ECTOPIC PREGNANCY CLINICAL GUIDELINES

Register No: 10121

Status: Public

Developed in response to: NICE Guidance QS0690

RCOG guideline
Contributes to CQC Outcome 4

Consulted With Post/Committee/Group Date

Mr Kennedy Clinical Director for Womens, Childrens & Sexual Health Directorate January 2014
Alison Cuthbertson Acting Head of Midwifery
Dr Madhu Consultant for Obstetrics and Gynaecology
Tasneen Yaqoob Associate Specialist Gynaecology
Carly Jones Senior Sister Writtle Ward
Debbie Anderson Gynaecology Sister Outpatients
Jan Medici Gynaecology Sister Outpatients
Sally Larcombe Gynaecology Sister Outpatients
Claire Fitzgerald Pharmacist
Professionally Approved By
Dr Anita Rao Lead Consultant for Obstetrics & Gynaecology January 2014

Version Number 2.1

Issuing Directorate Obstetrics and Gynaecology
Ratified By Documents Ratification Group, Chairmans Action
Ratified On 27th March 2014
Trust Executive Board Date April 2014
Next Review Date March 2017
Author/Contact for Information Dr Anita Rao, Consultant for Obstetrics and Gynaecology
Policy to be followed by (target staff) Obstetricians,
Gynaecology Nurses
Distribution Method Intranet & Website. Notified on Staff Focus
Related Trust Policies (to be read in conjunction 04071 Standard Infection Prevention
with) 04072 Hand Hygiene
06036 Guideline for Maternity Record Keeping including
Documentation in Handheld Records
08014 Management of women requiring antenatal
thromboprophylaxis
04184 Blood transfusion poilcy

Review No Reviewed by Review Date

1.0 Anita Rao 25th November 2010
2.0 Anita Rao 27th March 2014
2.1 Sarah Moon 17th November 2014

It is the personal responsibility of the individual referring to this document to ensure that they are viewing the latest
version which will always be the document on the intranet

1
INDEX

1. Purpose
2. Equality and Diversity
3. Incidence
4. Risk Factors
5. Symptoms and Signs
6. Diagnosis of an Ectopic Pregnancy
7. Human chorionic gonadotrophin measurements in women with Pregnancy of
Unknown location
8. Management of Ectopic Pregnancy
9. Conservative Management of Ectopic Pregnancy
10. Medical Management of Ectopic Pregnancy
11. Side Effects of Treatment
12. Information for the Clinician
13. Information for Patients
14. Outcome of Medical Management
15. Surgical Management of Ectopic Pregnancy
16. Management of a Ruptured Ectopic with Collapse
17. Unusual Types of Ectopic Pregnancy
18. Staff and Training
19. Infection Prevention
20. Audit and Monitoring
21. References
22. Appendices
A. Appendix A - A Guide to Choosing the Appropriate Treatment based on hCG
Measurements, the Expected Serial hCG Patterns in the follow-up of
Ectopic Pregnancy and Adnexal Mass Measurement
B. Appendix B - Unusual Types of Ectopic Pregnancies
C. Appendix C - Ultrasound Features in Early Pregnancy
D. Appendix D - A Brief Guide to Management of Early Pregnancy Features
E. Appendix E - Guidelines for Counselling Patients who have a Scan Diagnosed
Miscarriage

2
1.0 Purpose of Guideline
1.1 Ectopic pregnancy can be a devastating experience. Patients have to cope with the
loss of a baby, the possible loss of fertility and the possible loss of their life.

1.2 The psychological impact is not to be overlooked. The emotional as well as the clinical
needs of individual patients should be assessed and sensitively dealt with.

1.3 NICE clinical guideline 154 (December 2012) states that the rate of ectopic pregnancy
is 11 per 1000 pregnancies, with a maternal mortality of 0.2 per 1000 estimated
ectopic pregnancies.

2.0 Equality and Diversity

2.1 The Trust is committed to the provision of a service that is fair, accessible and meets
the needs of all individuals.

3.0 Incidence

3.1 The fallopian tube is the most common site accounting for nearly all ectopic
pregnancies. Other possible sites of an ectopic pregnancy are, interstitial, cervical,
ovarian, caesarean section scar or abdominal (rare). An abdominal ectopic pregnancy
may be primary or secondary resulting from a tubal miscarriage.

