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Introduction
• Ectopic pregnancies complicate 11:1000
  pregnancies (0.1%)
• Incidence of 32000 cases in the UK over a 3yr
  period
• Confidential Enquiry into Maternal Deaths
  showed greatest difficulty is in identifying
  ectopics
Objectives
• To audit compliance to national and local
  standards in the management of ectopic
  pregnancies
• To investigate complication rates in each
  method of management and identify areas for
  improvement
Standards
• RCOG:
  – Expectant management is a suitable option for asymptomatic,
    stable women with initial bHCG<1000
  – Methotrexate suitable for asymptomatic women with
    bHCG<3000, although good success rates in bHCG<5000
  – Nonsensitised women who are rhesus negative with a
    confirmed or suspected ectopic pregnancy should receive anti-D
    immunoglobulin
  – A laparoscopic approach to the surgical management of tubal
    pregnancy, in the haemodynamically stable patient, is preferable
    to an open approach.
  – Management of tubal pregnancy in the presence of
    haemodynamic instability should be by the most expedient
    method. In most cases this will be laparotomy.
Standards
• Trust guidelines here:
Methodology
• Retrospective study (cross site)
• All cases coded between Nov 2009 –Nov 2011
  – Ectopic pregnancy,
  – abdominal pregnancy,
  – tubal/ovarian pregnancy,
  – other pregnancy ( cervical, cornual,
    intraligamentous,mural)
  – Ectopic pregnancy unspecified
• Total 164 coded episodes
  – Of which 88 sets of notes tracked down as true
    ectopics
• Discrepancies due to wrongly coded episodes
  or multiple admissions.
Demographics
• Median Age: 30 (Mean=30)
• Pregnancy History:
  – 2 unknown
  – 36 primips, of which 21 were in their first
    pregnancy
• BMI:
  – Recorded in only 22 cases
  – Median=28
Risk Factor Screening
• PID/STI:
  – 44 cases not inquired
  – 14 cases with history of PID/STI
  – 30 cases deny history of infection
• Previous Ectopic:
  – No previous: 71
  – 1 previous: 12
  – 2 previous: 3
  – 3 previous: 2
History of PID/STI


34%
                      Not asked
             50%      Yes
                      No



      16%
Previous Ectopics



                      3%       No Prev
                               1 Prev
81%     19%
                          2%   2 Prev
                14%
                               3 Prev
• Contraception:
  – 22 cases not enquired
  – 4 cases IUCD in situ
  – 10 cases recent use of IUCD
• Scans:
  – Only 2 cases were diagnosed without a scan
    (ruptured x2)
  – Average no. of scans= 1
  – Median no. of scans= 1
No. of Attendances till Dx

             13%


  9%
                             1 Visit
                   44%
                             2 Visits
                             3 Visits
                             4 or more

       34%
Conservative Management
• 8 cases managed conservatively
  – Including 1 cervical ectopic which ended up
    needing methotrexate
• bHCG ranges:
  – Max= 25629 (cx)
  – Min= 101
• 50% success rate
  – 2 needed methotrexate as 2nd line
  – 2 needed salphingectomy as 2nd line management
Initial bHCG<1000iu?



             37%
                       Yes
                       No

 63%
Outcome of Expectant Management


      25%


                          Successful
                 50%      Methotrexate
                          Surgery


      25%
Methotrexate
• 25 cases in total
• Diagnosis to Treatment lag:
   – Mean=2.3days
   – Median= 1 Day
• No cases of aplasticanaemia or deranged LFT
• 2 cases were due to Cervical ectopic which was
  managed with ERPC+methotrexate
• Excluding 2 cases where adjuvant methotrexate was
  administered for Cx ectopic, all cases had bHCG<5000
Range of bHCG in Methotrexate
          Candidates
              4%
         5%



                           <1000
                           1000-2000
                   52%     2000-3000
   39%
                           3000-5000
• Complications:
  – 6 (27%) cases proceeded to laparoscopy due to
    abdo pain or static bHCG
  – bHCG ranged from 118-1604
• Follow up bHCG:
  – Median= 5 days
Methotrexate Success Rate

