In little more than a generation, the diagnosis and management of a woman with an early pregnancy failure have changed dramatically. Treatment has moved out of the hospital and into outpatient clinics, away from the surgical suite and toward medical or expectant management. Cases of management of shock and catastrophic bleeding are rare, while diagnosis and treatment before symptoms are experienced has become common. Technological advances and consideration of the risks associated with ectopic pregnancy have resulted in prompt, safe care (1
). Modern management has, however, resulted in new pitfalls and dilemmas. In this series of articles, we will explore how modern management of early pregnancy failure has increased iatrogenic complications, concomitantly to reducing morbidity and mortality associated with ectopic rupture.
A woman who presents with vaginal bleeding and pain is at risk for early pregnancy failure. By far, the most common complication is that of miscarriage. However, EP accounts for 1 to 2% of all pregnancies in the United States (2
). Ectopic pregnancy can compromise a woman’s health and future fertility, and is still a leading cause of maternal morbidity and mortality accounting for 6% of pregnancy deaths (1
). A ruptured EP presents with intraperitoneal hemorrhage and should be treated emergently. Currently most patients present before rupture and with non-specific symptoms, raising new questions: who needs aggressive diagnosis and how should those patients be managed?
The most recent mortality data available (estimated between 2003 and 2007) demonstrates that mortality resulting from EP has declined significantly to a five-year US national average of 0.50 per 100,000 live births. This translates to an average of 21 deaths from EP annually (2
). There has also been a dramatic change from open surgical procedures, transitioning through laparoscopic procedures, now shifted towards a predominance of medical management or even expectant management. These historical trends are well demonstrated in the article by Dr. van Mello (3
). Today, women not initially diagnosed with ultrasound are followed with algorithms involving serial hCG values, follow up ultrasounds, and, at times, laparoscopy or uterine curettage. As more women undergo such surveillance, it should be recognized that these algorithms and decision aids are not without error (4
). An error can result in false reassurance that a woman does not have an ectopic pregnancy, or conversely, interruption of a desired intrauterine pregnancy (IUP) during diagnosis and management.