4.0 Risk Factors

4.1 Risk factors are only present in 25%-50% of patients with an ectopic pregnancy. The
risk factors include a history of the following:
Previous pelvic inflammatory disease
Tubal surgery
Previous ectopic pregnancy
Infertility
Assisted reproductive technology
Intrauterine contraceptive device
4.2 Smoking and a maternal age >40 years are also associated with an increased
incidence of ectopic pregnancy.

4.3 The diagnostic performance based on the combined use of transvaginalsonography

(TVS) and serum human chorionic gonadotrophin (hCG) measurement reaches
sensitivities and specificity range 95%-100%. Patients who have had previous ectopic
pregnancies or are at risk of ectopic pregnancy should be advised to present early, at
6 weeks, in subsequent pregnancies for confirmation of a uterine pregnancy.

5.0 Symptoms and Signs

5.1 Symptoms:
Amenorrhoea
Vaginal bleeding
Lower abdominal pain
Faintness/dizziness
Shoulder tip pain
Gastrointestinal symptoms diarrhoea or pain on defecation
3
5.2 Signs:
Lower abdominal tenderness
Adnexal tenderness and/or mass
Cervical excitation
Shock/collapse

5.3 The clinical presentation and natural course of an ectopic pregnancy are
unpredictable. It is important to have a high index of suspicion for ectopic pregnancy,
because the patient may not be symptomatic until rupture occurs, or on the other hand
the patient may experience vague abdominal pain and/or vaginal bleeding.

6.0 Diagnosis of an Ectopic Pregnancy

(Refer to Appendix A, B, C, D and E)

6.1 Ultrasound features Like any pregnancy an ectopic pregnancy too has a natural
history of evolution, hence the ultrasound findings depend on the development stage
at the time of examination.

6.2 Almost all ectopic pregnancies occur in the fallopian tube. Ultrasound features
suggestive of ectopic pregnancy are a combination of uterine and adnexal findings:

6.3 Uterine:
An empty uterus
Variable degree of thickening of endometrium
A thin endometrium may exclude the possibility of an early intrauterine pregnancy
as it is not compatible with an ongoing early implantation
An intrauterine pseudo sac mere collection of variable amount of fluid with
uterine cavity, is found in approximately 5% of all ectopic pregnancies

6.4 Adnexal:
A hyperechogenic tubal ring (doughnut or bagel sign) is the most common
finding on scan, probably due to early scanning
A mixed adnexal mass either tubal miscarriage or tubal rupture
An ectopic sac with a yolk sac or an embryo with or without a heart beat
Fluid in the Pouch of Douglas

6.5 The corpus luteum may be present on the ipsilateral side in 85% of cases.

7.0 Human chorionic gonadotrophin measurements in women with Pregnancy of

Unknown location (PUL)

7.1 In the absence of any diagnostic features on ultrasound scan (inconclusive scan
result) serial hCG assay are performed. (Refer to PUL NICE guidelines)

7.2 A serum hCG level that is increasing or has plateaued may either show an ectopic
pregnancy at subsequent scan or remain as a pregnancy of unknown location (Refer
to PUL NICE guidelines)

7.3 Transvaginal ultrasound and quantitative assay of serum hCG not only play a role in
the diagnosis of an ectopic pregnancy but also in determining the management
options in a particular patient.

4
7.4 Both the hCG levels and the patterns of change of hCG are helpful in constructing a
plan for ectopic pregnancy. The clinical picture should always be considered with hCG
measurements.

8.0 Management of Ectopic Pregnancy

8.1 Inform women who have had an ectopic pregnancy that they can self-refer to an early
pregnancy assessment service in future pregnancies if they have any early concerns.

8.2 Give all women with an ectopic pregnancy oral and written information about:
How they can contact a healthcare professional for post-operative advice if
needed, and who this will be and
Where and when to get help in an emergency

8.3 Offer systemic methotrexate as a first-line treatment to women who are able to return
for follow-up and who have the following:
No significant pain
An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with
no visible heartbeat
A serum hCG level less than 1500 iu/L
No intrauterine pregnancy (as confirmed on an ultrasound scan)

Offer surgery where treatment with methotrexate is not acceptable to the woman.

