Ectopic pregnancy is a gynaecological emergency that often requires urgent treatment. Ectopic pregnancy occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity. The most common extrauterine location is the fallopian tube, which accounts for 91-95 percent of all ectopic pregnancies. Although rare, other locations can include ovarian pregnancy, cervical pregnancy, interstitial pregnancy, hysterectomy/caesarean scar pregnancy, abdominal pregnancy and heterotopic pregnancy.
Ectopic pregnancy is a notable cause of maternal morbidity and mortality, with haemorrhage resulting from ectopic pregnancy being responsible for up to 15 percent of all pregnancy related deaths and most significantly, 80 percent of deaths within the first trimester. This potentially life-threatening condition requires urgent medical or surgical treatment to reduce the risk of rupture and subsequent major haemorrhage. Early identification, sufficient pre-hospital care and transfer to an appropriate facility is affiliated with good outcomes that see minimal impact on future fertility and pregnancy rates.
The rate of ectopic pregnancy is around 1-2 percent with a maternal mortality of 0.2 per 1000 estimated ectopic pregnancies. The mortality ratio is 6.8 times higher in the non-Caucasian population and women over 35 are 3.5 times more likely to experience an ectopic pregnancy than women under 25. The majority of deaths can be attributed to sub-standard care, with the most vulnerable population being women who do not have access to sufficient medical assistance.
The disruption of normal tubal anatomy is the major cause of ectopic pregnancy and can be caused by congenital anomalies, tumours, previous surgery and infection. The highest risk factors include previous ectopic pregnancy and prior history of tubal surgery.
Women using contraception are at a very low risk of pregnancy, however if they do conceive, the probability of an ectopic pregnancy is high. Approximately 50 percent of diagnosed ectopic pregnancies are not associated with any known risk factors. Women with ectopic pregnancy are also commonly unaware of pregnancy.
Clinical manifestations generally occur 6-8 weeks after the last normal menstrual period.
In a retrospective study of 2026 pregnant women who presented to the emergency department with first-trimester vaginal bleeding and abdominal pain, 18 percent were diagnosed with ectopic pregnancy.
History taking is an integral aspect of the formation of a possible ectopic pregnancy diagnosis.
Important information can include:
Assessment should include
Paramedics should consider a differential diagnosis of ectopic pregnancy in all women of reproductive age who are presenting with abdominal pain and have a high suspicion when pain is accompanied by vaginal bleeding. Mismanaging the care of women with ectopic pregnancies is easier than making the correct diagnosis, partly because cases present infrequently, but mainly due to presentations not always being classical.
Diagnostic tests include serial Human chorionic gonadotropin (hCG) measurements and transvaginal ultrasound. Both medical and surgical management options exist and depend on the duration of pregnancy and haemodynamic status of the woman.
Conservative medical management is the goal for unruptured ectopic pregnancy and involves methotrexate therapy which comes with a high (above 90%) success rate and is found to have no adverse effects on ovarian function or future pregnancies. Only 35 percent of ectopic pregnancies suit the criteria for medical management.
Surgical management is necessary for hemodynamically unstable patients, patients with confirmed or impending rupture, patients with co-existing intrauterine pregnancy and patients who do not meet medical criteria. A laparoscopic approach is used and a salpingostomy is performed to remove the fallopian tube (in fallopian tube pregnancy). Prognosis is similar to the medically managed group. The rate of recurrent ectopic pregnancy is 15 percent, rising to 30 percent after two ectopic pregnancies.
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Kadogan Combes, AP20831
Ambulance Paramedic, Metropolitan Ambulance Service