Diagnosis and Management of Ectopic Pregnancy

Question 1

How is a tubal pregnancy diagnosed?

What are the ultrasound criteria?

Answer 1

• TVS is diagnostic tool of choice for tubal ectopic pregnancy.
• Tubal ectopic pregnancies should be positively identified, if possible, by visualising an adnexal mass that moves separate to the ovary

Question 2

How is a tubal pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 2

• serum progesterone level is not useful in predicting ectopic pregnancy.
• serum b-hCG level is useful for planning management of an ultrasound visualised ectopic pregnancy.

Question 3

How is a cervical pregnancy diagnosed?

What are the ultrasound criteria?

Answer 3

Following ultrasound criteria may be used for diagnosis of cervical ectopic pregnancy:
– an empty uterus, a barrel-shaped cervix, gestational sac present below level of internal cervical os, absence of the ‘sliding sign’ and blood flow around gestational sac using colour Doppler.

Question 4

How is a cervical pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 4

A single serum b-hCG should be carried out at diagnosis.

Question 5

How is a caesarean scar pregnancy diagnosed?
What are the ultrasound criteria?

How is an interstitial pregnancy diagnosed?
What are the ultrasound criteria?
The following ultrasound scan criteria may be used for the diagnosis of interstitial pregnancy:
empty uterine cavity, products of conception/gestational sac located laterally in the interstitial
(intramural) part of the tube and surrounded by less than 5 mm of myometrium in all imaging
planes, and presence of the ‘interstitial line sign’.
Sonographic findings in two-dimension can be further confirmed using three-dimensional
ultrasound, where available, to avoid misdiagnosis with early intrauterine or angular
(implantation in the lateral angles of the uterine cavity) pregnancy.
Supplementation with MRI can also be helpful in the diagnosis of interstitial pregnancy.
What biochemical investigations should be carried out?
A single serum b-hCG should be carried out at diagnosis to help with management. In some
cases, a repeat serum b-hCG in 48 hours may be useful in deciding further management.

Answer 5

• Clinicians should be aware that ultrasound is primary diagnostic modality, using transvaginal approach supplemented by transabdominal imaging if required.
• Defined criteria for diagnosing CS scar pregnancy on transvaginal scan have been described.
• MRI can be used as a second-line investigation if the diagnosis is equivocal and there is local expertise in MRI diagnosis of caesarean scar pregnancies.
  [New 2016]
  D

Question 6

How is a caesarean scar pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 6

No biochemical investigations are needed routinely.

Question 7

How is an interstitial pregnancy diagnosed?

What are the ultrasound criteria?

Answer 7

• following US scan criteria may be used for diagnosis of interstitial pregnancy:
• • empty uterine cavity, products of conception/gestational sac located laterally in interstitial (intramural) part of tube and surrounded by less than 5 mm of myometrium in all imaging planes, and presence of the ‘interstitial line sign’.
• • Sonographic findings in two-dimension can be further confirmed using three-dimensional ultrasound, where available, to avoid misdiagnosis with early intrauterine or angular (implantation in the lateral angles of the uterine cavity) pregnancy.
• • Supplementation with MRI can also be helpful in the diagnosis of interstitial pregnancy.

Question 8

How is an interstitial pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 8

• single serum b-hCG should be carried out at diagnosis to help with management.
• In some cases, a repeat serum b-hCG in 48 hours may be useful in deciding further management.

Question 9

How is a cornual pregnancy diagnosed?

What are the ultrasound criteria?

Answer 9

• The following ultrasound scan criteria may be used for the diagnosis of cornual pregnancy:
• visualisation of a single interstitial portion of fallopian tube in the main uterine body, gestational sac/products of conception seen mobile and separate from the uterus and
  completely surrounded by myometrium, and a vascular pedicle adjoining the gestational sac to unicornuate uterus.

Question 10

How is a cornual pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 10

• single serum b-hCG should be carried out at diagnosis to help with management.
• In some cases, a repeat serum b-hCG in 48 hours may be useful in deciding further management.

Question 11

How is an ovarian pregnancy diagnosed?

What are the ultrasound criteria?

Answer 11

• no specific agreed criteria for US diagnosis of ovarian ectopic pregnancy.

