Key learning points:
– Signs, symptoms and management of an ectopic pregnancy
– Physical and psychological impact
– Appropriate referral processes
Ectopic pregnancy (EP) is estimated to occur in one out of 80 women.1 Midwives and nurses are often the first port of call for a woman and therefore the importance of understanding the signs of symptoms of EP to ensure prompt referral and accurate advice is essential.2,3 This article will discuss signs and symptoms and discuss best practice guidance (CG154) from the National Institute for Clinical Excellence (NICE).4
An EP cannot be diagnosed in the community meaning that it is key to ensure that the patient is referred promptly to an early pregnancy assessment unit (EPAU) when any signs and symptoms of EP are displayed.5 It’s essential that a midwife has an understanding of the signs and symptoms in order for prompt and appropriate referral. Midwifery and nursing curriculums should ensure that they have the most up-to-date evidence to share with students to ensure they have the knowledge and expertise on qualification.
What is an ectopic pregnancy?
An ectopic pregnancy occurs when a fertilised ovum implants outside of the uterus, commonly in one of the fallopian tubes. The signs and symptoms may vary and diagnosis usually occurs between five and 13 gestational weeks. If an EP goes undetected and “ruptures” this can lead to haemorrhage and death.6,7 There are around 32,000 hospital admissions every three years in the UK and numbers are increasing worldwide.8,9 A crucial sign that a midwife should be observing for is shoulder tip pain, one-sided abdominal pain and scant dark coloured bleeding. The majority of EPs will implant in the fallopian tube, however there is an increase in the number of caesarean section scar EP implantations.10
Who is at risk?
Any sexually active woman is at risk of an EP.7 There are conditions that put a woman at an increased risk, these include:
1. Women who have damaged fallopian tubes through infection or sexually transmitted disease such as chlamydia.
2. Women who smoke as this may cause damage to the cilia in the fallopian tube.
3. Women who have had previous tubal surgery and surgery such as appendicitis.
4. Women who have had a previous lower segment caesarean section (LSCS).11
Midwives and nurses need to understand the risk factors and be prepared to counsel women, especially those who may have had a previous LSCS.3 A reasonable approach to tackle this issue would be to ensure women are informed about risk factors for developing an EP following a LSCS or appendix removal to ensure awareness of future signs and symptoms.
Diagnosis
Most women will present with a history of blood spotting and pelvic pain. The woman may not know that she is pregnant so it is imperative that every woman who presents with spotting and abdominal pain is tested for the human chorionic gonadotrophin (HCG) hormone, remembering that sometimes, the levels are too small to be picked up by a standard over the counter pregnant test. However, occasionally an EP will be detected in an asymptomatic woman. These EPs tend to imitate the development of a normal uterine pregnancy until sudden rupture occurs.
The Ectopic Pregnancy Trust recommends that healthcare workers should exercise caution in all women of childbearing age in order to rule out an EP.2 Diagnosis should include a number of investigations, these being testing for HCG and progesterone in the blood. In a normal uterine pregnancy HCG levels will double every 48 hours, but in an EP the levels will be low or diminishing. When a woman is being managed expectantly, her levels should be measured every 48 hours and she should be given the information about worsening symptoms. Strategies to empower a woman who may be at home but having regular blood tests could be for her to have the information in the form of a leaflet.
The Ectopic Pregnancy Trust provides excellent resources that are available for women and should be in every EPAU (see Resources section). A woman should be offered a transvaginal ultra sound scan and a vaginal examination, which may demonstrate cervical tenderness, however it is important to understand that diagnosis cannot always be attained simply through examination. Increased risk of mortality and morbidity often relates to the interval between diagnosis and treatment.12
Signs and symptoms
Some women who have an EP display no symptoms. More commonly women will present with some of the symptoms below:
– Abdominal pain.
– Bleeding (‘prune juice’ colour).
– Positive pregnancy test.
– Missed/late period.
– Bladder/bowel problems (caused by pressure in bowels frombloo collecting in the recto-uterine pouch).
– Shoulder tip pain.
– Pallor.
– Dizziness.
– Collapse.
– Feeling ‘not right’.
It is crucial to establish the colour of the bleeding. The prune juice colouring should raise concern and shoulder tip pain is a classical sign of potential tubal rupture alongside (usually) one sided lower abdominal pain. A number of confidential enquiries into maternal deaths have described cases where women’s symptoms of EP were dismissed as gastro-intestinal and urinary infections.13 Therefore, the importance in ensuring we consider EP in any woman of childbearing age cannot be under-estimated and with diagnostic testing healthcare providers are able to offer a number of options for treatment if discovered in a timely manner. Diagnosis should always be confirmed by a senior medical clinician,13 so a midwife or nurse should ensure appropriate timely referral to medical colleagues if an EP is suspected.
Management
NICE guidance CG154 published in 2012 recommends that all women should have access to a EPAU with specially trained staff members. There are a number of management options for consideration should an EP be diagnosed.
Laparoscopic surgery is preferable to laparotomy due to the woman having a quicker post-operative recovery time. The benefits of managing an EP laparoscopically also include a woman having a greater chance of subsequent intra uterine pregnancy1 and lower rates for a recurrence of an EP.8 However, the principal priority is the severity of the EP and if there are signs of rupture, a laparotomy should be undertaken without delay.4 The Ectopic Pregnancy Trust suggests that emergency admission is always acceptable due to the possibility of tubal rupture.
