Mrs Smith, a 37 year old woman, presents at your practice saying that she has had a previous ectopic pregnancy and has been told to come and see you when she thinks she is pregnant.
What questions would you ask about this pregnancy?
- Last menstrual period
- Cycle length
- Contraceptive use
- Vaginal discharge/bleeding
- Abdominal pain (unilateral or bilateral)
- Generalised feeling unwell
- Shoulder tip pain
What questions would you ask of previous obstetric and gynaecological history?
- Previous pregnancies
- Ectopic pregnancy – which side?
- Pelvic inflammatory disease
- Attendance at the GUM clinic
- Intra-uterine contraceptive use
- Tubal surgery
- Termination of pregnancy
- Sterilisation
Questions on past medical history?
- Any abdominal operations:
- appendicectomy
- caesarean section
- sterilisation
- ovarian cystectomy or oophorectomy
- pyosalpinx
- Smoking
Examination – what would you expect to find
- Tachycardia
- Hypotension
- Abdominal tenderness
- Unilateral guarding and rebound
- Pelvic examination:
- bulky uterus
- adnexal tenderness
- adnexal swelling
In most cases physical examination is unremarkable.
NB. If ectopic pregnancy is considered, vaginal examination should be deferred until the patient is seen in the hospital.
What special investigations would you arrange?
- Qualitative BhCG (50 iu)
- Quantitative BhCG (1500iu)
- Transvaginal ultrasound – fetal heart usually identified at 5-6 weeks
- Scan findings suggestive of ectopic pregnancy:
- empty uterus
- adnexal mass
- copious free fluid in the Pouch of Dougla
What operations can be performed?
Laparoscopy:
- Linear salpingostomy
- Partial salpingectomy
- Intra-tubal Methotrexate
Laparotomy:
- “Milking out” of pregnancy
- Linear salpingostomy
- Partial salpingectomy
Whether laparoscopy or laparotomy, conservative or radical surgery, the rate of success in subsequent pregnancy is the same. Laparoscopy results in a shorter hospital stay, although a higher rate of recurrent trophoblastic tissue.
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