E&P Ectopic

Question 1

Describe the setting?

Answer 1

• You are an FY working in obs and gynae
• Woman comes in for an early pregnancy scan arranged by her GP following lower abdominal pain
• She has been told she has an ectopic pregnancy and is in mild pain
• She had IVF transfer 6 weeks ago

Question 2

Past medical history?

Answer 2

• She had a miscarriage following a first attempt at IVF last year
• Laparoscopic treatment of endometriosis 3 years ago - currently takes progesterone vaginal pessaries

Question 3

What does the US show?

Answer 3

• US shows the fetus not where it should be, shows it in the right fallopian tube
• Tenderness on examination - that was where it is

Question 4

Your task?

Answer 4

Explain the findings of US and discuss the options for management of ectopic pregnancy

Question 5

Management options?

Answer 5

• Medical treatment - single injection into buttock
• Surgery - if you can’t come back in following the tablet

Question 6

Initiating interview?

Answer 6

1. Greets patient and obtains their name
2. Introduces self and role
3. Explains nature of interview

Question 7

How to start the interview off?

Answer 7

• assesses the patients starting point - what do they already know and how are they feeling

Question 8

After establishing patients starting point, what next?

Answer 8

• Gives clear signposting that serious important information is to follow
• Chunks and checks throughout
• Establish what information the patient would like

Question 9

Support mechanisms - suggest?

Answer 9

• Nurses
• Relatives
• Meeting patient again
• Leaflets

Question 10

At the end what is important to do?

Answer 10

Summarise about main points - including their concerns
Ensure clear follow up arrangements
Checks their support when they leave

Question 11

What is the medical management of an ectopic?

Answer 11

• So to manage this we would advise you to have this single injection (methotrexate) while you’re here (into buttock), this prevents you developing any serious complications
• You won’t need to stay in hospital after treatment - but regular blood tests will be carried out to check if the treatment is working
• We will measure bloods today, on day 4, and 7
• A second dose is sometimes needed and surgery if it doesn’t work
• Need to use contraception for at least 3 months after treatment - the medication is harmful if you were to get pregnant during this time
• avoid drinking alcohol during this time - It and the medication are bad for your liver in combination

Question 12

Risk factors she has to increase chance?

Answer 12

• Previous pelvic surgery - previously had surgery to remove endometriosis
• History of infertility
• IVF comes with an increase chance
• > 35 years (4.1% compared to 1.8%)

Question 13

Prevalence of Ectopics?

Answer 13

• 11 in 1000 pregnancies are ectopic
• Higher in IVF - reports vary between 0.8 -8.6%

Question 14

If we don’t treat?

Answer 14

• Pregnancy could keep growing and it will break through the tube - this can cause you to bleed into your stomach
• Its important to note this is severe so very important we treat

Question 15

If medical management doesn’t work or you can’t come back for a follow up?

Answer 15

Surgery - key hole surgery under general anaesthetic - remove the fertilised egg part of fallopian tube
- Small cuts made in the tummy, and a tube that you can see through is passed in, part of the fallopian tube is removed
- Most women can leave hospital a few days later but will take 4-6 weeks to fully recover

Question 16

Side effects of methotrexate?

Answer 16

• Tummy pain - mild and should pass within a day or two
• Dizziness
• Feeling and being sick
• Diarrhoea

Question 17

Red flags following treatment?

Answer 17

• Changes the fallopian tube ruptures: Sharp sudden intense pain in tummy, feeling dizzy or fainting, feeling very sick
  Call 999 or get to local A and E
• Surgery would be needed as an emergency - a larger incision in tummy

Question 18

Emotional support?

Answer 18

• I am here to talk about anything you want to, if there is anything I can do to help
• I can help organise counselling
• Support groups: The ectopic pregnancy trust, ectopic pregnancy foundation, miscarriage associate and cruse bereavement care

Question 19

Pregnancy in the future?

Answer 19

• Most women who have an ectopic can get pregnant again - chances of another ectopic are higher but risk is small
• This medicine won’t impact your fertility
• Need to wait at least 3 months as medicine could harm your baby
• Then can restart with the IVF journey
• In the future you can self-refer to an early pregnancy assessment service in future pregnancies, if they have any early concerns

Question 20

Contraception advice

Answer 20

• Any method of contraception can be safely used after ectopic pregnancy
• Additional precautions (eg. barrier/abstinence) are required if hormonal contraception is started 5 days or more after treatment
  Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of treatment of ectopic pregnancy.

Question 21

Could the fertilised egg survive?

Answer 21

No, unfortunately, a baby cannot survive an ectopic pregnancy. With an ectopic pregnancy, the fertilised egg implants outside of the space of the uterus (womb) which means it is not possible for the pregnancy to develop normally. It cannot be moved or re-implanted into the uterus. An ectopic pregnancy can be life-threatening for a woman or pregnant person and so must be diagnosed and treated quickly.