It is considered that almost a quarter of EPs may be suitable for non-surgical management with methotrexate, which can either be administered transvaginal or less commonly systemically.11 The woman should have her HCG levels tested a week following methotrexate administration to ensure levels are dropping. The midwife should keep in mind that the potential for rupture may still be a risk and be ready to refer if any deterioration occurs.
Expectant management can be offered to women who may be under six weeks gestation possibly experiencing bleeding but are not experiencing pain.4 However, information should be given to the woman about when to return to the EPAU (ie, if symptoms worsen).
Women who have a LSCS scar EP implantation, although unusual, may cause greater risk of haemorrhage for the woman due to the pregnancy potentially continuing and therefore the placenta embedding itself within the scar tissue.10 Careful counselling is needed in these cases and referral to centres of expertise may be deemed necessary to support a woman in her decision making.
Physical impact
The physical impact of emergency surgery for EP includes pain, scarring and post-operative risks such as chest infections and deep vein thrombosis. Needing time away from work and/or other children may put pressure upon a woman financially.2 NICE guidance says that post-surgery HCG levels should be tested until the result demonstrates no HCG in the blood. A rhesus negative woman should be routinely offered anti-D prophylaxis at 250iu to all women who have had surgical management.
Psychological impact
The psychological impact of an EP is an important factor for the midwife to consider when caring for a woman. The woman has suffered a loss and this needs to be acknowledged.3 Relationship difficulties may ensue and there is a risk of post-traumatic stress disorder (PTSD) especially if a woman has required emergency surgery.
Her fertility may be reduced due to tubal loss and the woman may be fearful of another pregnancy being an ectopic. The option for a woman to speak to a midwife post EP to acknowledge the loss should be offered.
Communication with respect and dignity is central to the NICE guidance4 with counselling being offered as routine. Healthcare professions should work with women and couples in a sensitive way, being mindful to the fact that the woman is grieving.
Fertility following an ectopic pregnancy
Dependent upon the management of the EP, fertility may be reduced. A woman can be advised to resume sexual activity when she feels comfortable to do so, however, it is advised that she wait for two menstrual periods until she conceives again. This is to give her body time to recover physically and emotionally.
It is important to have an understanding that although the woman may want to become pregnant, she may also be fearful of experiencing the same outcome. Women are at greater risk of having a second EP if she has already experienced one. The Ectopic Pregnancy Trust (EPT) suggests that approximately 65% of women have a successful pregnancy within two years of their EP.
Midwives can signpost women to support groups where women may find practical help and a shared experience with other women. The woman’s partner is likely to have questions and anxieties following an EP and an awareness of the partner’s emotions, especially when the woman may have suffered emergency surgery, is an important consideration for the healthcare professional.
Conclusion
Health professionals need to be aware of the signs and symptoms of an EP and recognise that diagnosis cannot be made in the community, therefore prompt and appropriate referral to an EPAU is essential.
A ruptured ectopic can be a life threatening situation and symptoms are not always typical. An EP should be ruled out in any woman of childbearing age who might be pregnant and presenting with lower abdominal pain and scanty, dark red (prune juice coloured) bleeding. Mindfulness of the psychological effect caused by the loss of a baby through an EP needs acknowledgement and sensitive support as well as caring for physical pain and post-operative needs.
Referral to organisations such as The Ectopic Pregnancy Trust may provide helpful support and information for a woman and useful evidence based advice for health professionals.
Resources
The National Institute for Health and Care Excellence – nice.org.uk/guidance/cg154
The Royal College of Obstetricians and Gynaecologists –
rcog.org.uk/globalassets/documents/guidelines/gtg21_230611.pdf
rcog.org.uk/globalassets/documents/guidelines/ca8-15072010.pdf
The Ectopic Pregnancy Trust – ectopic.org.uk
References
1. Epee-Bekima M, Overton C. Diagnosis and treatment of ectopic pregnancy. The Practitioner 2013;257(1759):15-8.
2. Abbott L. Ectopic pregnancy: symptoms, diagnosis and management. Nursing times 2003;100(6):32-3.
3. Abbott L. Ectopic pregnancy: a real issue for midwives. RCM midwives: the official journal of the Royal College of Midwives 2004;7(6):262-3.
4. Newbatt E, Beckles Z, Ullman R, Lumsden MA. Ectopic pregnancy and miscarriage: summary of NICE guidance, 2012.
5. Royal College of Obstetricians and Gyneacologist. The management of tubal pregnancy. rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/ (accessed 22 February 2016).
6. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA 2013;309(16):1722-9.
7. Karaer A, Avsar FA, Batioglu S. Risk factors for ectopic pregnancy: A case control study. Australian and New Zealand Journal of Obstetrics and Gynaecology 2006;46(6):521-7.
8. Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstetrics & Gynecology 1994;84(6):1010-5.
9. NICE CG154. Ectopic pregnancy and miscarriage: diagnosis and initial management, 2012. nice.org.uk/guidance/cg154 (accessed 16 February 2016).
10. O’Neill S, Khashan A, Kenny L, Greene R, Henriksen TB, Lutomski J, et al. Caesarean section and subsequent ectopic pregnancy: a systematic review and metaanalysis. International Journal of Obstetrics & Gynaecology 2013;120(6):671-80.
11. McQueen A. Ectopic pregnancy: risk factors, diagnostic procedures and treatment. Nursing Standard 2011;25(37):49-56.
12. Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer-2003-2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom London: CEMACH, 2007:114.
13. Barnhart KT. Ectopic pregnancy. New England Journal of Medicine 2009;361(4):379-87.
