RCOG World Congress 2023

Live abdominal ectopic pregnancy at 12 weeks gestation – a potential risk of pill-by-post medical termination?

DrSophie Renwick, DrSangeethaNagabushanam Musgrove Park Hospital, Taunton, UK

Case Report

Situation:Patient A presented to the emergency department with clinical signs of a ruptured ectopic pregnancy following ‘pill-by-post’ medical termination.

Background:28-year-old G4 P2, with a history of a medical termination of pregnancy (MTOP) 5 weeks ago at 6 weeks gestation. No ultrasound scan was performed prior to MTOP as part of a pilot programme during the COVID-19 pandemic.

Patient A had vaginal bleeding, but a positive urinary pregnancy test 3 weeks post-MTOP. She was reviewed at the pregnancy advisory clinic with an ultrasound scan, where no gestation sac was present. It was believed she had retained products of conception, and she was treated with further misoprostol 2 weeks prior to her presentation.

Assessment: Patient A presented to ED with syncopalepisodes, abdominal and shoulder tip pain and moderate vaginal bleeding.

Observations: Oxygen saturations 90%, Heart rate 130, Blood Pressure 110/60 Respiratory Rate 24. Venous Blood Gas: Lactate 5.8, Haemoglobin 107. Examination:Abdomen distended and peritonitic. Vaginal examination: cervix closed and minimal bleeding

Trans-abdominalultrasound in ED: Live pregnancy at 12 weeks gestation, seen suprapubicallybut extra-o uterine. Trans-vaginal ultrasound: empty uterus, andhaemoperitoneum. Blood tests: Serum bHCG44,041.

Management: Emergency laparoscopy. Findings: Haematoperitoneumwith a live ectopic pregnancy adherent to the anterior abdominal wall, with evidence of right fallopian tube rupture with trophoblastic tissue. Due to uncontrolled bleeding a laparotomy and right salpingectomy was performed. Weighed blood loss of 2478mland ITU admission post-operatively.

Discussion

•Abdominal ectopic pregnancies are rare, accounting for 0.6-4% of ectopic pregnancies, however due to difficulties in diagnosis and management, the risk of mortality is 7.7 x higher than a tubal ectopic pregnancy.

•The 2019 NICE guidance on abortion care permit medical abortion without ultrasound, and although a cohort study of 52,000 women published in the BJOG in 2021 demonstrated the effectiveness and advantages of a telemedicine model, there was a post-treatment ectopic rate of 0.03 for a no-scan approach, compared to 0.01 for the traditional model. Theseectopic pregnancies are likely to present later and be more difficult to diagnose post-treatment, increasing the risk of rupture and patient morbidity and mortaility.

•This case emphasises the need for careful case selection and thorough patient counselling with a pill-by-post system. Additionally, clinicians must maintain an index of suspicion for ectopic pregnancy when this method fails, as there has been no evidence of intrauterine pregnancy. Appropriate follow up with ultrasound and bHCGmonitoring should be utilised; In this case, if a bHCGsample had been taken when patient A represented with a positive pregnancy test, it is likely the diagnosis would have been made earlier.

Conclusions

Although a pill-by-post approach to medical termination has been proven to be a safe and effective model in many ways, the risk of an undiagnosed ectopic post-treatment is 3 times higher than the traditional model.

For the patients who have a delay in diagnosis of ectopic pregnancy, there may be a significant risk of morbidity and mortality.

RCOG World Congress 2023

Live abdominal ectopic pregnancy at 12 weeks gestation following no-scan medical abortion

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