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Ectopic Pregnancy – Causes, Symptoms, Diagnosis and Treatment

An ectopic pregnancy is the development of the fetus outside of the uterus. This can happen in the fallopian tubes, cervical canal, or the pelvic or belly. The cause of an ectopic pregnancy is usually scar tissue in the fallopian tube from infection or disease. The risk of ectopic pregnancy is increased in women who have had tubal sterilization procedures, especially women who were younger than age 30 at the time of sterilization.

Ectopic pregnancies happen in about 1 out of 50 pregnancies and can be very dangerous to the mother. Symptoms may include spotting and cramping. The longer an ectopic pregnancy goes on, the greater the chance that a fallopian tube will rupture. An ultrasound and blood tests may confirm the diagnosis. Treatment of an ectopic pregnancy may include medicine or surgical removal of the fetus.

Illustration demonstrating visible bleeding during pregnancy

Causes :

The causes of ectopic pregnancy are unknown. After fertilization of the oocyte in the peritoneal cavity, the egg takes about nine days to migrate down the tube to the uterine cavity at which time it implants. Wherever the embryo finds itself at that time, it will begin to implant.There are some speculative specific causes or associations. Smoking, advanced maternal age and prior tubal damage of any origin are well known risk factors for ectopic pregnancy. Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Damage to the cilia or blockage of the Fallopian tubes is likely to lead to an ectopic pregnancy. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia. If however both tubes were occluded by PID, pregnancy would not occur and this would be protective against ectopic pregnancy. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy. Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of ectopic pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound.

Symptoms:

  • Pain in the lower abdomen, and inflammation (Pain may be confused with a strong stomach pain, it may also feel like a strong cramp)
  • Pain while urinating
  • 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 miscarriage or the ‘implantation bleed’ of a normal early pregnancy.
  • Pain while having a bowel movement.
  • 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 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 gynaecologic problems.

Diagnosis:

Pregnancy test

The human chorionic gonadotropin (hCG) blood test to confirm that you’re pregnant. Levels of this hormone increase during pregnancy. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy — usually about five to six weeks after conception.

Transvaginal ultrasound

A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. For this test, a wandlike device is placed into your vagina. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor.

Treatment :

Treatment

Nonsurgical treatment Early treatment of an ectopic pregnancy with the antimetabolite methotrexate has proven to be a viable alternative to surgical treatment since 1993 (though the literature dates back to at least 1989). If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy.

Surgical treatment 

If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy).

Chances of future pregnancy 

The chance of future pregnancy depends on the status of the adnexa left behind. The chance of recurrent ectopic pregnancy is about 10% and depends on whether the affected tube was repaired (salpingostomy) or removed (salpingectomy). Successful pregnancy rates vary widely between different centries, and appear to be operator dependent. Pregnancy rates with successful methotrexate treatment compare favorably with the highest reported pregnancy rates. Often, patients may have to resort to in vitro fertilisation to achieve a successful pregnancy. The use of in vitro fertilisation does not preclude further ectopic pregnancies, but the likelihood is reduced.

Risk Factors :

Previous ectopic pregnancy
Abnormal fallopian tubes
Maternal DES
Endometriosis
History of Tubal Surgery
Use of an IUD device
History of infertility
Multiple sexual partners
Exposure to cigarette smoke

 

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