follow-up, lives near medical facility, no contraindications to methotrexate

Surgical Management Decision

Procedure	Indications	Advantages	Disadvantages
Salpingostomy	Desires future fertility, contralateral tube damaged/absent, unruptured ectopic, tube not severely damaged	Preserves tube	Risk of persistent ectopic (5-20%), requires bHCG follow-up
Salpingectomy	Ruptured ectopic, severely damaged tube, contralateral tube healthy, recurrent ectopic in same tube	Definitive, lower risk of persistent trophoblast	Loss of tube

Note: The discriminatory zone (bHCG level above which intrauterine pregnancy should be visible on transvaginal ultrasound) is typically 1000-1500 IU/mL, though this varies by institution.

Counselling About Future Pregnancy

Risk of Recurrence

• Having one ectopic pregnancy increases the risk of another ectopic pregnancy
• Risk of recurrent ectopic: approximately 10-15% (compared to 1-2% in general population)
• However, majority of women (60-80%) with subsequent pregnancies will have successful intrauterine pregnancies

No Consensus on Best Treatment Method

• There is no consensus on the best method of treatment from a long-term fertility point of view
• Both medical and surgical approaches have similar subsequent fertility rates
• Salpingostomy vs salpingectomy outcomes are similar if contralateral tube is healthy

Early Detection in Future Pregnancies

The following information is useful for diagnosing another early ectopic so it can be treated medically rather than requiring further surgery:

When to Seek Early Assessment:

• If any period of amenorrhoea occurs, perform a serum quantitative bHCG test
• If positive, arrange early transvaginal ultrasound:
  • At 6 weeks amenorrhoea, OR
  • When bHCG > 1500 IU (discriminatory zone)
• This allows visualization of intrauterine sac to confirm normal pregnancy location

General Advice

• Seek early antenatal care in any future pregnancy
• Report any symptoms immediately: abdominal pain, vaginal bleeding, shoulder tip pain, dizziness
• Early ultrasound (6-7 weeks) should be arranged to confirm intrauterine pregnancy
• Serial bHCG monitoring may be considered if presentation is early and ultrasound non-diagnostic

Emotional Support

• Acknowledge the loss and emotional impact
• Provide information about support services and counseling
• Reassure about good chances of successful future pregnancy
• Encourage to wait for one normal menstrual cycle before trying to conceive (if medically managed, wait until bHCG undetectable)

Follow-Up

• Post-treatment: Follow bHCG to ensure resolution (medical management) or confirm no persistent trophoblast (salpingostomy)
• Contraception advice: If methotrexate used, avoid pregnancy for 3 months; take folic acid when planning pregnancy
• Review risk factors: Address modifiable factors (smoking, pelvic infections)