8.4 Offer surgery as a first-line treatment to women who are unable to return for follow-up
after methotrexate treatment or who have any of the following:
An ectopic pregnancy and significant pain
An ectopic pregnancy with an adnexal mass of 35 mm or larger
An ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
An ectopic pregnancy and a serum hCG level of 5000 iu/L or more

8.5 Offer the choice of either methotrexate or surgical management to women with an
ectopic pregnancy who have a serum hCG level of at least 1500 iu/L and less than
5000 iu/L, who are able to return for follow-up and who meet all of the following
criteria:
No significant pain
An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with
no visible heartbeat
No intrauterine pregnancy (as confirmed on an ultrasound scan)

Advise women who choose methotrexate that their chance of needing further
intervention is increased and they may need to be urgently admitted if their condition
deteriorates.

9.0 Conservative Management of Ectopic Pregnancy

9.1 Not all ectopic pregnancies progress and pose a risk to the mother. Spontaneous
resolution of tubal ectopic pregnancies has been well documented in a number of
reports.

5
9.2 Selection criteria for conservative management as follows:
Adnexal mass less -<2cm
Serum hCG less than 1000 iu/L and declining progressively
Asymptomatic patients
Absense of haemoperitoneum
No sign of rupture or intraperitoneal bleeding
No fetal parts

9.3 Follow up with twice weekly serum hCG and scan once a week and show a trend of
falling serum hCG and scan decrease in size of adnexal mass. Follow up until serum
hCG is less -<10 iu/L.

9.4 The risk of rupture in a patient with an ectopic exists until the hCG level has fallen to
<10 iu/L. It often involves frequent hospitalisation and/or follow up. Both the physician
as well as the patient should be well motivated to accept the long recovery time.

10.0 Medical Management of Ectopic Pregnancy

10.1 Methotrexate is the most commonly used drug for the medical management of ectopic
pregnancy. A single injection of methotrexate is well tolerated and is effective.
Published studies have shown a success rate varying form 52% to 94% for single
dose methotrexate.

10.2 Systemic methotrexate treatment in ectopic pregnancy methotrexate is a folic acid-

antagonist (anti-metabolite) which prevents growth of rapidly dividing cells by
interfering with DNA synthesis. It can be used both as initial treatment for an ectopic
pregnancy or as an additional treatment after surgery to conserve the tube. It is
effective in 90% of cases.

10.3 Inclusion criteria as follows:

Haemodynamically stable
Mass 35mm or less
Minimal or no symptoms
Ongoing intrauterine pregnancy excluded
Unruptured tubal or other ectopic pregnancy <35mm
Persistent trophoblast after salpingotomy
An ectopic pregnancy with serum hCG less than 1500iu/L
An ectopic pregnancy with serum hCG value less than 1000 iu/L should have
repeat serum hCG within 48 hours if the patient remains haemodynamically stable
The treatment should begin if the levels are plateauing
If the levels are rising, one must exclude intrauterine pregnancy before starting
treatment
Normal liver function tests (LFTs), uric acid and electolytes (U&Es) and full blood
count (FBC)
Patients must seek consent to have medical management and are willing to
comply with several weeks follow-up on a weekly basis.

10.4 Exclusion criteria as follows:

If there is any evidence of intraperitoneal haemorrhage i.e. haemoperitoneum on
TVS
Patients wants surgical management
6
 Difficulty or unwillingness of patient for prolonged follow-up (average follow-up 35
days)
Serum Beta hCG >3000iu/L (relative C/I)
Ectopic mass >35mm
The presence of cardiac activity in an ectopic pregnancy
Breast feeding
Any Hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood
dyscrasia (WCC <2000 cells cm3)
Medical problems: Patients on concurrent corticosteroid therapy, acute infection,
severe anaemia, renal or liver impairment, active peptic ulcer of colitis, blood
disorders, active pulmonary disease or immunodeficiency

10.5 Treatment Protocol as follows;

Discuss options for management expectant/medical/surgical
Satisfy eligibility and exclusion criteria
Counsel the patient and explain treatment protocol. Give information leaflet
Record height and weight
Prescribe Methotrexate
Organise base line blood tests FBC, blood group, LFTs and U&Es
The prescription with the height and weight documented on it is sent to Aseptics in
Pharmacy Department to make up the drug
Check blood results
Carry out observations, ie, blood pressure, temperature and pulse
Methotrexate is given intramuscularly in buttock or lateral thigh. The empty
syringe and/or needle should be placed in a separate sharp safe, labelled
Cytotoxic waste for special incineration
Patient rests up for one hour. Check for any local reaction. If local reaction noted
consider antihistamine or steroid cream
Repeat observations, blood pressure, temperature and pulse
Arrange follow-up in EPU (Early Pregnancy Unit)

