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ECTOPIC PREGNANCY |
| An ectopic pregnancy is an abnormal pregnancy in which a fertilized eggs outside of the uterus, usually found in one of fallopian tube. It can occur in several places, eg. The ovary, the abdomen, the cervix, at the join between the tube and the womb (cornua), but the most common place is within the fallopian tube. Pregnancy can even occur in both the womb and the tube at the same time (heterotopic pregnancy), but this is rare, occurring in only about 1/10,000 pregnancies. Almost all ectopic pregnancies occur in fallopian tubes (tubes from uterus), so this is also known as Tubal Pregnancy. |
What Causes the Ectopic Pregnancy? |
The risk of having an ectopic pregnancy depends upon many factors. Anything that alters the tubal function may affect further pregnancies. An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube may have partially or entirely blocked it. Pelvic inflammatory disease (PID) is the most common of these infections.
Fallopian tubes aren't like a hollow pipe that sits there with the egg rolling down. They have little hairs on the inside (cilia) which move with a wave-like motion to encourage the egg toward the womb. If the tube becomes blocked or the cilia damaged then ectopic is more likely.
Endometriosis, when cells from the lining of the uterus detach and grow elsewhere in the body or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress. |
Symptoms |
Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.
The early signs are:
- Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms.
- Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarraige or the 'implantation bleed' of a normal early pregnancy.
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Patients with a late ectopic pregnancy typically have pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms.
- External bleeding is due to the falling progesterone levels.
- Internal bleeding is due to hemorrhage from the affected tube.
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The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID.
More severe internal bleeding may cause:
- Lower back, abdominal, or pelvic pain.
- Shoulder pain. This is caused by free blood tracking up the abdominal cavity, and is an ominous sign.
- There may be cramping or even tenderness on one side of the pelvis.
- The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.
- Ectopic pregnancy is noted that it can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynecologic problems
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What are the treatment ? |
There are several different treatments to diagnose ectopic pregnancy. It is not possible to take the pregnancy from the tube and put it into the womb. The options are as follows:
- Expectant management - a proportion of all ectopics will not progress to tubal rupture, but will regress spontaneously and be slowly absorbed. This may be appropriate if the level of hCG is falling and a woman is clinically well.
- Medical treatment - with a drug called methotrexate, which is given by injection. This makes the ectopic pregnancy shrink away by stopping the cells dividing. Only a few ectopics can be treated this way, which is the least invasive. Certain criteria must be fulfilled, such as small diameter of the ectopic and low level of hCG. Close follow-up with further scans and blood tests is also necessary.
- Laparoscopic surgery - via 'keyhole' surgery, it may be possible to either open the tube and remove the pregnancy (salpingotomy), or remove the tube altogether (salpingectomy). The decision on which of these options is taken is very specific to each patient. Follow-up with blood tests for hCG will more than likely be needed as persistent ectopic tissue can occur in 5% to 10% of patients.
- Open surgery (laparotomy) - this involves a 5cm incision at the top of the pubic hairline. The affected tube is brought out and either salpingotomy or salpingectomy performed.
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What about Future Pregnancies? |
In the future one may wish to try again for a pregnancy after having an ectopic pregnancy, a woman is at risk of it happening again. The risk of another ectopic depends on several factors, in particular the type of surgery that has taken place, the presence of any damage to the other tube and whether there were any difficulties conceiving first time around. Studies that compare removing the tube (salpingectomy) with opening it at the time of surgery and removing the pregnancy (salpingostomy) have found that when the other factors above have been controlled for, the risk of repeat ectopic is about 9% if the tube is removed and 12% if the tube is left behind. There is no difference in outcome whether the operation was an open one or key-hole surgery was used (laparoscopy), but recovery is certainly quicker with the key-hole option.
Approximately 30% of women who have had ectopic pregnancies will have difficulty becoming pregnant again. Your prognosis depends mainly on the extent of the damage and the surgery that was done. |
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