Ectopic means “out of place.” in a normal pregnancy, a fertilized egg travels through a fallopian tube to the uterus. The egg attaches in the uterus and starts to grow. But in an ectopic pregnancy, the fertilized egg attaches (or implants) someplace other than the uterus, most often in the fallopian tube. (This is why it is sometimes called a tubal pregnancy.) In rare cases, the egg implants in an ovary, the cervix (neck of womb), or the belly.
There is no way to save an ectopic pregnancy. It cannot turn into a normal pregnancy. If the egg keeps growing in the fallopian tube, it can damage or burst the tube and cause heavy bleeding that could be deadly. If you have an ectopic pregnancy, you will need quick treatment to end it before it causes dangerous problems. A classical ectopic pregnancy does not develop into a live birth.
Symptoms of Ectopic Pregnancy
The most common symptoms are bleeding and cramping. If you are pregnant or may be pregnant and you experience any or all of the following symptoms, you should immediately seek medical attention for evaluation of a possible ectopic pregnancy.
- Colicky, crampy pain with tenderness, usually in the lower abdomen that may worsen on straining of bowels, coughing or moving.
- Sharp, steady pain in the pelvis
- Vaginal bleeding
- Nausea and vomiting
- Dizziness or weakness (i.e., if the tube ruptures, a weak pulse, clammy skin and fainting are common because of internal bleeding)
- Shoulder pain
- Feeling of rectal pressure
What Causes an Ectopic Pregnancy?
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 might have partially or entirely blocked it. Pelvic inflammatory disease, which can be caused by gonorrhea or chlamydia, is a common cause of blockage of the fallopian tube.
Endometriosis (when cells from the lining of the uterus implant 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.
Ectopic pregnancy is suspected in any female of reproductive age with pelvic pain, vaginal bleeding or unexplained syncope or hemorrhagic shock, regardless of sexual, contraceptive, and menstrual history. Findings of physical (including pelvic) examination are neither sensitive nor specific. Diagnosis of ectopic pregnancy is dependent on clinical assessment and on investigations. The investigations include measuring a certain hormone called ? subunit of human Chorionic Gonadotrophin (? B-hCG) and performing an ultrasound assessment. The ultrasound is done first since visualizing pregnancy within the womb will exclude an ectopic pregnancy. However, in very rare situations there may be pregnancy within the womb and outside as well.
If the ultrasound cannot confirm the presence of intrauterine pregnancy and the patient is clinically stable, which means no signs of internal haemorrhage then ?-hCG is measured to decide further management. Depending on the results it will be decided whether to treat patient conservatively by repeating the measurements of undergoing operative interventions as laparoscopy.
If ectopic pregnancy appears unlikely and patients are stable, serum levels of can be measured serially on an outpatient basis. Normally, the level doubles every 1.4 to 2.1 days up to 41 days; in ectopic pregnancy (and in abortions), levels may be lower than expected by dates and usually do not double as rapidly. Progesterone levels may be measured when the diagnosis is unclear; as they can help in reaching a diagnosis in combination with ultrasound assessment and ?-hCG.
Options for Treatment
Treatment of an ectopic pregnancy varies, depending on how medically stable the woman is and the size and location of the pregnancy.
An early ectopic pregnancy can sometimes be treated with an injection of a drug called methotrexate, which stops the growth of the embryo. If the blood tests show that the level of hormones are declining then sometimes patients are followed up closely without any interventions or medications until the ectopic pregnancy resolves completely.
If the pregnancy is further along, you’ll likely need surgery to remove the abnormal pregnancy. In the past, this was a major operation, requiring a large incision across the pelvic area. This might still be necessary in cases of emergency or extensive internal injury.
However, the pregnancy is often removed using laparoscopy or key-hole surgery, a less invasive surgical procedure. The surgeon makes small incisions in the lower abdomen and then inserts a tiny video camera and instruments through these incisions. The image from the camera is shown on a screen in the operating room, allowing the surgeon to see what’s going on inside of your body without making large incisions. The ectopic pregnancy is then surgically removed and any damaged organs are repaired or removed. The usual practice is to remove the damaged tube containing the pregnancy, as if left behind there is a higher chance of a repeat ectopic pregnancy within the same tube in further pregnancies. Sometimes the tube is conserved and only the pregnancy removed from within the tube if the other tube has already been removed or if it looks severly damaged. In these cases patients should be counselled as regards the risk of future ectopic pregnancy.
Whatever your treatment, the doctor will want to see you regularly afterward to make sure your ?-hCG levels return to zero. This may take several weeks. An elevated ?-hCG could mean that some ectopic tissue was missed. This tissue may have to be removed using a drug called methotrexate or through performing additional surgery.
What About Future Pregnancies?
Some women who have had an ectopic pregnancy will have difficulty becoming pregnant again. This difficulty is more common in women who also had fertility problems before the ectopic pregnancy. Your prognosis depends on your fertility before the ectopic pregnancy, as well as the extent of the damage that was done.
The likelihood of a repeat ectopic pregnancy increases with each subsequent ectopic pregnancy. Once you have had one ectopic pregnancy, you face an approximate 15% chance of having another. Therefore in future pregnancies it is important to be reviewed early on in the pregnancy and to have ultrasound examination to confirm that the pregnancy is in the right place within the womb.
Who’s at Risk for an Ectopic Pregnancy?
While any woman can have an ectopic pregnancy, the risk is highest for women who are over 35 and have had:
- Pelvic inflammatory disease( infection within the pelvis involving the tubes and ovaries)
- A previous ectopic pregnancy
- Surgery on a fallopian tube especially in the presence of scar tissue within the pelvis
- Infertility problems or medication to stimulate ovulation
- Some birth control methods can also affect your risk of ectopic pregnancy. If you get pregnant while using progesterone-only oral contraceptives, intrauterine contraceptive device ( coil or loop) or the morning-after pill, you might be more likely to have an ectopic pregnancy.
- Smoking and having multiple sexual partners also increases the risk of an ectopic pregnancy.
When to seek medical advice?
If you believe you’re at risk for an ectopic pregnancy, meet with your doctor to discuss your options before you become pregnant. You can help protect yourself against a future ectopic pregnancy by not smoking and by always using condoms when you’re having sex but not trying to get pregnant. Condoms can protect against sexually transmitted infections (STDs) that can cause infection within the pelvis.
If you are pregnant and have any concerns about the pregnancy being ectopic, talk to your doctor, it’s important to make sure it’s detected early. You and your doctor might want to plan on checking your hormone levels or scheduling an early ultrasound to ensure that your pregnancy is developing normally.
Call your doctor immediately if you’re pregnant and experiencing any pain, bleeding, or other symptoms of ectopic pregnancy. When it comes to detecting an ectopic pregnancy, the sooner it is found, the better.