What is an Ectopic Pregnancy?
An Ectopic Pregnancy is abnormal implantation of the fertilized egg outside of the normal inner lining within the cavity of the uterus. The most common location for an Ectopic Pregnancy is at various regions within the fallopian tubes, it can however also be present in the abdominal cavity, the ovaries, or the cervix. The embryo in an Ectopic Pregnancy does not survive.
Is Ectopic Pregnancy a Medical emergency?
An Ectopic Pregnancy is a medical emergency and immediate medical attention is warranted to prevent potentially fatal complications.
An Ectopic Pregnancy can be of the following types:
- Tubal pregnancy: When the embryo attaches itself to the fallopian tubes. A tubal pregnancy may be:
- Ampullary tubal pregnancy (most common)
- Isthmic tubal pregnancy
- Fimbrial tubal pregnancy
- Cornual or Interstitial tubal pregnancy
- Nontubal pregnancy:
- Abdominal pregnancy
- Ovarian pregnancy
- Cervical pregnancy
- Heterotopic pregnancy: When there are two fertilized eggs, and one of the implants inside the uterus and one implants outside the uterus.
- Persistent Ectopic Pregnancy: When there is a continuation of the growth of some tissue related to the pregnancy, even after the Ectopic Pregnancy is removed.
- Pregnancy of unknown location: When a pregnancy test is positive, but the pregnancy cannot be visualized by transvaginal ultrasonography.
In an Ectopic Pregnancy, the fertilized egg is unable to reach the cavity of the uterus while passing through the fallopian tubes. The main reasons for this could be damaged or improperly shaped fallopian tubes.
The risk factors for Ectopic Pregnancy are as follows:
- Sexually transmitted diseases and multiple sex partners
- Previous ectopic pregnancies
- Pelvic inflammatory disease
- Birth control pills
- Intrauterine device (IUD)
- Fertility treatments.
- Previous surgical procedures on the fallopian tubes such as tubal ligation
Signs & symptoms
The symptoms and signs vary greatly between different individuals after a positive pregnancy test and the absence of menstrual periods.
Some of them may include the following:
- Pain in the pelvic area
- Light vaginal bleeding
If the Ectopic Pregnancy grows and ruptures, the following may be seen:
- Sudden and severe abdominal pain or pain in the pelvic region may radiate to the shoulder.
- Abnormal vaginal bleeding
- Extreme dizziness or fainting
- Fast heart rate and breathing
- Sweating and increased thirst
The following investigation may be done to establish a diagnosis of Ectopic Pregnancy:
- Laboratory tests:
- CBP & ESR - To rule out anemia and infections.
- Beta HCG - The levels of beta HCG rise as the pregnancy progresses. The levels of the BHCG are interpreted in relation to other tests for confirmation.
- Imaging tests:
- Ultrasound/transvaginal ultrasonography - It is used to visualize the presence of a gestational sac inside the uterine cavity.
- Culdocentesis: To test for the presence of blood in the fluid between the vaginal wall and the rectum.
- D&C (Dilatation and Curettage): It is only done once a viable pregnancy inside the uterus has been completely ruled out. It is done when:
- There is no visible intrauterine pregnancy and a BHCG value of more than 2000 mIU/ml is present
- An abnormal rise of BHCG over a period of 48 hours
- An abnormal fall of BHCG over a period of 48 hours
A diagnosis of an Ectopic Pregnancy is to be suspected in every woman who has abdominal pain and vaginal bleeding after a positive pregnancy test. The diagnosis is confirmed based on medical history, clinical evaluation, and results of the investigations done.
The treatment of an Ectopic Pregnancy is aimed at the earliest termination and removal of the pregnancy to prevent life-threatening complications. Depending on when the Ectopic Pregnancy is discovered, it may be managed either medically or surgically.
The medical management is done if it is discovered at an early stage and without complications. The management includes:
- Methotrexate: It is a chemotherapeutic agent that is used in the treatment of cancers. It is usually given as a single dose injection. It works by destroying the growth and the multiplication of the tissues formed after fertilization. It may be prescribed when the Ectopic Pregnancy is present in the:
- Cornual or interstitial portion of the fallopian tubes
The surgical management of Ectopic Pregnancy in the above locations is usually associated with an increased risk of bleeding and complications.
It is not prescribed if:
- There is active bleeding
- The size of the embryo is greater than 4 cm
- There is fetal cardiac activity
- There is a tubal rupture
- BHCG levels are less than 5000 mIU/ml
- Leucovorin - It is given as a folic acid supplement when methotrexate is prescribed
Interventional including surgery and indications for surgery
Minimally invasive surgical procedures are usually employed for the surgical management of ectopic pregnancies.
The following procedures may be were done:
- Laparoscopic salpingostomy - Minimally invasive surgery where the ectopic tubal pregnancy is removed from the tube and the tube is repaired.
- Laparoscopic tubal resection and salpingectomy - Minimally invasive surgery where a part of the entire tube is removed along with the ectopic tubal pregnancy.
After surgical procedures, BHCG levels are monitored on a weekly basis to ensure that there is no leftover gestational tissue.
- Laparotomy: An open abdominal surgery may be required if there is heavy bleeding.
Role of diet/ Exercise/ Lifestyle changes/ Preventive measures
There are no methods or measures to prevent an Ectopic Pregnancy. However, some of the risk factors may be minimized by:
- Cessation of smoking
- Avoiding multiple sex partners
- Using protection during sex to avoid sexually transmitted diseases
It can rupture or burst and can lead to fatal complications such as:
- Peritonitis and peritonism: Inflammation of the peritoneum and the abdominal contents
- Hypovolemic shock: Due to severe blood loss
The prognosis for ectopic pregnancies that are diagnosed early and managed properly is generally good. However, these are diagnosed late, and progress to complications can have a poor prognosis and increased mortality of the mother.
When to contact the doctor or hospital? / How to identify the emergency or complications?
It is advisable to seek immediate medical attention at the first sign of bleeding and pelvic pain after a positive pregnancy test to rule out an Ectopic Pregnancy. If at any time during pregnancy there is heavy bleeding with abdominal pain or pelvic pain, seeking immediate medical attention is warranted.
Indications for hospitalization if required
Hospitalization may be required for surgical management.
Suggested clinical specialist/ Departments to consult for this condition
An Ectopic Pregnancy will be attended to by specialists from the department of gynecology.