Every year in the UK there are more than 20,000 emergency admissions to hospital for ectopic pregnancy.
VOL: 100, ISSUE: 06, PAGE NO: 32
Laura Abbott, BSc, BA, RGN, RM, DipN, is an independent midwife and co-founder of ‘Homebirths’ and a medical adviser for the Ectopic Pregnancy Trust
Ectopic pregnancy affects one in every 80-100 pregnancies (Royal College of Obstetricians and Gynaecologists (RCOG), 2002). It is a life-threatening condition and a gynaecological emergency. The incidence of ectopic pregnancy is rising due to the increased incidence of Chlamydia trachomatis (Tay et al, 2000). Most ectopic pregnancies implant in the fallopian tube and, as the pregnancy grows, cause bleeding and pain. If not treated in time, the tube can rupture and cause severe bleeding, which can lead to collapse and death.
Importance of diagnosis
According to the Ectopic Pregnancy Trust two young women have died from misdiagnosed ectopic pregnancies in the last five months. Both women sought medical help before their collapse (one woman saw three different doctors). However, their symptoms were dismissed as being stomach upsets. Both women were found dead by their partners the day after seeking medical advice. Five women a year continue to die from ectopic pregnancy. These deaths are mainly caused by failure to suspect ectopic pregnancy and give appropriate care. This makes death from ectopic pregnancy the third biggest killer of pregnant women in the UK after thromboembolism and hypertensive disorders.
From a medico-legal standpoint, the alleged breach of duty in misdiagnosing ectopic pregnancy relates directly to the delay in diagnosis. Tay et al (2000) suggest that the diagnosis cannot be made in the community and that ectopic pregnancy must be excluded in a sexually active woman who has a positive pregnancy test, vaginal bleeding and abdominal pain.
With modern transvaginal scanning (TVS) an intra-uterine pregnancy can be seen from four weeks onwards with absolute consistency (Jain et al, 1988). It has been reported that a gestational sac is always seen with human chorionic gonadotrophin (HCG) levels of 300mIU/ml or more (Bernaschek et al, 1998; Stabile, 1996). However, despite this, the Ectopic Pregnancy Trust continues to hear from many women who have had the symptoms of ectopic pregnancy but were either not investigated or were given the wrong diagnosis. Worryingly, most women report that they had not been given any information about the signs of rupture or informed about the possibilities of an ectopic pregnancy.
Clements and Brennan (2000) concluded that if standard clinical guidelines produced by the RCOG (2002) were followed most cases of misdiagnosis and subsequent rupture would never arise.
Risk factors
Stabile (1996) suggests the most important stage in early diagnosis is to identify those women who may be at risk. Common causes and risk factors include:
- Damage to the fallopian tube causing blockage or narrowing so the eggs cannot move into the uterus;
- Previous pelvic infection;
- Chlamydia. This infection is increasingly common in young women. It is crucial that school nurses, midwives, health visitors and teachers warn young women of the problems that untreated sexually transmitted infections (STIs) can cause to their health and future fertility;
- Previous appendicitis;
- Women with a history of infertility (Stabile, 1996);
- Caesarean section. With the rise in the Caesarean section rate in this country, this is an important factor to consider when informing women of their choices;
- Women aged 35 or older;
- Smoking.
However, in many instances the cause is not known.
Symptoms
Stabile (1996) points out that mortality and morbidity are a direct result of the delay between presentation and treatment. It is essential that any woman of childbearing age be investigated appropriately if any symptoms of this condition are displayed. The most common are:
- Abdominal pain: this is usually one-sided, but not necessarily the side of the ectopic pregnancy;
- Bleeding that could be just spotting or abnormal bleeding. The blood is often darker than a normal period and can be described as ‘watery or prune juice coloured’;
- Shoulder tip pain, which can be caused by irritation to the diaphragm caused by internal bleeding, and is a classic sign of ruptured ectopic pregnancy;
- Bladder and bowel problems: pain when going to the toilet and a feeling of pressure in the bowels;
- Dizziness, pallor and nausea;
- Collapse.
The woman may not know she is pregnant or may think she is having an unusual period. In addition she may have been fitted with a coil.
Some women express a feeling that something is very wrong; this is often accompanied by a feeling of impending doom. Pregnancy testing may be positive but this is not always the case. Up to 75 per cent of women may present with subacute symptoms (Stabile, 1996).
Management
It is vital to diagnose an ectopic pregnancy early to prevent further damage to the tube and reduce the likelihood of morbidity as well as trying to preserve fertility.
