Ectopic pregnancy in the era of medical abortion: are we ready for it? Spectrum of sonographic findings and our experience in a tertiary care service hospital of India

Abstract

Aim: The aim of this study was to share our experience of clinical presentation and ultrasonographic findings in cases of ectopic pregnancy especially in the context of usage of unsupervised medical abortifacients.

Settings and design: This is prospective study conducted over a period of 1 year extending from August 01, 2009 to July 31, 2010 in a tertiary care Armed Forces Hospital of India.

Materials and methods: Clinically and or sonologically suspected cases of ectopic pregnancy formed the study group. Detailed clinical, menstrual, and treatment history was obtained for each patient. Ultrasonography (USG) was done with multifrequency convex (2.5-6 MHz) followed by transvaginal (6-10 MHz) probes. Operative findings were noted and recorded in each case.

Results: In the study period, a total of 1958 pregnant patients were admitted and treated, which included 1690 deliveries and 268 abortions. Based on USG findings, 16 cases (0.8 %) of ectopic pregnancy were diagnosed. While four patients were treated medically (with methotrexate), 12 cases underwent surgery. Out of 16 cases, 10 cases were suspected clinically as ectopic pregnancy. Features suggestive of menorrhagia, threatened abortion, and pelvic inflammatory disease were present in five, three, and three cases, respectively. History of intake of medical abortifacients (MA) (mifepristone followed by misoprostol) was present in 07 (43.75 %) cases. On USG, commonest abnormality was a complex adnexal mass seen in 12 (75 %) cases. Gestational sac with definite embryo within and surrounding echogenic rim was seen in five cases. Live ectopic pregnancy was diagnosed in two (12.5 %) cases. Endometrial thickness was less than 10 mm in all cases who had taken MA. Pseudo gestation sac was seen in 02 (12.5 %) cases. Significant hemoperitoneum was present in 10 out of 12 cases operated. Organized hematoma in pelvis masking the presence of adnexal mass was noted in three cases.

Conclusion: Over-the-counter availability, failure to strictly follow the guidelines, unsupervised usage of MA along with atypical clinical history have increased diagnostic dilemma in ectopic pregnancy. Sonographic findings are frequently atypical in such cases. Ectopic pregnancy may remain under-diagnosed with potentially serious consequences in patients who have taken MA without prior confirmation of intrauterine gestation.

Keywords: Ectopic pregnancy; Medical abortifacients; Ultrasonography.

Fig. 1

a, b Transvaginal sonogram in a patient who had taken medical abortifacients without prior confirmation of intrauterine gestation. a An ill-defined left adnexal mass with an irregular margined sac-like structure (single white arrow) within is noted. Note that the trophoblastic reaction surrounding the sac is indistinct. b Significant particulate fluid consistent with hemoperitoneum (double white arrow) is noted in the pelvis. Also note that the endometrial thickness and reaction are not very prominent

Fig. 2

Transvaginal sonogram in a 26-year-old female who had taken medical abortifacients without prior confirmation of intrauterine gestation. A gestation sac with an embryo (7 weeks 2 days) within is clearly visible in the right adnexa. The inset picture shows the presence of cardiac activity confirming a diagnosis of live ectopic pregnancy

Fig. 3

a, b Per operative finding and specimen of the same patient as in Fig. 2. a The ectopic gestation being delivered from the ampullary end of right Falopian tube with intact sac (white arrow). b Photograph of the specimen taken immediately after the ectopic gestation was delivered. Note that the embryo is contained within an intact gestation sac