10.6 Single-dose regimen: Day Management

Day 0 - Serum hCG, FBC, U&Es, LFTs, G&S
Day 1 - Administer intramuscular methotrexate 50 mg/m
Day 4 - Serum hCG, FBC, U&Es, LFTs
Day 7 - Serum hCG, FBC, U&Es, LFTs
2nd dose of Methotrexate if hCG increase <15% day 4-7
If hCG decrease >15% repeat hCG weekly until <10iu/L. If hCG levels plateau or rise,
reassess the womans condition for further mananagment

11.0 Side Effects of Treatment

11.1 Most patients do not experience any side effects. Some patients will experience the
following side effects:
Nausea and vomiting
Stomatitis
Diarrhoea
Abdominal discomfort
Photosensitivity skin reaction
Impaired liver function, reversible
7
 Haematosalpinx
RARE severe neutropenia, pneumonitis, alopecia

12.0 Information for the Clinician

12.1 Up to 75% of patients may complain of pain on days 3-7 (thought to be due to tubal
miscarriage).

12.2 hCG levels may initially rise days 1-4 (up to 86% of patients).

12.3 Mean time to resolution is 35 days.

12.4 A second dose of Methotrexate may be given at 7 days if hCG levels fail to fall by
more than 15% between day 4 and day 7 (14% of medically treated patients will
require more than one dose of Methotrexate).

12.5 Risk of tubal rupture is 7% and the risk remains while there is persistent hCG.

12.6 Folinic acid rescue is not required for the single dose regime.

12.7 Avoid vaginal examination. TVS may be undertaken during first treatment week or
subsequently if clinically indicated.

12.8 Ovarian cysts may be found in the post treatment phase, which undergo spontaneous
resolution.

13.0 Information for Patients

13.1 Medical treatment for ectopic pregnancy is now well established, and approximately
90% of patients do not require further surgery. Methotrexate is used for a variety of
clinical conditions, e.g. psoriasis, as well as for malignancies.

13.2 Prolonged follow-up is required with blood tests until serum hCG level is below 10 iu/L.

13.3 A further dose of methotrexate may be necessary.

13.4 Three quarters of patients experience abdominal pain following treatment, which is
due to the drug acting on tubal pregnancy. It usually occurs on days 3-7.

13.5 To contact the gynaecology ward if severe abdominal pain or heavy vaginal bleeding
reoccurs.

13.6 Pregnancy should be avoided for three months after methotrexate has been given,
because of a possible teratogenic effect advice should be to use a reliable barrier or
hormonal contraception.

13.7 Side effects of the methotrexate are minimal but may include nausea, vomiting and
stomatitis.

13.8 Maintain ample fluid intake.

13.9 Avoid alcohol or folic acid containing vitamins during treatment.

13.10 Avoid sexual intercourse until resolution of the ectopic pregnancy.

8
13.11 Avoid exposure to sunlight.

13.12 Avoid aspirin, NSAIDs

14.0 Outcome of Medical Management

14.1 90% successful treatment with single dose regime.

14.2 Recurrent ectopic pregnancy 10-20%.

14.3 Tubal patency approximately 80%.

15.0 Surgical Management of Ectopic Pregnancy

Offer surgery as a first-line treatment to women who are unable to return for follow-
up after methotrexate treatment or who have the following:
An ectopic pregnancy and significant pain
An ectopic pregnancy with an adnexal mass of 35mm or larger
An ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
An ectopic pregnancy and a serum hCG level of 5000iu/L or more

15.1 Laparoscopy Advantages as follows:

Shorter hospital stay (1-2 days)
Significantly less blood loss
Less adhesions formation
Lower analgesic requirements
Quicker post-operative recovery time
Recurrent ectopic pregnancy rate lower (5%) than after Laparotomy (16.6%)
Subsequent intrauterine pregnancy (IUP) rate better (70%) than after Laparotomy

When surgical treatment is indicated for women with an ectopic pregnancy, it should
be performed laparoscopically whenever possible, taking into account the condition of
the woman and the complexity of the surgical procedure.

15.2 Disadvantages as follows:

Increased risk of bowel/vascular damage

15.3 A Laparoscopic approach is superior to a Laparotomy in terms or recovery from

Surgery.