If an ectopic pregnancy is suspected the woman should attend hospital. An ultrasound scan and a pregnancy test should be performed. If the test is positive and the scan shows an empty uterus, an ectopic pregnancy is likely and needs to be ruled out (Tay et al, 2000). If the woman is well this can be done by serial blood tests every 48 hours to check the level of the pregnancy hormone, beta-HCG. However, Tay et al (2000) recommend caution as they found that this has a high failure rate. Ankum (2000) proposes laparoscopy as the preferred option.
If diagnosis is made early before the tube ruptures, keyhole surgery or drug treatments such as methotrexate can be offered. This promotes a quicker recovery time and increases women’s chances of future fertility. This is the view expressed in the RCOG guidelines (2002), which suggest a laparoscopic approach is highly preferable to undertaking a laparotomy because patients recover more quickly. It also results in less morbidity, a shorter hospital stay and greatly reduced costs.
Patient education
One of the roles of the nurse or midwife must be educating women and their partners in the signs and symptoms of ectopic pregnancy. As an advocate a nurse midwife or health visitor must ‘act always in a manner as to promote and safeguard the interests of patients and clients’ (UKCC, 1998).
Studies have found that many patients are dissatisfied with the information given by health care providers (Brown et al, 1999). In the situation where a woman has a suspected ectopic pregnancy it is essential that she and her partner be advised regarding the potential effect this may have on her health and fertility and be warned of the signs and symptoms of a ruptured ectopic pregnancy.
A leaflet is available free of charge from the Ectopic Pregnancy Trust. By providing information to patients nurses may well be able to prevent rupture and aid early diagnosis of ectopic pregnancy, thus not only minimising the need for major surgery but also potentially saving a woman’s life.
Psychological impact
The loss of a baby and emergency surgery can have an enormous impact on a woman’s psychological health and on her relationships. In addition, the surgery to treat ectopic pregnancy has an impact on the woman’s fertility, usually decreasing it by 50 per cent or more. Many women who seek help from The Ectopic Pregnancy Trust are exhibiting symptoms of post-traumatic stress disorder, experiencing flashbacks, nightmares, hypervigilance and depression (Herman, 1997).
It is vital that midwives and nurses have an awareness of the emotional trauma of ectopic pregnancy when taking a history from a woman. Abbott (2002) suggests that an ectopic pregnancy is similar to having ‘a termination without consent’. Sizoo (2002) speaks of feeling ‘robbed of that special feeling pregnancy bestows on you … tricked, as if someone has played an almighty practical joke’.
Recommendations
Deaths from ectopic pregnancy should not still be occurring, therefore:
- Women should be informed of the signs and symptoms of ectopic pregnancy so that they can become empowered when seeking help;
- Health care professionals should have greater vigilance in the detection of ectopic pregnancy.
This article has been double-blind peer-reviewed.
USEFUL CONTACTS
The Ectopic Pregnancy Trust
Telephone helpline 01895 238025
Or visit: www.ectopic.org.uk
- For an information leaflet send a large SAE to:
The Ectopic Pregnancy Trust
c/o Maternity Unit, Hillingdon Hospital
Pied Heath Road, Uxbridge
Middlesex UB8 3NN
Within the last 2 decades, a more conservative surgical approach to unruptured ectopic pregnancy using minimally invasive surgery has been advocated to preserve tubal function. The conservative approaches include linear salpingostomy and milking the pregnancy out of the distal ampulla. The more radical approach includes resecting the segment of the fallopian tube that contains the gestation, with or without reanastomosis.
Laparoscopy has become the recommended approach in most cases. [61] Laparotomy is usually reserved for patients who are hemodynamically unstable or for patients with cornual ectopic pregnancies; it also is a preferred method for surgeons inexperienced in laparoscopy and in patients in whom a laparoscopic approach is difficult (eg, secondary to the presence of multiple dense adhesions, obesity, or massive hemoperitoneum).
Multiple studies have demonstrated that laparoscopic treatment of ectopic pregnancy results in fewer postoperative adhesions than laparotomy. Furthermore, laparoscopy is associated with significantly less blood loss and a reduced need for analgesia. Finally, laparoscopy reduces cost, hospitalization time, and convalescence period.
Linear salpingostomy along the antimesenteric border to remove the products of conception is the procedure of choice for unruptured ectopic pregnancies in the ampullary portion of the tube. Ectopic pregnancies in the ampulla are usually located between the lumen and the serosa and, thus, are ideal candidates for linear salpingostomy. Several studies have demonstrated no benefit of primary closure (salpingotomy) over healing by secondary intention (salpingostomy).
Total salpingectomy is the procedure of choice in a patient who has completed childbearing and no longer desires fertility, in a patient with a history of an ectopic pregnancy in the same tube, or in a patient with severely damaged tubes.
In cases involving uncontrolled bleeding and hemodynamic instability, conservative treatment methods are avoided in favor of radical surgery.
