RCOG World Congress 2023

Ectopic Pregnancy in Epsom and St Helier Hospital: An Audit of Diagnosis and Management

Sasha Ang, Hassan Shehata, Emma Doherty, Asli Ucyigit, Nadia Amokrane

Introduction:

An ectopic pregnancy is defined as any pregnancy implanted outside of the endometrial cavity
The incidence is 11/1000 pregnancies in the UK
withanestimated11000 ectopic pregnancies diagnosed each year
The incidence of ectopic pregnancy in women attending early pregnancy units is 2–3%
Risk factors include tubal damage following surgery or infection, smoking and IVF

Aims:

To audit the diagnosis and management of ectopic pregnancies in the Early Pregnancy Unit (EPU) in Epsom and St Helier University Hospitals
To compare our management against the auditable standards listed in the RCOG Greentop Guideline 21 for Ectopic Pregnancy

Methods:

All women with an ultrasound scan diagnosis of ectopic pregnancy or ectopic pregnancy diagnosed at laparoscopy from January to December 2022 were retrospectively identified from electronic records in Epsom and St Helier Early Pregnancy Units and theatre records
The management of all cases were assessed against

auditable standards listed in the RCOG Greentop Guideline 21 for Ectopic Pregnancy
Data was collected on Excel, analysed and checked by 2 doctors

Results:

Ultrasound Scan Outcomes:

Management:

74% of women were surgically managed, whilst 13% were managed medically with Methotrexate and 12% managed conservatively
There was a 10% failure rate (n= 1) out of those conservatively managed, whilst 36% (n=4) of those medically managed proceeded to have surgical management
One significant event of an incorrect sided salpingectomy occurred and proceeded to medical management
4% (n=3) of women surgically managed had a negative diagnosis of ectopic pregnancy

Complications:

16% (n=14) of all women had ruptured on laparoscopy, and 35% of these women had more than 1 liter blood loss
Out of the women that ruptured on laparoscopy, 42% of these women ruptured after first presentation to our unit
3% (n=2) of women surgically managed were converted to laparotomy

Conclusions: Positives

All women offered appropriate management
Women suitable for laparoscopic management were managed laparoscopically
Overall, only 3% (2/67) of women were managed via laparotomy
Number of cases where methotrexate given for a false-positive diagnosis of ectopic pregnancy was 0%
Negative laparoscopy rate after positive identification of ectopic pregnancy on scan was only 4%

Conclusions: Standards Not Met

Diagnosis of ectopic achieved on first scan (45%):

• 6 patients (7%) ruptured after the first visit

• Delayed diagnosis will result in more follow- up visits and have a negative impact on patient anxiety
Percentage of women provided with information containing support group details is not known

Recommendations:

In order to improve on initial scan diagnosis:
- Aim for 2 opinions for all non-diagnostic scans in EPU cross-site
- Increased consultant presence in EPU cross-site
- Follow-up and oversight of complex patients in EPU and of patients with a diagnosis of pregnancy of unknown location
- Multi-disciplinary approach to unusual cases
Important to inform women when counselling them on the management options to consider the following:
- Overall, 90% patients who had initial planned conservative management were successful
- 36% patients who started with medical management ended up having surgical management

Diagnosis and Management of Ectopic Pregnancy in the Early Pregnancy Unit