Obstetrics/Gynecology: Ectopic Pregnancy Remains a Malpractice Dilemma

Ruptured ectopic pregnancies present major emergencies that account for 12 percent of all maternal deaths in the United States. Consequently, ectopic pregnancy is the major cause of maternal mortality in the first trimester of pregnancy.

The incidence of ectopic pregnancy is related to early sexual activity. More than half of adolescent girls are sexually active, and along with sexual activity comes the possibility of pregnancy and sexually transmitted disease. Salpingitis, a leading cause of ectopic pregnancy, can be initiated by Neisseria gonorrhea, chlamydia, or other pathogens.

Along with the increased frequency of ectopic pregnancies are more frequent tubal pregnancies and ruptures, as well as uterine pregnancies after tubal ligations.

Note: Patients must be informed and understand that although the purpose of a tubal ligation is permanent sterilization, recanalization of the tube with subsequent pregnancy remains a possibility. Failure to inform patients of this possibility can also become a basis for subsequent litigation. You must consider ectopic pregnancy when diagnosing a patient who has a suggestive history, even if her tubes have been "tied."

Early Diagnosis

Early diagnosis of ectopic pregnancy is complicated by the fact that no single laboratory test is sufficient for differential diagnosis.

In general, ectopic pregnancy is known as an atypical disease because of the variability of history and physical findings. To attain the highest diagnostic percentage possible, you must be ever conscious of the possibility of pregnancy in females from ages 12 to 50.

Conducting a detailed physical examination and obtaining a complete history are essential. A positive pregnancy test result, however, indicates either an intrauterine or viable extrauterine pregnancy. A single positive test is therefore of little value to differentiate a diagnosis between these two conditions. A positive result can be helpful, however, to differentiate an ectopic pregnancy from salpingitis, appendicitis, or an ovarian cyst complication.

A negative pregnancy test result does not exclude tubal pregnancy, because the placenta in tubal location can be either compromised or nonviable and therefore not able to produce enough human chorionic gonadotropin for a positive pregnancy test result. But the possibility of an intact intrauterine gestation is unlikely with a negative result, and if dilation and curettage (D and C) are contemplated, they can be done without fear of inducing abortion.

Radioimmunoassay (RIA) of the serum B-subunit of human chorionic gonadotropin (BHCG) is recognized as a rapid and unequivocal test for assessing trophoblastic viability. The use of BHCG-RIA is recommended in cases of suspected ectopic pregnancy.

Culdocentesis may be performed using an 18- or 20-gauge spinal needle if there is a cul de sac bulging or the suggestion of intraperitoneal bleeding. Free-flowing, non-clotting blood with a hematocrit level of at least 12 percent is a positive sign and usually signifies a leaking or ruptured ectopic pregnancy, especially when combined with a positive pregnancy test.

No matter how remote the possibility, any patient of childbearing age who presents with a missed period or has a sudden onset of abdominal pain should be carefully evaluated for ectopic pregnancy.

Note: Women wearing IUDs may not realize that they are unprotected against extrauterine implantation.

Treatment

There is considerable controversy about whether the proper surgical treatment for ectopic pregnancy is a conservative operation or a salpingostomy for tubal pregnancy, particularly the unruptured variety.

Laparoscopy vs. Laparotomy for Removal of an Ectopic Pregnancy

Advanced laparoscopic procedures have been developed to manage and remove ectopic pregancy. Although assisted reproductive procedures (e.g., in-vitro fertilization) have improved over time, linear salpingostomy is still preferable in many cases of unruptured ectopic pregnancies. The decision to perform a salpingectomy vs. a salpingostomy lies in the patient’s desire to preserve fertility and in the condition of the affected tube compared with that of the contra lateral tube.

Some physicians who argue that a healthy contra lateral tube will make up for a diseased tube and recommend salpingectomy as treatment for ectopic pregnancy. But if the affected tube is presumed capable of a successful future pregnancy (e.g., early, unruptured ectopic pregnancy in a non-diseased tube), then salpingostomy might be considered.

If at all possible, discuss treatment options in detail with the patient, and give her a choice in the decision. In urgent situations, consultation with a responsible family member is desirable. For patients in shock, laparoscopy might be a reasonable approach, but laparotomy should be performed only if the patient cannot be stabilized by the time surgery commences.

After conservative surgery for an ectopic pregnancy, serial blood levels of the BHCG should be followed for several weeks to rule out persistent troplioblaster tissue left behind.

Medical Treatment of Early Ectopic Pregnancy

Advances in microsurgery for the treatment of tubal disease have led to early identification of at-risk patients. Such patients must be:

• told they are at increased risk
• instructed to call and be seen by their physicians if their periods are five days late

Today’s highly sensitive urine pregnancy tests allow physicians to initiate serial blood assessments of at-risk patients’ quantitative BHCG levels—usually by studying them every two to three days. A healthy intrauterine pregnancy will produce BHCG levels that double every 48 to 72 hours. If, however:

• the "doubling time" begins to plateau, the BHCG level should be repeated the next day; if the plateau persists, the pregnancy is nonviable
• suction D and C reveals no products of conception, the patient has an ectopic pregnancy

Methyltrexate Therapy

If the BHCG level is below 5,000miu, consider Methyltrexate therapy, which should be researched through up-to-date literature. In the "single-shot" method used by many institutions, patients are given 1.5mg per meter of Methyltrexate intramuscularly after pertinent laboratory tests are confirmed as normal.

After one week, the BHCG blood level should be the same or less than it was at the time of injection. If the BHCG is still rising, a second shot is given, and blood levels are retaken in another week. If there is still no decline in the BHCG level, surgical intervention is advised.

Patients undergoing this treatment must agree to have access to prompt transportation should signs of intra-abdominal bleeding appear. Some abdominal pain may occur during the observation period.

The success of this approach has been more than 80 percent, thus avoiding surgery. Early data on subsequent intrauterine pregnancies have been encouraging.

Abortions

In abortions performed early, if no products of conception are evident grossly or microscopically, a pregnancy may still exist in the uterus or elsewhere—particularly if the BHCG level persists or rises. The physician performing the abortion is responsible for confirming the state of pregnancy, either from the curettings or by an outside pathological exam.

Failure to uphold this responsibility could expose the physician to potential malpractice liability. The diagnosis can be further refined by ultrasonography or laparoscopy if the BHCG level continues to rise above 2,000miu.

Possible Additional Treatment Measures

Once ectopic pregnancy treatment is completed, consider:

• administering Rh immunoglobulin to an unsensitized Rh negative woman, unless she is declared sterile
• repeating quantitative serum B-subunit LCG every week until levels in the blood are normal
• providing contraceptive advice

Conclusion

A famous Midwestern teaching center has prominently displayed a sign in the examining room that asks, "Does this woman have an ectopic pregnancy?" Physicians who keep this question in mind at all times will have no reason to fall prey to the mysteries and whims of this condition.

J4209 12/99

Updated: December 1999
Originally published: April 1990