A systematic review and meta-analysis compared the fertility outcomes of salpingectomy with those of salpingostomy among patients treated for tubal ectopic pregnancies. The two randomized, controlled trials included in the review showed no difference in the odds of a subsequent intrauterine pregnancy between salpingectomy and salpingostomy. However, in the 16 cohort studies that were reviewed, the likelihood of a subsequent intrauterine pregnancy was lower in patients who underwent salpingectomy. [70]
In linear salpingostomy, the involved tube is identified and freed from surrounding structures. To minimize bleeding, a dilute solution containing 20 U of vasopressin in 20 mL of isotonic sodium chloride solution may be injected into the mesosalpinx just below the ectopic pregnancy. Make sure that the needle is not in a blood vessel by aspirating before injecting, because intravascular injection of vasopressin may precipitate acute arterial hypertension and bradycardia.
Next, using a microelectrode, scissors, harmonic scalpel, or laser, a 1- to 2-cm linear incision is made along the antimesenteric side of the tube along the thinnest segment of the gestation. (See the image below.)
Linear incision being made at the antimesenteric side of the ampullary portion of the fallopian tube.
At this time, the pregnancy usually protrudes out of the incision and may slip out of the tube. Occasionally, it must be teased out using forceps or aqua-dissection, which uses pressurized irrigation to help dislodge the pregnancy. (See the images below.)
Laparoscopic picture of an ampullary ectopic pregnancy protruding out after a linear salpingostomy was performed.
Schematic of a tubal gestation being teased out after linear salpingostomy.
Coagulation of oozing areas may be necessary and can be accomplished using microbipolar forceps. Some ampullary pregnancies can be teased out and expressed through the fimbrial end (milking of the tube) by using digital expression, suction, or aqua-dissection. However, this approach carries with it a higher rate of bleeding, persistent trophoblastic tissue, tubal damage, and recurrent ectopic pregnancy (33%).
In some cases, resection of the tubal segment containing the gestation or a total salpingectomy is preferred over salpingostomy. This is true for isthmic pregnancies, in which the endosalpinx is usually damaged. These patients do poorly with linear salpingostomy, with a high rate of recurrent ectopic pregnancy occurring.
Segmental tubal resection is performed by grasping the tube at the proximal and distal borders of the segment of the tube containing the gestation and coagulating thoroughly from the antimesenteric border to the mesosalpinx. This portion of the tube is then excised. The underlying mesosalpinx is also coagulated and excised, with particular attention to minimize the damage to the surrounding vasculature.
Delayed microsurgical reanastomosis can be performed to reestablish tubal patency if enough healthy fallopian tube is present. Take care to minimize the thermal injury to the tube during excision, so that an adequate portion of healthy tube remains for the reanastomosis.
Total salpingectomy can be achieved by progressively coagulating and cutting the mesosalpinx, starting from the fimbriated end and advancing toward the proximal isthmic portion of the tube. At this point, the tube is separated from the uterus by coagulating and excising with scissors or laser.
The optimal surgical management for a patient with an ectopic pregnancy depends on several factors, including the following:
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Patient's age, history, and desire for future fertility
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History of previous ectopic pregnancy or pelvic inflammatory disease (PID)
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Condition of the ipsilateral tube - Ie, ruptured or unruptured
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Condition of the contralateral tube - Eg, adhesions, tubal occlusion
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Location of the pregnancy - Ie, interstitium, ampulla, isthmus
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Presence of confounding complications
In a patient who has completed childbearing and no longer desires fertility, in a patient with a history of an ectopic pregnancy in the same tube, or in a patient with severely damaged tubes, total salpingectomy is the procedure of choice. The presence of uncontrolled bleeding and hemodynamic instability warrants radical surgery over conservative methods. The preferred approach based on the location of the pregnancy varies, as previously discussed. In all instances, regardless of desired fertility, fully inform the patient of the possibility of a laparotomy with bilateral salpingectomy.
Throughout the procedure, take care to minimize blood loss and reduce the potential for retained trophoblastic tissue, which can reimplant and persist. Remove large gestations in an endoscopic bag, and perform copious irrigation and suctioning to remove any remaining fragments. Inspect the peritoneal cavity and remove any detected residual trophoblastic tissue.
Note the condition of the contralateral tube, the presence of adhesions, or other pathologic processes because this helps in the postoperative counseling of the patient with regard to future fertility potential.
Proper pain control and hemodynamic stability are important postoperative considerations. Most often, patients treated with laparoscopy are discharged on the same day of surgery; however, overnight admission may be necessary for some patients in order to monitor postoperative bleeding and achieve adequate pain control. Patients treated by laparotomy are usually hospitalized for a few days.