     6


                   Successful
                   Laparoscopy


            19
Surgery
• Total of 55 cases needing surgery
  –   48 cases opted for primary surgery
  –   5 cases due to failed methotrexate/conservative
  –   2 emergency due to collapse/shock
  –   No negative laparoscopies
• 23 cases were confirmed as ruptured ectopic
• bHCG:
  – Median= 2523
  – Mean= 9442
Type of Surgery

     13%
4%
                         Laparoscopic
                         salphingectomy(unilateral)
5%                       Laparoscopic
                         salphingectomy(bilateral)
                         Laparotomy following
                         laparoscopy
                         Laparotomy
               78%
• Complications:
  – 1 wound infection
  – 3 needed blood transfusion post op
Anti-D prophylaxis in Surgery

              18%



                           Yes
                           No record
    56%                    N/A
                    26%
Anti-D prophylaxis in Methotrexate

               5%
                    6%


                               Yes
                               No
                         28%
                               No Data
       61%                     N/a
Anti-D prophylaxis in Conservative
          Management
              0%




                                     Yes
                                     No




              100%
Anti-D Overall

             14%
     25%

                        Yes
                        N/A

6%                      No
                        No data


              55%
Conclusions
• Conservative management:
  – Only 37% compliant to national standards of
    having bHCG<1000
  – Intervention rate of 50% is higher than national
    average of 23-29%
• Methotreate:
  – 96% compliant to national standards of
    bHCG<3000
  – 100% compliant to local standards
• Methotrexate success:
  – 14% of women will require a 2nd dose, only 1 woman
    offered this
  – Intervention rate of 27% is greater than most studies
    (approx 10%). Of note those needing intervention
    were in the bHCG<3000 category
• Surgery:
  – Still by far the most popular method of management.
  – Of the cases, <50% were due to tubal rupture
  – Low complication rate (approx 1%)
• Anti-D:
  – RCOG recommends that all ectopics receive anti-D
    if necessary.
  – Overall 69% confirmed compliant.
  – 25% had no data recorded. (Need to improve on
    record keeping)
  – 6% were not offered with no reason documented.
Limitations and Recommendations
• Limitations:
  – Retrospective audit
  – Patients identified by how each episode was coded
    and hence subject to coding error
• Recommendations:
  – Wider advocacy of methotrexate management to
    pregnancy
  – Suspected ectopic pregnancy/PUL
    diagnosis/management pathway to prompt staff to
    check Rhesus status and risk factors for ectopic.

