Introduction

• Ectopic pregnancies complicate 11:1000 pregnancies (0.1%)

• Incidence of 32000 cases in the UK over a 3yr period

• Confidential Enquiry into Maternal Deaths showed greatest difficulty is in identifying ectopics

Objectives

• To audit compliance to national and local standards in the management of ectopic pregnancies

• To investigate complication rates in each method of management and identify areas for improvement

Standards• RCOG:

– Expectant management is a suitable option for asymptomatic, stable women with initial bHCG <1000

– Methotrexate suitable for asymptomatic women with bHCG <3000, although good success rates in bHCG <5000

– Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin

– A laparoscopic approach to the surgical management of tubal pregnancy, in the haemodynamically stable patient, is preferable to an open approach.

– Management of tubal pregnancy in the presence of haemodynamic instability should be by the most expedient method. In most cases this will be laparotomy.

Standards

• Trust guidelines here:

Methodology

• Retrospective study (cross site)• All cases coded between Nov 2009 –Nov 2011– Ectopic pregnancy, – abdominal pregnancy, – tubal/ovarian pregnancy, – other pregnancy ( cervical, cornual,

intraligamentous,mural)– Ectopic pregnancy unspecified

• Total 164 coded episodes– Of which 88 sets of notes tracked down as true

ectopics• Discrepancies due to wrongly coded episodes

or multiple admissions.

Demographics

• Median Age: 30 (Mean=30)• Pregnancy History:– 2 unknown– 36 primips, of which 21 were in their first

pregnancy• BMI:– Recorded in only 22 cases– Median=28

Risk Factor Screening

• PID/STI:– 44 cases not inquired – 14 cases with history of PID/STI– 30 cases deny history of infection

• Previous Ectopic:– No previous: 71– 1 previous: 12– 2 previous: 3– 3 previous: 2

History of PID/STI

50%

16%

34%

Not askedYesNo

Previous Ectopics

81%

14%

3% 2%

No Prev1 Prev2 Prev3 Prev

• Contraception:– 22 cases not enquired– 4 cases IUCD in situ– 10 cases recent use of IUCD

• Scans:– Only 2 cases were diagnosed without a scan

(ruptured x2)– Average no. of scans= 1– Median no. of scans= 1

No. of Attendances till Dx

44%

34%

9%

13%

1 Visit2 Visits3 Visits4 or more

Conservative Management

• 8 cases managed conservatively– Including 1 cervical ectopic which ended up needing

methotrexate• bHCG ranges:– Max= 25629 (cx) – Min= 101

• 50% success rate– 2 needed methotrexate as 2nd line– 2 needed salphingectomy as 2nd line management

Initial bHCG <1000iu?

38%

63%

YesNo

Outcome of Expectant Management

50%

25%

25%

SuccessfulMethotrexateSurgery

Methotrexate

• 25 cases in total• Diagnosis to Treatment lag:

– Mean=2.3days– Median= 1 Day

• No cases of aplastic anaemia or deranged LFT• 2 cases were due to Cervical ectopic which was managed

with ERPC+methotrexate• Excluding 2 cases where adjuvant methotrexate was

administered for Cx ectopic, all cases had bHCG <5000

Range of bHCG in Methotrexate Candidates

52%

39%

4%4%

<10001000-20002000-30003000-5000

• Complications:– 6 (27%) cases proceeded to laparoscopy due to

abdo pain or static bHCG– bHCG ranged from 118-1604

• Follow up bHCG:– Median= 5 days

Methotrexate Success Rate

19

6

SuccessfulLaparoscopy

Surgery

• Total of 55 cases needing surgery– 48 cases opted for primary surgery– 5 cases due to failed methotrexate/conservative– 2 emergency due to collapse/shock– No negative laparoscopies

• 23 cases were confirmed as ruptured ectopic• bHCG:– Median= 2523– Mean= 9442

Type of Surgery

78%

5%

4%

13%

Laparoscopic salph-ingectomy(unilateral)Laparoscopic salph-ingectomy(bilateral)Laparotomy following laparoscopyLaparotomy

• Complications:– 1 wound infection– 3 needed blood transfusion post op

Anti-D prophylaxis in Surgery

18%

25%

56%

Yes No record N/A

Anti-D prophylaxis in Methotrexate 6%

6%

28%

61%

YesNoNo DataN/a

Anti-D prophylaxis in Conservative Management

100%

YesNo

Anti-D Overall

14%

55%

6%

25%

Yes N/ANoNo data

Conclusions

• Conservative management:– Only 37% compliant to national standards of

having bHCG <1000– Intervention rate of 50% is higher than national

average of 23-29% • Methotreate:– 96% compliant to national standards of bHCG

<3000– 100% compliant to local standards

• Methotrexate success:– 14% of women will require a 2nd dose, only 1 woman

offered this– Intervention rate of 27% is greater than most studies

(approx 10%). Of note those needing intervention were in the bHCG <3000 category

• Surgery:– Still by far the most popular method of management. – Of the cases, <50% were due to tubal rupture– Low complication rate (approx 1%)

• Anti-D:– RCOG recommends that all ectopics receive anti-D

if necessary.– Overall 69% confirmed compliant.– 25% had no data recorded. (Need to improve on

record keeping)– 6% were not offered with no reason documented.

Limitations and Recommendations

• Limitations:– Retrospective audit– Patients identified by how each episode was coded and

hence subject to coding error• Recommendations:– Wider advocacy of methotrexate management to

pregnancy– Suspected ectopic pregnancy/PUL

diagnosis/management pathway to prompt staff to check Rhesus status and risk factors for ectopic.