Question 12

How is an ovarian pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 12

• single serum b-hCG should be carried out at diagnosis to help with management.
• In some cases, a repeat serum b-hCG in 48 hours may be useful in deciding further management.

Question 13

How is an abdominal pregnancy diagnosed?

What are the ultrasound criteria?

Answer 13

• Defined ultrasound criteria can be used to diagnose an abdominal pregnancy.
• MRI can be a useful diagnostic adjunct in advanced abdominal pregnancy and can help to plan surgical approach.

Question 14

How is an abdominal pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 14

A high index of suspicion is based upon an elevated serum b-hCG level in combination with ultrasound findings.

Question 15

How is heterotopic pregnancy diagnosed?

What are the ultrasound criteria?

Answer 15

• heterotopic pregnancy is diagnosed when ultrasound findings demonstrate an intrauterine pregnancy and a coexisting ectopic pregnancy.

Question 16

How is heterotopic pregnancy diagnosed?

What biochemical investigations should be carried out?

Answer 16

-A serum b-hCG level is of limited value in diagnosing heterotopic pregnancy.

Question 17

What are the surgical, pharmacological or conservative treatment options for tubal pregnancy?

Answer 17

• A laparoscopic surgical approach is preferable to an open approach.
• In presence of healthy contralateral tube, salpingectomy should be performed in preference to salpingotomy.
• In women with a history of fertility-reducing factors (previous ectopic pregnancy, contralateral tubal damage, previous abdominal surgery, previous pelvic inflammatory disease), salpingotomy should be considered.
• If a salpingotomy is performed, women should be informed about the risk of persistent trophoblast with the need for serum b-hCG level follow-up. They should also be counselled that there is a small risk that they may need further treatment in the form of systemic
  methotrexate or salpingectomy.
• Systemic methotrexate may be offered to suitable women with a tubal ectopic pregnancy. It should never be given at the first visit, unless the diagnosis of ectopic pregnancy is absolutely clear and a viable intrauterine pregnancy has been excluded.
• Expectant management is an option for clinically stable women with an ultrasound diagnosis of ectopic pregnancy and a decreasing b-hCG level initially less than 1500 iu/l.

Question 18

What are the surgical, pharmacological or conservative treatment options for cervical pregnancy?

Answer 18

• Medical management with methotrexate can be considered for cervical pregnancy.
• Surgical methods of management are associated with a high failure rate and should be reserved for those women suffering life-threatening bleeding.

Question 19

What are the surgical, pharmacological or conservative treatment options for caesarean scar pregnancy?

Answer 19

• Women diagnosed with caesarean section scar pregnancies should be counselled that such
  pregnancies are associated with severe maternal morbidity and mortality.
• Medical and surgical interventions with or without additional haemostatic measures should be
  considered in women with first trimester caesarean scar pregnancy.
• There is insufficient evidence to recommend any one specific intervention over another for caesarean scar pregnancy, but the current literature supports a surgical rather than medical approach as the most effective.

Question 20

What are the surgical, pharmacological or conservative treatment options for interstitial pregnancy?

Answer 20

• Nonsurgical management is acceptable option for stable interstitial pregnancies.
• Expectant management is only suitable for women with low or significantly falling b-hCG levels in whom the addition of methotrexate may not improve the outcome.
• A pharmacological approach using methotrexate has been shown to be effective, although, there is insufficient evidence to recommend local or systemic approach.
• Surgical management by laparoscopic cornual resection or salpingotomy is an effective option.
• Alternative surgical techniques could include hysteroscopic resection under laparoscopic or
  ultrasound guidance.
• There is insufficient evidence on safety and complications in future pregnancies to recommend
  other nonsurgical methods.

Question 21

What are the surgical, pharmacological or conservative treatment options for cornual pregnancy?

Answer 21

• Cornual pregnancies should be managed by excision of rudimentary horn via laparoscopy or laparotomy.

Question 22

What are the surgical, pharmacological or conservative treatment options for ovarian pregnancy?

