[CG] Non-tubal ectopic pregnancies, diagnosis and management

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Objectives

The purpose of this guideline is to aid the management of women diagnosed with a non-tubal ectopic pregnancy.

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Ectopic pregnancies in locations other than the fallopian tubes are becoming more common. In vitro fertilisation, pelvic inflammatory disease and the rise in the caesarean section rate are known risk factors. Whilst non tubal pregnancies only account for 5% of all ectopic pregnancies they disproportionately account for morbidity and mortality associated with ectopic pregnancy.

Management

An unstable patient should be managed in accordance with emergency protocols.

A stable patient should have a group and save, FBC and if appropriate a βhCG taken.

Initial diagnosis, management and scans or biochemical results of non tubal pregnancies must be discussed with a consultant gynaecologist. A gynaecologist with early pregnancy expertise should be involved in planning ongoing care and management.

Site of ectopic

Ultrasound features

Biochemical investigations

Management options

Cervical pregnancy

Empty uterine cavity

Barrel shaped cervix

Gestational sac (GS) below the level of the internal cervical os

Blood flow around the GS

Absence of sliding signi

Serum βhCG  

Consider systemic methotrexate if:

  • βhCG levels <10000iu
  • absence of fetal cardiac activity
  • <12+0 weeks gestation

Consider systemic methotrexate +/- surgical debulking +/- intracervical methotrexate if:

  • βhCG ≥10000iu
  • Evidence of fetal cardiac activity
  • CRL ≥10 mm

Caesarean ectopic

Empty uterine cavity

GS or trophoblast located anteriorly at the level of the internal cervical os

Embedded at site of previous caesarean section

Thin or absent myometrium between GS and bladder

Evidence of prominent trophoblastic circulation on doppler examination

Empty endocervical canal

Not routinely required

Consider MRI if diagnosis is in doubt

Treatment requires individualised care

1st trimester options:

  • Surgical management is the most effective
  • Consideration of surgical evacuation with Foley catheter insertion for additional haemostasis
  • Local injection of methotrexate into the GS. Risk of haemorrhage remains high from degenerating placental tissue

If the pregnancy continues after the first trimester then the patient must be highlighted to the Obstetric Consultant leading the patient’s care as there is a risk of invasive placentation.

Interstitial pregnancy

Empty uterine cavity

GS located in the intramural part of the fallopian tube

<5mm of myometrium in all planes

Presence of interstitial lineii

Consider sequential βhCG

Consider MRI to aid diagnosis following discussion with gynaecology consultant

Medical management with systemic methotrexate should be considered 1st line

Consider expectant management in those with low initial βhCG levels

Cornual pregnancy

GS mobile and separate from the uterus and surrounded by myometrium

Vascular pedicle adjoining the unicornuate uterus

Consider sequential βhCG 48 hours apart

Surgical management should be 1st line

Removal of the rudimentary horn should be undertaken

Ovarian pregnancy

Empty uterus

Internal anechoic area on the ovary

Consider sequential βhCG 48 hours apart

Laparoscopic management should be 1st line

Abdominal pregnancy

Empty uterus

GS surrounded by loops of bowel and separated from them by peritoneum

Mobile mass when pressing with the transvaginal probe

βhCG

Laparoscopic management should be 1st line.

Heterotopic pregnancy

Intrauterine pregnancy and co-existing ectopic pregnancy

Not required

Management needs to be individualised based on the intrauterine pregnancy and wishes of the patient

Surgical management is 1st line with salpingectomy of the ectopic

Systemic methotrexate should only be used if the intrauterine pregnancy Is non-viable or patient wishes termination

Scan following surgery to assess viability of intrauterine pregnancy

i Sliding sign: the vaginal probe is used to apply pressure onto the cervix. In a miscarriage, the gestational sac slides against the cervical canal, but does not do so in a pregnancy implanted in the endocervix or caesarean section scar.
ii Interstitial line sign: an echogenic line from the mass to the endometrial echo.

Last reviewed: 26 November 2019

Next review: 30 November 2024

Author(s): Fiona Hendry

Approved By: Dr Ros Jamieson, Clinical Director