Case 41: Ectopic pregnancy management

 

Case 41: Ectopic pregnancy management

CASE 41: ECTOPIC PREGNANCY MANAGEMENT

History

A 33-year-old woman presented to the early pregnancy unit of the hospital reporting brown

vaginal discharge and some mild lower abdominal pain for 2 days. Her last period started

6 weeks 3 days ago and this is her first pregnancy.

Examination

The heart rate is 78/min and blood pressure 115/68 mmHg. The patient appears comfortable.

The abdomen is not distended and no masses are palpable. There is no tenderness on palpation.

Speculum examination is normal with no active bleeding seen and the cervix appears normal and closed. No cervical motion tenderness or adnexal tenderness is apparent on bimanual examination.

INVESTIGATIONS

Urinary pregnancy test: positive

Transvaginal ultrasound: an empty uterus is noted and a 25 mm mass is seen adjacent to

the left ovary which has the appearance of an ectopic pregnancy. A small gestation sac

is seen within the mass but no embryo or heartbeat is visible. There is no significant free

fluid in the pouch of Douglas.

Serum hCG: 4322 IU/L

In view of the high hCG level, medical and expectant management of this ectopic pregnancy

are contraindicated. Laparoscopic surgical management is therefore advised.

Questions

• Assuming you are the doctor obtaining informed consent for the surgical procedure, how would you counsel the woman regarding whether a salpingectomy or

salpingotomy is performed?

• Following surgery what advice should be given to this woman before discharge home?100 Cases in Obstetrics and Gynaecology

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ANSWER 41

Salpingectomy or salpingotomy?

Salpingectomy (removal of the fallopian tube with ectopic pregnancy within it) and salpingotomy (linear incision along the antimesenteric border of the tube to remove the ectopic

pregnancy) are both reasonable options for this woman, depending on her wishes after

full counselling. Although it may seem intuitive to the woman that the tube should not be

removed, the following issues should be explained:

1. The risk of persistent trophoblast (due to incomplete removal of all ectopic pregnancy tissue) is 4–8 per cent after salpingotomy but extremely rare after salpingectomy. Therefore there is a small chance of needing methotrexate for a non-declining

hCG after salpingotomy.

2. An ectopic pregnancy may suggest a previously poorly functioning tube, prone to

recurrent ectopic pregnancy. In addition, the current ectopic pregnancy will have

distended the tube and the salpingotomy would damage it further. Thus leaving a

damaged tube increases further the risk of subsequent ectopic pregnancy.

3. The risk of repeat ectopic pregnancy after salpingectomy and salpingotomy is

approximately 15 and 10 per cent respectively.

4. The intrauterine pregnancy rate after salpingotomy or salpingectomy is approximately 60 per cent with a nonsignificant trend toward an improved likelihood of

subsequent normal intrauterine pregnancy with salpingectomy.

5. At laparoscopy the contralateral tube would be assessed and if it seemed abnormal

(blocked or surrounded with adhesions) then all attempts would be made to perform

salpingotomy rather than salpingectomy on the tube containing the ectopic pregnancy.

6. It may not be technically possible to perform a salpingotomy and excessive bleeding may necessitate salpingectomy even if salpingectomy is the preferred option

preoperatively.

Figures 41.1 and 41.2 show the ultrasound appearance of the ectopic pregnancy and the laparoscopic findings, respectively.

Figure 41.1 Transvaginal ultrasound scan. Figure 41.2 Laparoscopy findings (see

colour insert).Case 41: Ectopic pregnancy management

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Advice before discharge

The box below summarizes the important counselling and advice for a woman following

diagnosis of ectopic pregnancy. In addition, if the woman has undergone salpingotomy or

there was a suggestion of possible spillage of trophoblast at salpingectomy, then she should

have hCG monitoring until the hCG returns to the non-pregnant level (<5 IU/L).

! Postoperative counselling points after ectopic pregnancy

• Explanation of diagnosis and operation.

• Appropriate counselling that the woman may grieve (this is the loss of a pregnancy) with advice about further support.

• Avoid the progesterone only contraceptive pill (POP) and intrauterine contraceptive device (IUCD) (both are associated with a slightly higher risk of ectopic

pregnancy).

• Approximately 60 per cent of women who have had an ectopic pregnancy go on

to have a live birth in the next three years, but there is a 10–15 per cent chance of

a further ectopic pregnancy.

• Early transvaginal scan is indicated at around 5 weeks’ gestation to confirm the

location of any future pregnancy.

• Effective contraception should be used if the woman does not wish to become

pregnant again at the moment.

KEY POINTS

• The indications for surgical management of ectopic pregnancy (rather than

expectant or medical) are:

• haemodynamic instability

• live ectopic pregnancy (cardiac activity seen)

• hCG greater than 3000 IU/L

• significant pain

• presence of significant haemoperitoneum on ultrasound

• patient choice/poor compliance with conservative treatment.

• The decision to perform a salpingectomy, rather than salpingotomy, depends on

patient choice and operative findings.

• hCG follow-up after salpingotomy is essential.