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.