Answer 22

• Definitive surgical treatment is preferred if laparoscopy is required to make the diagnosis of ovarian ectopic pregnancy.
• Systemic methotrexate can be used to treat ovarian ectopic pregnancy when the risk of surgery is high, or postoperatively in the presence of persistent residual trophoblast or persistently raised b-hCG levels.

Question 23

What are the surgical, pharmacological or conservative treatment options for abdominal pregnancy?

Answer 23

• Laparoscopic removal is an option for treatment of early abdominal pregnancy.
• Possible alternative treatment methods would be systemic methotrexate with ultrasound guided fetocide.
• Advanced abdominal pregnancy should be managed by laparotomy.

Question 24

What are the surgical, pharmacological or conservative treatment options for heterotopic pregnancy?

Answer 24

• The intrauterine pregnancy must be considered in the management plan.
• Methotrexate should only be considered if intrauterine pregnancy is nonviable or if woman does not wish to continue with the pregnancy.
• Local injection of potassium chloride or hyperosmolar glucose with aspiration of the sac contents is an option for clinically stable women.
• Surgical removal of the ectopic pregnancy is the method of choice for haemodynamically unstable women and is also an option for haemodynamically stable women.
• Expectant management is an option in heterotopic pregnancies where the ultrasound findings are of a nonviable pregnancy.

Question 25

Do rhesus D (RhD)-negative women with an ectopic pregnancy require anti-D immunoglobulin?

Answer 25

• Offer anti-D prophylaxis as per national protocol to all RhD-negative women who have surgical removal of an ectopic pregnancy, or where bleeding is repeated, heavy or associated with abdominal pain.

Question 26

What are the long-term fertility prospects following an ectopic pregnancy?

Answer 26

• In the absence of a history of subfertility or tubal pathology, women should be advised that there is no difference in the rate of fertility, the risk of future tubal ectopic pregnancy or tubal patency rates between the different management methods.
• Women with a previous history of subfertility should be advised that treatment of their tubal ectopic pregnancy with expectant or medical management is associated with improved reproductive outcomes compared with radical surgery.
• Women receiving methotrexate for the management of tubal ectopic pregnancy can be advised that there is no effect on ovarian reserve.
• Women undergoing treatment with uterine artery embolisation and systemic methotrexate for nontubal ectopic pregnancies can be advised that live births have been reported in subsequent pregnancies.
• Women undergoing laparoscopic management of ovarian pregnancies can be advised that their future fertility prospects are good.

Question 27

What support and counselling should be offered to women undergoing treatment for ectopic pregnancy?

Answer 27

• Women should be advised, whenever possible, of the advantages and disadvantages associated with each approach used for the treatment of ectopic pregnancy, and should participate fully in selection of the most appropriate treatment.
• Women should be made aware of how to access support via patient support groups, such as Ectopic Pregnancy Trust, or local bereavement counselling services.
• Muscle relaxation training may be of use to women undergoing treatment for ectopic pregnancy with methotrexate.
• It is recommended that women treated with methotrexate wait at least 3 months before trying
  to conceive again.

Question 28

What is the most appropriate setting for management of women with an ectopic pregnancy?

Answer 28

• Providers of early pregnancy care should provide a 7-day early pregnancy assessment service with direct access for women referred by general practitioners and accident and emergency departments, i.e. along current NHS recommendations. Available facilities for the management of suspected ectopic pregnancy should include diagnostic and therapeutic algorithms,
  transvaginal ultrasound and serum b-hCG estimations.
• Women should have access to all appropriate management options for their ectopic pregnancy. If local facilities do not provide all options, then clear referral pathways should exist to allow them to access appropriate care.

Question 29

What are the training implications for those managing women with ectopic pregnancy?

Answer 29

• Clinicians undertaking the surgical management of ectopic pregnancy must have received appropriate training. Laparoscopic surgery requires appropriate equipment and trained theatre staff.
• Clinicians undertaking ultrasound for the diagnosis of ectopic pregnancy must have received appropriate training.
• Clinicians undertaking medical management via ultrasound-guided needle techniques must have
  received appropriate training.
• If clinicians undertaking surgical management of ectopic pregnancy cannot carry out the full range of surgical procedures, appropriately experienced support must be available if necessary.
• Virtual reality simulators can be used as a training tool for salpingectomy.