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Article history:
Received 16 September 2016 Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at
Accepted 21 October 2016 post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of
ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to
Keywords: identify the ectopic gestation before tubal rupture. This enables health care professionals to offer
Ectopic pregnancy management options that consider not only maternal mortality, but morbidity and fertility outcomes as
Diagnosis well. In spite of this, diagnostic techniques and management options are not without limitations.
Management Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment
Salpingectomy
algorithms and safe methods of triaging patients. This article aims to review the current literature on the
Salpingotomy
diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care
and achieve the best possible outcome.
© 2016 Elsevier Ireland Ltd. All rights reserved.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Historical perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Diagnostic techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Inaccuracy in traditional methods of diagnosing ectopic pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using predictive risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using ultrasound scan findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using serum beta hCG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using serum progesterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Individualizing treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Patient categorisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Triaging of patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Using a combination of beta hCG, ultrasound and symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Management options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Expectant management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Medical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Surgical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Conservative surgery: salpingotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Radical surgery: salpingectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Extraneous factors affecting choice of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Cost and logistics of service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Impact of treatments on quality of life and patient satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
http://dx.doi.org/10.1016/j.ejogrb.2016.10.037
0301-2115/© 2016 Elsevier Ireland Ltd. All rights reserved.
70 F. Odejinmi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75
andsurgically treated patients are hospitalised longer (1.3–2.7 vs. The utopic clinical situation
0–1.1 days) than medically treated patients. In medically
managed patients, direct costs were caused by the repeated The care of women with ectopic pregnancy has evolved from a
laboratory tests, ultrasound examinations and consultant life-saving event to an ambulatory treatment for most women.
reviews. They concluded that the management of small ectopic The utopic patient would be one with the following character-
pregnancies with bhCG <1500 IU medically was more cost istics:
effective than surgery. At bhCG levels between 1500–3000 IU the
costs were similar and with bhCG >5000 IU, surgical management Asymptomatic.
was more cost effective. No risk factors for an ectopic pregnancy.
A low activity ectopic pregnancy found on ultrasound scan.
Impact of treatments on quality of life and patient satisfaction bhCG level of 1000 IU or less at presentation.
A decline in bhCG levels 48 h later.
With the availability of different modalities of management of
ectopic pregnancy, as part of informed consent, quality of life In such a scenario, after discussion expectant management
issues need to be considered. Van Mello et al. assessed the impact would be the best course of action.
on the quality of life (QOL) by expectant management vs Where the bhCG is between 1000–3000 IU and the patient is
methotrexate [65] and found that the mode of management had asymptomatic, expectant management may not be successful thus
no impact on the QOL. Van Mello also found that women preferred medical management would be ideal and would be cost effective.
a salpingectomy over salpingotomy as it avoided a repeat ectopic Above this level cost effectiveness is lost and the patient may be
pregnancy. This preference was held even though there was a best served by operative laparoscopy.
perceived decreased chance of a spontaneous intrauterine
pregnancy [66]. Surgical treatment
Nieuwkerk et al. performed a randomised controlled trial
comparing the QOL after laparoscopic salpingectomy vs. systemic For patients who require surgery, laparoscopic surgery is the gold
methotrexate. They found that overall quality of life was more standard irrespective of haemodynamic status, provided local
impaired following medical management with patients feeling health care delivery systems can provide safe care, with the level
more depressed with limitations on both physical and social of expertise required. This should be the objective of all centres
function [67]. that care for women with ectopic pregnancy.
Deepa et al. identified factors that influence the woman’s If the contralateral tube is normal on the basis of current
satisfaction during the process of treatment of ectopic pregnan- evidence, a laparoscopic salpingectomy should be performed.
cies. The amount of haemoperitoneum and need for blood Alternatively, if the contralateral tube is abnormal or the patient
transfusion had a significant influence on the overall satisfaction is aged over 35 with a history of infertility or tubal damage,
rates (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and laparoscopic salpingotomy would be the best option.
>800 ml – 72%, p = 0.001). Good communication pre-operatively
(87% satisfaction with good communication vs. 30% without, A proposed pathway for the management of patients with an
p < 0.001), provision of post-operative leaflets prior to discharge ectopic pregnancy based on the above conclusion is outlined in
(90% vs. 68%, p = 0.001) and adequate pain relief (89% vs. Fig. 1.
64%, p = 0.001) resulted in good patient experience [68]. Thus It should be remembered that each patient should be
in the modern management of ectopic pregnancies, taking considered on an individual basis and care provided in a
patient satisfaction into account is imperative to achieve holistic compassionate and holistic manner taking into consideration
care. the patient’s presentation and her expectations.
Conflicts of interest [26] Check JH, Chase JS, Nowroozi K, Epstein R, Vetter B. Pitfalls in the use of a single
rapid progesterone assay to diagnose early ectopic pregnancy. Am J Gynecol
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[28] Fernandez H, Lelaidier C, Baton C, Bourget P, Frydman R. Return of reproductive
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