15.4 Salpingectomy and Salpingotomy

15.5 Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless
they have other risk factors for infertility.

15.6 Consider salpingotomy as an alternative to salpingectomy for women with risk factors
for infertility such as contralateral tube damage.

15.7 Inform women having a salpingotomy that up to 1 in 5 women may need further
treatment. This treatment may include methotrexate and/or a salpingectomy.

9
15.8 For women who have had a salpingotomy, take 1 serum hCG measurement at 7 days
after surgery, then 1 serum hCG measurement per week until a negative result is
obtained.

15.9 Advise women who have had a salpingectomy that they should take a urine pregnancy
test after 3 weeks. Advise women to return for further assessment if the test is
positive.

15.10 In the presence of a healthy contralateral tube there is no clear evidence that
salpingotomy should be used in preference to salpingectomy. Early Pregnancy Unit
staff (EPU) should ensure that post-salpingotomy histology must be followed-up. If
there is no evidence of chorionic tissue, the patient should be followed-up with weekly
serum hCG until the levels reach <10iu/L.

15.11 Laparoscopic salpingotomy should be considered as the primary treatment when

managing tubal pregnancy in the presence of contralateral tubal disease and the
desire for future fertility. All these patients should be followed up by weekly hCG
levels until it falls <10iu/L.

15.12 Discuss treatment with the patient and options for conserving or removing the fallopian
tube.

15.13 The RCOG Recommendations are as follows:

At laparoscopy for ectopic pregnancy, precise documentation of the state of the
pelvis, with particular emphasis on the affected and contralateral tube and ovaries,
should be undertaken to determine prognosis of future fertility.
The definitive procedure undertaken at surgery (removal of the ectopic;
salpingotomy; unilateral salpingectomy; bilateral salpingectomy) should be
determined by the reproductive aspirations of the patient, her reproductive history,
the state of the pelvis and the availability of assisted conception services.
Fimbrial evacuation (milking) of ectopic pregnancy from the fallopian tube should
not be done as it predisposes to persistence of tubal pregnancy.

15.13 While trophoblast remains in the fallopian tube it has a capacity to rupture;
therefore the follow-up regime after salpingotomy is as follows:
Follow-up at weekly intervals until serum hCG is <10iu/L
If hCG level is rising or plateauing consider further treatment with Methotrexate or
surgery if hCG levels >5000iu/L

15.14 Suturing the salpingotomy lesion provides no benefit.

15.15 The outcome after conservative surgery in patients with one fallopian tube is as
follows:
Recurrent ectopic pregnancy rate 20.5%
Intrauterine pregnancy (IU) rate 5%

15.16 Conservative surgery may be appropriate but only if the patient is aware of the risk
involved. Salpingectomy followed by in-vitro fertilisation (IVF) is an alternative therapy
in such cases.

10
16.0 Management of a Ruptured Ectopic with Collapse

16.1 The following list details the management of a ruptured ectopic with collapse:

Airway, Breathing, Circulation of resuscitation

Call for assistance; call senior SPR on call and the anaesthetist
Site two IV lines (at least 16g), commence IV fluids (crystalloid), give facial oxygen
via a reservoir mask 10 litres/minute and insert an indwelling urinary catheter
Send bloods FBC, clotting screen and cross-match at least 4 units of blood (Refer
to the guideline for Blood transfusion policy; register number 04184)
Arrange admission and emergency laparotomy
Continue fluid resuscitation and endure intensive monitoring of haemodynamic
state whilst awaiting transfer to the operation theatre
Do not wait for the blood pressure (BP) and pulse to normalise prior to transfer
Proceed to a pfannensteil incision, locate tube directly and clamp
Perform a salpingectomy and wash out the abdomen
Assess bloods and consider a CVP/HDU transfer, discuss with the anaesthetist
Record operative findings including the state of the remaining tube in the patients
healthcare records
Anti-D immunoglobulin at a dose of 250 iu (50 micrograms) to be given to rhesus
negative patients on instructions from the blood transfusion laboratory who have a
surgical procedure to manage ectopic pregnancy. (Refer to the guideline or Blood
transfusion policy; register number 04184)
Do not use Anti-D immunoglobulin who have medical management to manage
ectopic pregnancy
Do not use a Kleihauer test for quantifying feto-maternal haemorrhage

17.0 Unusual Types of Ectopic Pregnancy

17.1 Ultrasound features of non-tubal pregnancies and their management have been well
documented. Management of these ectopic pregnancies is not straightforward.
Treatment has to be individualised based on the size of the pregnancy and its viability.

