Ectopic presentation

349 views

Published on

Published in: Health & Medicine, Technology
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
349
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
7
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Ectopic presentation

  1. 1. 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
  2. 2. 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
  3. 3. 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.
  4. 4. Standards• Trust guidelines here:
  5. 5. 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
  6. 6. • Total 164 coded episodes – Of which 88 sets of notes tracked down as true ectopics• Discrepancies due to wrongly coded episodes or multiple admissions.
  7. 7. 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
  8. 8. 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
  9. 9. History of PID/STI34% Not asked 50% Yes No 16%
  10. 10. Previous Ectopics 3% No Prev 1 Prev81% 19% 2% 2 Prev 14% 3 Prev
  11. 11. • 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
  12. 12. No. of Attendances till Dx 13% 9% 1 Visit 44% 2 Visits 3 Visits 4 or more 34%
  13. 13. 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
  14. 14. Initial bHCG<1000iu? 37% Yes No 63%
  15. 15. Outcome of Expectant Management 25% Successful 50% Methotrexate Surgery 25%
  16. 16. 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
  17. 17. Range of bHCG in Methotrexate Candidates 4% 5% <1000 1000-2000 52% 2000-3000 39% 3000-5000
  18. 18. • 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
  19. 19. Methotrexate Success Rate 6 Successful Laparoscopy 19
  20. 20. 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
  21. 21. Type of Surgery 13%4% Laparoscopic salphingectomy(unilateral)5% Laparoscopic salphingectomy(bilateral) Laparotomy following laparoscopy Laparotomy 78%
  22. 22. • Complications: – 1 wound infection – 3 needed blood transfusion post op
  23. 23. Anti-D prophylaxis in Surgery 18% Yes No record 56% N/A 26%
  24. 24. Anti-D prophylaxis in Methotrexate 5% 6% Yes No 28% No Data 61% N/a
  25. 25. Anti-D prophylaxis in Conservative Management 0% Yes No 100%
  26. 26. Anti-D Overall 14% 25% Yes N/A6% No No data 55%
  27. 27. 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
  28. 28. • 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%)
  29. 29. • 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.
  30. 30. 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.

×