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What is ectopic pregnancy or tubal pegnancy?
Pregnancy in which the fertilized ovum implants on any tissue other than the endometrial lining of the uterus.
95% occur in the tube. 1.5% are abdominal, 0.5% are ovarian and 0.03% are cervical.
Ectopic or tubal pregnancy occurs when the site of implantation is outside of the womb. 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 in the
fallopian tube. Pregnancy can even occur in both the womb and the tube at the same time (heterotopic pregnancy), but this
is rare, about 1/10,000 pregnancies.
What does ectopic mean?
Ectopic means "out of place."
Expectations (prognosis)
About 85% of the women who have experienced one ectopic pregnancy (also called tubal pregnancy) are later able to achieve a normal pregnancy. A subsequent ectopic pregnancy may occur in 10 to 20% of cases. Some women fail to become pregnant again, while others become pregnant and spontaneously abort during the first trimester.
The maternal death rate from ectopic pregnancy in the U.S. has decreased in the last 30 years to less than 0.1%.
Causes of ectopic pregnancy?
Many factors are known to increase the risk of having an ectopic pregnancy. Anything that alters the tubal function may affect further pregnancies. 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.
Often none of the risk factors below are present and there is no obvious reason - it was just bad luck.
- Advancing age
- Pelvic inflammatory disease - eg. previous chlamydia or gonorrhoea.
- Tubal surgery - women who have had operations on their tubes.
- Previous ectopic.
- DES exposure - this is a drug that was once used during pregnancy.
- Previous termination of pregnancy
- IVF (test-tube baby) and ovulation induction
Symptoms of Ectopic Pregnancy
- lower abdominal or pelvic pain
- mild cramping on one side of the pelvis
- amenorrhea (cessation of regular menstrual cycle)
- abnormal vaginal bleeding -- usually scant amounts, spotting
- breast tenderness
- nausea
- back pain, low
Tests for Ectopic Pregnancy
Obviously first of all a pregnancy test. If a sensitive urinary ELISA test is negative then ectopic pregnancy is virtually excluded. This may be backed up with a blood sample being taken.
Vaginal ultrasound scan can reliably demonstrate a pregnancy in the womb from about 4.5-5 weeks onward. Once this is proven, an ectopic is once again virtually excluded (except in the case of the extremely rare heterotopic pregnancy). Sometimes scan can show an ectopic pregnancy clearly in the tube next to the womb.
Unfortunately, there is about an 11-14 day window when a pregancy test may be positive, but it is too early for ultrasound scan to confirm excactly where it is. In this case, it is important to watch for change in clinical signs, such as worsening pain, more tender on examination, fall in blood pressure, etc. This may mean staying in hospital until it is sorted. We can also check the exact level of the pregnancy hormone (hCG). In a normal pregnancy this should double every 48-72 hours; in an ectopic it may climb at a lower rate or plateau. The clinical signs and blood tests guide who should undergo laparoscopy.
Laparoscopy means having a general anaesthetic. A telescope is placed into the abdomen and the tubes visualised. This is the 'gold standard' for diagnosing ectopics, but it isn't done for everyone because of the need for an anaesthetic, and the modest risks of the procedure.
Treatment for Ectopic Pregnancy
In the event that pelvic-organ rupture has occurred because of the ectopic pregnancy, internal bleeding and/or hemorrhage may lead to shock. This is the first symptom of nearly 20% of ectopic pregnancies.
It is an emergency condition. Therefore, initial treatment may be needed to address shock by keeping the woman warm, elevating her legs, and administering oxygen. Treatment with intravenous fluids and sometimes a blood transfusion is performed as soon as possible.
Surgical laparotomy is performed to stop the immediate loss of blood (in cases in which rupture has already occurred), or to confirm the diagnosis of ectopic pregnancy, remove the products of conception, and repair surrounding tissue damage as much as possible. In some cases, removal of the involved fallopian tube may be necessary.
In non-emergency cases, mini-laparotomy or laparoscopy are the most common surgical treatments. Such procedures have similar outcomes. However, they are less invasive and are available at a lower cost because they require minimal hospitalization or outpatient treatment.
Non-surgical (medical) management is being implemented in many medical centers for ectopic pregnancies without suspected immediate danger of rupture. In such cases, methotrexate is administered with careful outpatient monitoring of the woman and serial quantitative HCGs, CBCs, and liver funtion tests.
Ectopic pregnancies cannot continue to term, so removal of the developing cells is necessary to save the life of the mother.
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