A clinical audit: On the management of Ectopic pregnancy

N. Suchitra1, E. Elavarasi2, Sudha Santhi. M3, Harshvani4

OBG Team, Kauvery Hospital, Cantonment, Trichy

Definition

  1. An ectopic pregnancy is any pregnancy implanted outside the endometrial cavity.
  2. Rate of ectopic pregnancy is 11/1000, with maternal mortality of 0.2/1000.
  3. Fatality rate has decreased over recent years, showing that early diagnosis and appropriate management make a difference.

Risk Factors of Ectopic Pregnancy

  1. Previous ectopic pregnancy
  2. Prior tubal surgeries
  3. Abdominal and pelvic surgeries
  4. Pelvic inflammatory disease
  5. Endometriosis
  6. Assisted reproductive techniques such as IVF
  7. Advanced age
  8. Intrauterine device users
  9. Emergency contracepttion
  10. Cigarette smoking.

Types of Ectopic Gestation

  1.  97.7% occur  in the Fallopian tube
  2. Ampullary- 80%
  3. Isthmic- 12%
  4. Fimbrial- 5%
  5. 2-3%- interstitial
  6. Caesarean section scar on the uterus
  7. Less than < 1% are cervical (1 in 2000)
  8. Cornual (1 in 76000)
  9. 0.5-3% Ovarian
  10.  < 1% are abdominal
  11.  < 1% are heterotopic pregnancies.

Management of Ectopic Pregnancies

  1. Expectant management
  2. Medical management
  3. Surgical management.

Based on NICE Guidelines

Treatment

Sr.Beta hcg

Adnexal mass

Fetal heart Beat

Hemoperitoneum Symptomatic
Expectant <1500 <35 mm Absent No
Medical <5000 <35 mm Absent No
Surgical >5000 >35 mm Present Yes

Mode of Surgery

    1. Laparoscopic excision of ectopic sac: Hemodynamically stable patient.
    2. Laparotomy: Hemodynamically unstable patient.
    3. Salpingectomy:

a. Indicated if contralateral tube is healthy and no fertility reducing factors.

b. Follow up the patient with UPT after 3 weeks.

    1. Salpingotomy:

a. Salpingotomy is indicated with history of fertility-reducing factors (previous ectopic pregnancy, contralateral tubal damage, previous abdominal surgery, and previous pelvic inflammatory disease).

b. Post salpingotomy follow up the patient with weekly HCG till negative.

Aim

To analyze the demographic profile, risk factors, clinical presentation, radiological findings, outcomes and management of ectopic pregnancy in a tertiary care hospital.

Objective

To evaluate the risk factors involved, the patient’s clinical presentation, radiological results, laboratory results and to assess the management of ectopic pregnancy in accordance with NICE guidelines in order to consider the areas that were lacking in ectopic pregnancy management.

Materials and Methods

A Retrospective data collection was done of all women with ectopic pregnancy within the time frame of January 2021-august 2023 to assess the age, parity, previous surgical history/other risk factors and the lab findings like radiological findings, laboratory findings, medical management, and surgical management.

Inclusion Criteria: Presenting symptoms like,

  1. Abdominal pain
  2. Amenorrhea
  3. Per vaginal bleed
  4. Shock

It was then compared with NICE guidelines regarding the management protocol.

Demographic Profile

In our study group,

  1. Total no of deliveries – 903
  2. Total no of ectopic – 47.

Parameters

Most common

Percentage (%)
Age 25-30 40
Gravida Multigravida 57

Risk factors

Past surgical H/O

Total

Percentage (%)
No risk 22 47
Previous LSCS without ST 23 49
Previous Ectopic History 2 4
Over all 47 100

Type of Ectopic Gestation

Type

Total

Percentage (%)
Tubal 39 83
Cornual 4 9
Hetrotropic 2 4
Scar ectopic 2 4
Over all 47 100

Management

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Medical Management

  1. Out of 47 ectopic, 17 were medically managed.
  2. Out of 17, 11 were successfully managed in our institution.
  3. The 6 were surgically managed.

Surgical Management

Out of 47 ectopic, 34 were managed surgically.

Surgical management

Laparotomy

Laparoscopy
34 18 16

Laboratory Findings

Management

Sr. Beta hcg<5000

Sr. Beta hcg>5000
Total 26 21

Radiological Findings

1. Gestational Sac

<35mm

 26 55%

>35mm

 21 44%

2. FH

Present

 3 6%

Absent

 44 94%

3. Hemoperitoneum

Yes

 23 49%

No

 24 51%

Results

  1. All 47 ectopics had sr. beta hcg and TV ultrasound at the time of presentation (100%).
  2. In 16 out of 17 women, who received methotrexate were within hospital guidelines for medical management (99%).
  3. In11 out of 17 were successfully managed (65%).
  4. All women who were surgically intervened for tubal ectopics underwent salpingectomy (100%).
  5. In 28 out of 28 had clear indication documented for surgery within local protocol (100%).

Areas to Improve

  1. Emphasize on documentation of risk factors pertaining to the disease.
  2. The reason for salpingectomy rather than salpingotomy should be documented in OT notes for future reference.
  3. Option of salpingotomy as a surgical alternative can be considered.
  4. Maintaining ectopic register for future follow up.

Reference

Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE guideline [NG126]. 2019

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Dr. N. Suchitra

HOD and Senior Consultant

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Dr. E. Elavarasi

Consultant Obstetrics & Gynecologist

Sudha-Santhi-1

Dr. Sudha Santhi. M

Department of Obstetrics and Gynecology

Harshvani

Dr. Harshvani

Department of Obstetrics and Gynecology

Journals

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