probability of an ectopic pregnancy is higher in women with clinical symptoms. For example, a woman with a previous ectopic pregnancy who presents with unilateral iliac fossa pain is more likely to have an ectopic pregnancy than an asymptomatic woman in her first pregnancy. Hence the result of an ultrasound scan is influenced by the prior odds.12 According to a meta-analysis, risk factors for ectopic pregnancy include previous ectopic pregnancy, previous tubal surgery, documented tubal pathology and previous genital infections, including PID, Chlamydia and gonorrhoea.13 In another study, contraception and the risk of ectopic pregnancy has also been evaluated.14 Although women becoming pregnant after sterilization or while currently using an intrauterine contraceptive device are at an increased risk of ectopic pregnancy should they become pregnant, neither is a risk factor for ectopic pregnancy.14 Pregnant women whose ultrasound in the first trimester demonstrates haemoperitoneum (Figure 3.4) will often, but not always, have abdominal pain. This ultrasound finding is generally thought to be associated with tubal rupture. In fact although the incidence of haemoperitoneum is between 18% and 34%7,15,16 this does not necessarily mean that tubal rupture has occurred. The majority of ectopic pregnancies with blood in the pouch of Douglas have 'leakage' from the lumen of the fimbrial
Whilst the incidence of ectopic pregnancy has progressively increased, the morbidity and associated mortality have substantially decreased. Over 10 000 ectopic pregnancies are diagnosed annually in the UK. The incidence of ectopic pregnancy in the UK is 9.6/1000 pregnancies and the mortality is 4/1000 ectopic pregnancies.1 The ratio of intra- to extrauterine pregnancies may be as high as 50:1. In tertiary referral EPUs, as many as 3% of women may have an underlying ectopic pregnancy. A total of 95% of ectopic pregnancies are tubal and the majority of these are located in the ampullary region of the fallopian tube. Non-tubal ectopic pregnancies (5%) will be discussed in detail in Chapter 12.
Although spontaneous heterotopic pregnancy is rare (between 1:10 000 and 1:50 000), the incidence is as high as 1% in women following ARTs.18 In these women, even more care must be taken when inspecting the adnexae using TVS even when an intrauterine sac has been visualized. In our unit, three heterotopic pregnancies have been seen in the last 4 years, one spontaneous and two following ARTs. In the last two cases, although an intrauterine sac was visualized on TVS, these women were admitted with ongoing lower abdominal pain, but were not diagnosed until the time of laparoscopy for declining clinical condition. The management of ectopic pregnancy is discussed in detail in Chapters 9-13.
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