17.2 Unusual types of ectopic pregnancy:

Heterotopic pregnancy
Interstitial pregnancy
Cervical pregnancy
Ovarian pregnancy
Pregnancy in a caesarean section scar
Abdominal pregnancy
(Refer to Appendix B)

18.0 Staff and Training

18.1 All Gynaecology ward staff must attend yearly statutory training, which includes skills
and drills training.

18.2 All Gynaecology ward staff is to ensure that their knowledge and skills are up-to-date
in order to complete their portfolio for appraisal

11
19.0 Infection Prevention

19.1 All staff should follow Trust guidelines on infection control by ensuring that they
effectively decontaminate their hands before and after each procedure.

19.2 All staff should ensure that they follow Trust guidelines on infection prevention. All
invasive devices must be inserted and cared for using High Impact Intervention
guidelines to reduce the risk of infection and deliver safe care. This care should be
recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork
(Medical Devices).

20.0 Audit and Monitoring

20.1 The gynaecology ward sister will review all risk event forms and complaints. Any
immediate training or educational issues relating to lack of compliance with this
guideline will be addressed on a one to one basis.

20.2 Audit of compliance with this guideline will be considered annually in accordance with
the Maternity annual audit work plan. The Audit Lead in liaison with the Risk
Management Group will identify a lead for the audit.

21.0 References

Ling F.W. and Stovall T.G. (1994) Update on the diagnosis and management of
ectopic pregnancy. Advances in obstetrics and gynaecology.Pp55-83, Chicago.
Mosby Year Book, Inc.

Reccommendations for clinic practice arising from 33rd RCOG Study Group (No 23).
Problems of Early Pregnancy Advances in Diagnosis and Management. London:
RCOG Press, 1997.

Korhonen et al (1994) Serum hCG dynamics during spontaneous resolution of ectopic

pregnancy. Fertil, Steril. 61: 632-6.

Trio et al (1995) Prognostic factors for successful expectant management of ectopic

pregnancy. Fert, Ster. 63: 469-72.

Yao M and Tulandi T (1997) Current status of surgical and non surgical management
of ectopic pregnancy.Fert, Steril. 67: 421-433.

Royal College of Obstetricians and Gynaecologists.The management of tubal

pregnancy.Guidelines No 21. London: RCOG, 2004.

Recommendations arising from the 33rd RCOG Study Group: Problem in Early
Pregnancy: Advances in Diagnosis and Management. London: RCOG Press, 1997.

Condous G, Okaro E, Bourne T (2003) The conservative management of early

pregnancy complications: a review of the literature. Ultrasound Obstet Gynecol. 22:
42-430.

Coady AM (2005). Ectopic Pregnancy: A review of Sonographic Diagnosis.

Ultrasound. 13: No1. 18-29.

12
Jurkovic D, Hillaby K, Woelfer B, et al (2003) First-trimester diagnosis and
management of pregnancies implanted into the lower uterine segment Caesarean
section scar. Ultrasound Obstet Gynecol. 21: 220-227.

Gun M, Mavrogiorgis M (2002) Cervical ectopic pregnancy: a case report and

literature review. Ultrasound Obstet Gynecol. 19: 297-301.

Jurkovic D, Hacket D, Campbell S (1996) Diagnosis and treatment of early cervical

pregnancy: a review and a report of two cases treated conservatively. Ultrasound
Obstetric and Gynecol. 8: 373-38.

13
 Appendix A

A Guide to Choosing the Appropriate Treatment based on hCG Measurements,

the Expected Serial hCG Patterns in the follow-up of Ectopic Pregnancy and
Adnexal Mass Measurement

hCG Level/Adnexal Method of Treatment Expected hCG Pattern

Mass
Low <1000iu/L and Expectant Twice weekly hCG with
declining progressively management steady downward trend
Adnexal Mass -<2cm until <10iu/L
No significant pain Rescan regularly
<1500iu/L Medical management There may be an initial
Adnexal Mass <35mm rise of hCG. In first week
with no visible heartbeat of treatment hCG
No significant pain repeated on Day 4 and 7
No intrauterine then weekly until <10iu/L
pregnancy If hCG increase >15%
between Day 4-7, repeat
dose of methotrexate on
Day 7
FBC, LFTs/U&Es Pre
methotrexate and on
Days 4 and 7 then weekly
until the hCG is <10iu/L
Level at least 1500iu/L Medical management As above
but less than 5000iu/L Surgical management As below
Adnexal Mass <35mm Laparoscopy
with no visible heartbeat (Salpingectomy)
No significant pain (Salpingotomy)
No intrauterine
pregnancy

