This document summarizes an audit of the management of ectopic pregnancies at a UK trust between 2009-2011. It found that conservative management often did not follow guidelines to only include cases with initial hCG <1000. Methotrexate management mostly adhered to guidelines but some patients required intervention. Surgery remained the most common treatment. Overall compliance with anti-D prophylaxis was 69% but improvements in documentation were needed. The audit recommended increased use of methotrexate and improved clinical pathways to ensure guideline adherence.

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.

5. Standards
• Trust guidelines here:

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.