Diagnosis and Management of Ectopic Pregnancy

Key Recommendations

• Ectopic pregnancy occurs in approximately 1 in 80 pregnancies
• Most common site is the ampulla of the fallopian tube (70%)
• Other sites: isthmus (12%), fimbria (11%), cornual/interstitial (2-3%), ovarian (1-3%), cervical (<1%), abdominal (<1%), caesarean scar
• Heterotopic pregnancy incidence increases with assisted conception (1 in 100 with IVF)

Risk Factors

• Previous ectopic pregnancy (10-15% recurrence risk)
• Previous tubal surgery or pelvic surgery
• Pelvic inflammatory disease / tubal damage
• IVF and assisted reproduction
• Intrauterine contraceptive device (IUCD) in situ — does not increase absolute risk but if pregnancy occurs, higher proportion are ectopic
• Progesterone-only contraception
• Smoking
• Increasing maternal age
• Endometriosis

Diagnosis

• Transvaginal ultrasound (TVUS) is the primary diagnostic tool
• Discriminatory zone: serum hCG level above which an intrauterine pregnancy should be visible on TVUS (typically 1500-2000 IU/L)
• Serum hCG: doubling time in normal IVP is approximately 48 hours (minimum rise 63% in 48 hours)
• Suboptimal rise (<63% in 48h) or plateau suggests ectopic or failing pregnancy
• Pregnancy of unknown location (PUL): positive pregnancy test with no pregnancy seen on TVUS — requires serial hCG monitoring

Medical Management (Methotrexate)

• Single-dose intramuscular methotrexate (50mg/m2)
• Criteria for medical management:
  • Confirmed ectopic on TVUS or persistent PUL with rising hCG
  • Haemodynamically stable, no significant pain
  • Unruptured ectopic, adnexal mass <35mm
  • No intrauterine pregnancy
  • Serum hCG <5000 IU/L (some centres accept <3000)
  • No significant haemoperitoneum
  • Able to attend for follow-up
• Contraindications: hepatic, renal or haematological dysfunction, active infection, peptic ulcer, immunodeficiency, breastfeeding
• Monitoring: hCG on days 4 and 7 — must fall by >15% between days 4 and 7; repeat dose or surgery if insufficient decline
• Avoid NSAIDs, folic acid supplements, alcohol, sexual intercourse, and prolonged sun exposure during treatment
• Reliable contraception for 3 months after methotrexate

Surgical Management

• Laparoscopy is preferred over laparotomy
• Salpingectomy is first-line surgical treatment
• Salpingotomy considered if: contralateral tube damaged/absent, desire for future fertility
• With salpingotomy: monitor serial hCG to exclude persistent trophoblast (occurs in 5-20%)
• Emergency surgery required if: haemodynamically unstable, signs of rupture, significant haemoperitoneum

Expectant Management

• Suitable for clinically stable women with declining hCG
• Criteria: hCG <1500 IU/L and declining, minimal symptoms, reliable follow-up
• Serial hCG monitoring until <5 IU/L
• Success rate approximately 50-70% for appropriately selected patients

Future Fertility

• Intrauterine pregnancy rate after ectopic: approximately 60-70%
• Recurrence risk: 10-15% after one ectopic, 25% after two
• No significant difference in future fertility between salpingectomy and salpingotomy when contralateral tube is healthy
• Advise early TVUS in subsequent pregnancies

Important Facts for MRCOG

• hCG rise <63% in 48 hours is suggestive of ectopic or failing pregnancy
• Ampulla is the most common site for tubal ectopic
• Salpingectomy is first-line over salpingotomy when contralateral tube is normal
• Methotrexate requires hCG <5000, unruptured ectopic <35mm, haemodynamic stability
• Anti-D should be given to RhD-negative women with ectopic pregnancy if managed surgically or with >48 hours gestation

Source: RCOG Green-top Guideline No. 21 (2016)

Read the original on rcog.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2016

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