Level of 5000iu/L or Surgical management

more (Salpingectomy) No need for serum hCG
Adnexal Mass 35mm or - Urine pregnancy test in 3
more with visible weeks
heartbeat Weekly monitoring of beta
With significant pain (Salpingotomy) - hCG until <10iu/L

14
 Appendix B

Unusual Types of Ectopic Pregnancies

Ectopic Ultrasound features Management

pregnancy
Heterotopic An intrauterine pregnancy and a Laparoscopy/
concurrent ectopic pregnancy Salpingectomy for
ectopic.
Scan after surgery to
check viability of
intrauterine
pregnancy.
Interstitial Bright echogenic trophoblastic tissue Conservative/
or gestation sac (GS) in the cornual Methotrexate
region
GS located away from the lateral
margin of the myometrium
Thinning of the myometrial mantle
Cervical Intracervical GS Conservative/
Thick trophoblastic ring medical/surgical
No distortion of endometrium and
cavity
Closed cervical canal in continuity with
the endometrial cavity
Internal os not funnelled
(Should be differentiated from isthmico-
cervical pregnancies that are implanted low
in the uterine cavity, above the cervical
canal)

Ovarian Hyperechogenic mass within the Surgical

ovary
Subcapsular bleeding
(Must be distinguished from a haemorrhagic
cyst)

Caesarean Uterine cavity is empty Individual case

scar GS implanted into the scar management
Negative sliding sign
Abdominal Empty uterus separate from the fetus Methotrexate/
Fetus seen without the surrounding Laparotomy
uterine mantle
Unusual location of the placenta
Extremely low volume of liquor

15
 Appendix C

Ultrasound Features in Early Pregnancy

Gestational age Anatomical landmarks Comments

4 weeks and 2 Eccentrically placed gestational May represent pseudo sac

days sac with GSD 2-3mm. 10-20% of ectopic
pregnancies have an
intrauterine pseudo
gestational sac.
5th week DDS Results from approximation
of decidua capsularis and
decidua vera. May be
present in one third of
ectopics.
5th week GSD 5mm. Confirms IUP.
Yolk sac (YS) size varies from 3- Large YS >10mm poor
8mm (average 5mm) prognosis.
6th week GSD 10mm. Confirms IUP
Embryo 2-3mm. Confirms viability
Cardiac activity (CA) (97% of embryos with CA
have normal outcome)
7th week GSD 20mm. GS >20mm, if no YS poor
Head and trunk distinguishable.
8th week GSD 25mm. GS >25mm, if no embryo
Head size = YS. poor prognosis.
Limb buds.
Mid-gut herniation.
Rhombencephalon.
9th week Choroid plexus, spine, limbs.
10th week Cardiac chambers, stomach,
bladder, skeletal ossification.
11th week Gut returning, most structures
identified.