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Ectopic presentation

  • 1.
  • 2. Introduction • Ectopic pregnancies complicate 11:1000 pregnancies (0.1%) • Incidence of 32000 cases in the UK over a 3yr period • Confidential Enquiry into Maternal Deaths showed greatest difficulty is in identifying ectopics
  • 3. Objectives • To audit compliance to national and local standards in the management of ectopic pregnancies • To investigate complication rates in each method of management and identify areas for improvement
  • 4. Standards • RCOG: – Expectant management is a suitable option for asymptomatic, stable women with initial bHCG<1000 – Methotrexate suitable for asymptomatic women with bHCG<3000, although good success rates in bHCG<5000 – Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin – A laparoscopic approach to the surgical management of tubal pregnancy, in the haemodynamically stable patient, is preferable to an open approach. – Management of tubal pregnancy in the presence of haemodynamic instability should be by the most expedient method. In most cases this will be laparotomy.
  • 6. Methodology • Retrospective study (cross site) • All cases coded between Nov 2009 –Nov 2011 – Ectopic pregnancy, – abdominal pregnancy, – tubal/ovarian pregnancy, – other pregnancy ( cervical, cornual, intraligamentous,mural) – Ectopic pregnancy unspecified
  • 7. • Total 164 coded episodes – Of which 88 sets of notes tracked down as true ectopics • Discrepancies due to wrongly coded episodes or multiple admissions.
  • 8. Demographics • Median Age: 30 (Mean=30) • Pregnancy History: – 2 unknown – 36 primips, of which 21 were in their first pregnancy • BMI: – Recorded in only 22 cases – Median=28
  • 9. Risk Factor Screening • PID/STI: – 44 cases not inquired – 14 cases with history of PID/STI – 30 cases deny history of infection • Previous Ectopic: – No previous: 71 – 1 previous: 12 – 2 previous: 3 – 3 previous: 2
  • 10. History of PID/STI 34% Not asked 50% Yes No 16%
  • 11. Previous Ectopics 3% No Prev 1 Prev 81% 19% 2% 2 Prev 14% 3 Prev
  • 12. • Contraception: – 22 cases not enquired – 4 cases IUCD in situ – 10 cases recent use of IUCD • Scans: – Only 2 cases were diagnosed without a scan (ruptured x2) – Average no. of scans= 1 – Median no. of scans= 1
  • 13. No. of Attendances till Dx 13% 9% 1 Visit 44% 2 Visits 3 Visits 4 or more 34%
  • 14. Conservative Management • 8 cases managed conservatively – Including 1 cervical ectopic which ended up needing methotrexate • bHCG ranges: – Max= 25629 (cx) – Min= 101 • 50% success rate – 2 needed methotrexate as 2nd line – 2 needed salphingectomy as 2nd line management
  • 15. Initial bHCG<1000iu? 37% Yes No 63%
  • 16. Outcome of Expectant Management 25% Successful 50% Methotrexate Surgery 25%
  • 17. Methotrexate • 25 cases in total • Diagnosis to Treatment lag: – Mean=2.3days – Median= 1 Day • No cases of aplasticanaemia or deranged LFT • 2 cases were due to Cervical ectopic which was managed with ERPC+methotrexate • Excluding 2 cases where adjuvant methotrexate was administered for Cx ectopic, all cases had bHCG<5000
  • 18. Range of bHCG in Methotrexate Candidates 4% 5% <1000 1000-2000 52% 2000-3000 39% 3000-5000
  • 19. • Complications: – 6 (27%) cases proceeded to laparoscopy due to abdo pain or static bHCG – bHCG ranged from 118-1604 • Follow up bHCG: – Median= 5 days
  • 20. Methotrexate Success Rate 6 Successful Laparoscopy 19
  • 21. Surgery • Total of 55 cases needing surgery – 48 cases opted for primary surgery – 5 cases due to failed methotrexate/conservative – 2 emergency due to collapse/shock – No negative laparoscopies • 23 cases were confirmed as ruptured ectopic • bHCG: – Median= 2523 – Mean= 9442
  • 22. Type of Surgery 13% 4% Laparoscopic salphingectomy(unilateral) 5% Laparoscopic salphingectomy(bilateral) Laparotomy following laparoscopy Laparotomy 78%
  • 23. • Complications: – 1 wound infection – 3 needed blood transfusion post op
  • 24. Anti-D prophylaxis in Surgery 18% Yes No record 56% N/A 26%
  • 25. Anti-D prophylaxis in Methotrexate 5% 6% Yes No 28% No Data 61% N/a
  • 26. Anti-D prophylaxis in Conservative Management 0% Yes No 100%
  • 27. Anti-D Overall 14% 25% Yes N/A 6% No No data 55%
  • 28. Conclusions • Conservative management: – Only 37% compliant to national standards of having bHCG<1000 – Intervention rate of 50% is higher than national average of 23-29% • Methotreate: – 96% compliant to national standards of bHCG<3000 – 100% compliant to local standards
  • 29. • Methotrexate success: – 14% of women will require a 2nd dose, only 1 woman offered this – Intervention rate of 27% is greater than most studies (approx 10%). Of note those needing intervention were in the bHCG<3000 category • Surgery: – Still by far the most popular method of management. – Of the cases, <50% were due to tubal rupture – Low complication rate (approx 1%)
  • 30. • Anti-D: – RCOG recommends that all ectopics receive anti-D if necessary. – Overall 69% confirmed compliant. – 25% had no data recorded. (Need to improve on record keeping) – 6% were not offered with no reason documented.
  • 31. Limitations and Recommendations • Limitations: – Retrospective audit – Patients identified by how each episode was coded and hence subject to coding error • Recommendations: – Wider advocacy of methotrexate management to pregnancy – Suspected ectopic pregnancy/PUL diagnosis/management pathway to prompt staff to check Rhesus status and risk factors for ectopic.