A tubal ectopic pregnancy with a visible yolk sac
As trainee gynaecologists one of the first things we learnt is the idea that a women with pain/bleeding/almost any symptoms has an ectopic pregnancy until proved otherwise. Over time maybe this teaching has slipped. In a recent study from Nora van Mello and colleagues in Amsterdam (published in Fertility and Sterility) the conclusion was that relatively poor outcomes were usually due to substandard care rather than something intrinsic about the ectopic pregnancies themselves.
In this study poor outcome was defined as severe intra-abdominal bleeding needing a blood transfusion of more than four units of blood. In these cases substandard care was reported in 43% compared to 14% of stable ectopic pregnancies. The poor care was most often misdiagnosis.
This study was on relatively small numbers – just 128 cases. Furthermore socio-economic data were not available in all women from the study – which may be a very significant factor. However this study certainly suggests that there is no room for complacency with ectopic pregnancy. In “developed” countries this is possible as trainee doctors see fewer women who have collapsed secondary to blood loss from an ectopic. Although at risk of sounding like Methuselah – this was not so uncommon when I was training. The result is that clinicians and even patients do not give ectopic pregnancy the respect it deserves. Medicine has a habit of biting you just when you think things are OK, and ectopic pregnancy falls into this category. Most ectopic pregnancies are found early and treatment is straightforward – even though the impact on an individual couple may be huge. However a lack of awareness, failing to carry out a urinary pregnancy in all women of fertile age with pain, not recognising that gastro-intestinal symptoms such as diarrhoea are sometimes a feature – all these things can lead to a disaster. There is also a need for education amongst women. Any women should be educated to be aware of the risk factors and to carry out a home pregnancy test in the event that they have suggestive symptoms. If everyone is aware of the possible risk then severe morbidity should be avoided in most cases.
