Ectopic pregnancy: diagnosis and management

Reasons, experiences and expectations of women with delayed medical care for ectopic pregnancies in Chinese urban edges: a qualitative study

OBJECTIVE

To explore the experiences of patients with ectopic pregnancies with delayed medical care, with the goals to promote timely access to care, reduce subsequent physical and psychological impacts, and provide recommendations for improved management of ectopic pregnancies.

DESIGN

A qualitative study.

SETTING

A 1000-bed urban edge hospital located in the suburban area of Guangzhou, China, between December 2022 and February 2023.

PARTICIPANTS

21 patients with delays in seeking medical care for ectopic pregnancy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Semistructured, in-depth, face-to-face interviews were conducted to understand the experience and expectations of these women.

RESULTS

Three main themes emerged, including delaying medical care, physical and psychological experiences, and expectations of their healthcare providers. Each of these main themes had several subthemes. The central theme of reasons for delaying medical care had five subthemes, including lack of knowledge on early symptoms of ectopic pregnancy, family dynamics and circumstances, traditional fertility ideology and intentions, avoidance of medical treatment behaviour, and medical delays. The main theme of physical and psychological experiences had two subthemes, including learnings from the experiences and negative impacts of the experiences. The main theme of expectations of their healthcare providers included three subthemes that were reducing the length of outpatient examinations and waiting times, increasing public understanding of early symptoms of ectopic pregnancy and increasing male awareness of safe contraceptive methods.

CONCLUSIONS

A lack of knowledge about the early symptoms of ectopic pregnancy was the main reason for delays in seeking medical care and had a dual impact on patients' physical and mental health, affecting their recovery and future healthcare. A collective effort from patients, families, healthcare providers and medical institutions is required for better medical education, family support, specialised professional training and local fertility policy to decrease the incidence of delayed medical care and achieve satisfactory pregnancy outcomes.

Case report: Ectopic pregnancy in the interstitial part of the fallopian tube

Ectopic pregnancy remains one of the most common causes of pregnancy-related death in the first trimester. 2.4% of ectopic pregnancies occur in the interstitial part of the fallopian tube. As the symptoms of this condition are non-specific and the localization is associated with a higher risk of bleeding, early diagnosis of interstitial pregnancies is important, based not only on clinical symptoms, but also on additional diagnostic methods. Early diagnosis leads to better treatment-related outcomes. We report a 32-year-old female patient who came to the emergency department because of pain in the lower abdomen and right iliac region and bloody vaginal discharge. During palpation of the abdomen, the pain was localized in the lower part of the abdomen. Human chorionic gonadotropin (hCG) was significantly increased in biochemical tests. Transvaginal ultrasound examination of internal genital organs, abdominal and pelvic computer tomography (CT) were per-formed. An ectopic pregnancy was suspected. Thus, the patient was hospitalized in the gynecology department for surgical treatment. A laparoscopy was performed and an ectopic pregnancy was diagnosed in the interstitial part of the right fallopian tube and in the right uterine corner, which led to right salpingectomy and right uterine angle resection. Thus, interstitial pregnancy is a rare and life-threatening gynecological condition due to the higher risk of bleeding compared to other ectopic pregnancies. However, appropriate diagnosis based on clinical signs, transvaginal ultrasound findings and hCG levels in the blood ensures early diagnosis of interstitial pregnancy, which leads to the choice of medical treatment with methotrexate or minimally invasive surgical techniques.

Interstitial ectopic pregnancy successfully treated with methotrexate

An ectopic pregnancy (EP) occurs when the fertilised ovum implants outside the endometrial cavity. An EP has an incidence of 1%, with the majority occurring in the fallopian tube. It has a maternal mortality of 0.2 per 1000, with about two-thirds of these deaths associated with substandard care. An interstitial pregnancy occurs when the EP implants in the interstitial part of the fallopian tube. An interstitial ectopic pregnancy (IEP) shows few early clinical symptoms, hence it is associated with serious or fatal bleeding and a mortality rate up to 2.5%. With the advent of transvaginal ultrasound scan (TV USS), correlated with serum beta human chorionic gonadotropin (BHCG) assay, earlier diagnosis of an EP can be established. An EP is often diagnosed in women who are trying to conceive; therefore, the prognosis of future fertility is one of the main concerns associated with this diagnosis. Management can be surgical, expectant or medical with methotrexate (MTX). However, the best approach is tailored to the woman's individual case. The authors present the case of a primigravida woman presenting with abdominal pain and vaginal bleeding at 6 weeks gestation following assisted reproduction. Her BHCG showed a suboptimal rise. Her TV USS showed no evidence of an intrauterine pregnancy. There was no evidence of an adnexal mass or free fluid. As her BHCG remained static, she underwent a diagnostic laparoscopy. A right sided IEP was identified. Due to the high risk of bleeding requiring transfusion or hysterectomy and her desire to preserve her fertility, she received medical management with MTX. Indeed, research has shown that women successfully managed expectantly achieve better reproductive outcomes, with the shortest time to achieve a subsequent intrauterine pregnancy. This case acts as a cautionary reminder of the challenges associated with identifying an IEP on TV USS. A high index of clinical suspicion is required to prevent maternal morbidity and mortality.

Laparoscopic reversible occlusion of uterine arteries and cornuostomy for advanced interstitial pregnancy

During laparoscopic enucleation of an interstitial pregnancy, adequate hemostatic control is of paramount importance due to the high vascularization of the uterine cornus. However, no consensus or guidance exists regarding the optimal hemostatic technique. We report laparoscopic reversible uterine arteries occlusion as hemostatic technique during laparoscopic enucleation by cornuostomy of an interstitial pregnancy at advanced gestational age (46 × 40 mm gestational sac). Preliminary identification of the uterine arteries and bilateral reversible occlusion by Hem-o-Lok clips allowed bleeding control during surgery. The laparoscopic procedure was performed without complications and with limited blood loss. The reported case reinforces the feasibility of this minimally invasive technique in interstitial pregnancy.

Fertility after ectopic pregnancy in a district hospital in Cameroon

OBJECTIVE

To assess spontaneous conception after an ectopic pregnancy (EP) in a rural area of a low-resource country.

METHODS

The present prospective cohort study enrolled patients aged 15-45 years who were treated for EP at Sangmelima District Hospital, Cameroon, between January 2006 and December 2008. All patients who wished to become pregnant in the future were included and followed up from treatment for EP either until termination of a subsequent pregnancy or for 3 years if they did not become pregnant, whichever came first. Patients who were followed up for less than 18 months without a pregnancy were excluded from analysis.

RESULTS

The final analysis included 56 women, of whom 23 (41%) became pregnant (21 [38%] had intrauterine pregnancies, 2 [4%] EPs). The mean interval between treatment for EP and first conception was 11.82±7.46 months. In multivariate analysis, absence of contralateral adnexal pathology was significantly associated with higher fertility (hazard ratio 9.00, 95% confidence interval 1.48-54.67; P=0.017).

CONCLUSION

Fertility after EP in a rural area of Cameroon was found to be low, but recurrence of EP was rare.