GSD = Gestational sac diameter

DDS = Double decidual sign
IUP = Intrauterine pregnancy

16
 Appendix D

A Brief Guide to Management of Early Pregnancy Features

Ultrasound Appearance Diagnosis Plan of Management

Intrauterine gestational Viable intrauterine Back to GP for referral to

sac (GS), embryo and pregnancy ANC. If bleeding persists
cardiac activity (CA) upto 14 days from scan,
rescan. If over 14 days and
bleeding had stopped and
started again GP to refer
again.
If actively bleeding Admit for reassurance.
If a significant haematoma Rescan 1 (one) week later.
noted
If viable intrauterine Check the need for Anti_D
pregnancy > 12 weeks immunoglobulin.
with bleeding
GS < 25mm no fetal pole Early Gestational sac Rescan 1 (one) week later
(EGS) and review.
GS > 25mm no fetal pole Empty sac Seek second opinion and/or
rescan 1 (one) week later. If
no change in 2nd scan
discuss management of
miscarriage.
Crown rump length (CRL) Pregnancy of uncertain Rescan 1 (one) week later.
< 7mm. CA not viability (PUV) Further scans maybe
demonstrated needed before a diagnosis
can be made.
CRL > 7mm CA not Early fetal loss Seek second opinion on
demonstrated viability and/or rescan 1 (one
) week later. If no changed
in 2nd scan discuss
management of miscarriage.
Empty uterus. Pregnancy of unknown If serum hCG negative
No adnexal abnormality location (PUL). (<10iu/L) = Complete
miscarriage or never
pregnant. No further follow
up.
Possible early pregnancy.
If serum hCG is positive
repeat serum hCG 48 hours
later. If increase in hCG
>63% rescan 7-14 days
later. Warn cannot rule out
ectopic pregnancy, to report
Possible complete if any pain.
miscarriage
If serum hCG is positive and
decreases >50% patient to
carry out urine pregnancy
test 14 days later if

17
 negative no further follow up
if positive to call EPU for
further review.
Possible ectopic
pregnancy If serum hCG is between
less than 50% decline and
63% rise inclusive refer for
clinical assessment/review
within 24 hours. Warn the
possibility of ectopic
pregnancy, to report if any
pain.
Empty uterus with adnexal Ruptured ectopic Admit for assessment:
mass, fluid in Pouch of pregnancy Observation
Douglas (POD), pain Laparascopy/Laparotomy
Salpingectomy/Salpingotomy
Empty uterus with adnexal Unruptured ectopic Discuss
mass <3cm pregnancy Conservative/medical
management.
No other Follow up with serial hCG.
findings/symptoms

Endometrium/tissue Complete miscarriage Pregnancy test in 3 (three)

diameter <15mm weeks. If positive to contact
EPU.
Endometrium/tissue Incomplete miscarriage Discuss management.
diameter
>15mm If resolution of pain and
bleeding indicate
miscarriage has completed
during 7-14 days advise to
carry out urine pregnancy
test after three weeks and if
negative no further follow up,
if positive to call EPU for
further assessment/review.

If no bleeding or having
persisting bleeding and/or
increasing bleeding rescan
two weeks after last scan.
Homogeneous mass Suspect trophoblastic Surgical evacuation.
within the uterus disease
Pregnancy of unknown Diagnosis by exclusion Follow up with serial hCG,
location (PUL) then weekly until <10iu/L,
rescan when required if pain
or levels plateau.

18
 Appendix E

Guidelines for Counselling Patients who have a Scan Diagnosed Miscarriage

The following aspects of clinical management should be discussed with all the ladies in
order for them to make an informed choice regarding their treatment options.

Expectant Management
This option allows the lady to miscarry naturally without medical or surgical intervention:

Treatment success rate Missed Miscarriage (sac insitu) 50-60%

Incomplete Miscarriage (RPOC) 85-95%
Risk of infection 2-3%
Risk of blood transfusion - <1%
Average period of clinical observation 2-6 weeks. Scan every 2 weeks, most reach
completion by 3 weeks of observation
At any time the lady can opt for medical/surgical treatment
The lady can have admission to hospital at any time

Medical Management
This option allows the lady to miscarry naturally with hormone treatment to speed the
process up, requiring a day stay on Writtle Ward:

Treatment success rate - 85-95%

Admission to hospital as a day case
Risk of infection 2-3%
Risk of blood transfusion - <1%
Usually a follow up scan, if lady bleeds for two weeks thereafter and would prefer not
to have a rescan, she can carry out a home urine pregnancy test and if positive she
must contact EPU to arrange further follow up/review
If heavy bleeding or follow-up shows persistent RPOC for surgical evacuation

Surgical Management (SMM)

This option involves surgical removal of products of conception under general
anaesthetic by suction:

Treatment success rate 98%

Risk of needing to repeat procedure 1-2%
Least risk of unplanned admission
Least duration of bleeding
Risk of infection 2-3%
Risk of injury to the cervix/uterus - <1%
Risk of blood transfusion <1%
Very small risk of anaesthesia (will be discussed by anaesthetist)

19
 METHOD CHOSEN DATE CHOSEN COUNSELLED BY
EXPECTANT
MANAGEMENT

MEDICAL
MANAGEMENT

SURGICAL
MANAGEMENT

PATIENTS SURNAME

PATIENTS FIRST NAME

HOSPITAL NUMBER:

NHS NO:

This counselling aid has been audited with success in a 2 year study

20