Ectopic Pregnancy

What is an Ectopic Pregnancy?

An Ectopic Pregnancy is the abnormal implantation of the fertilized egg outside the normal inner lining within the uterus cavity. 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. 

Is Ectopic Pregnancy a Medical Emergency?

It is a medical emergency; immediate medical attention is warranted to prevent potentially fatal complications like rupture and internal bleeding.

Types

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, one may implant inside the uterus while the other implants outside the uterus.
• Persistent Ectopic Pregnancy: When the growth of some tissue related to the pregnancy continues, even after the Ectopic Pregnancy is removed.
• Pregnancy of unknown location: When the pregnancy test is positive, but the pregnancy cannot be visualized by transvaginal ultrasonography.

Causes

In an ectopic pregnancy, the fertilized egg cannot reach the uterus cavity while passing through the fallopian tubes. The main reasons for this could be damaged or improperly shaped fallopian tubes.

Risk Factors

The risk factors are as follows:

• Smoking
• 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 significantly between individuals after a positive pregnancy test and the absence of menstrual periods.
Some of them may include the following:

• Pain in the lower abdomen
• 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
• Anxiety

Investigations

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.
  • Laparoscopy
• 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 48 hours
  • An abnormal fall of BHCG over 48 hours

Diagnosis

A diagnosis 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 investigation results.

Treatment options

The treatment 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.

Medical Management

Medical management is done if it is discovered early 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 multiplication of the tissues formed after fertilization. 
• It may be prescribed when Ectopic Pregnancy is present in the ovaries, cervix, 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 to manage ectopic pregnancies.
The following procedures may be 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 weekly to ensure that there is no leftover gestational tissue.

• Laparotomy: An open abdominal surgery may be required for 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

Complications

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

Prognosis

The prognosis for ectopic pregnancies that are diagnosed early and managed correctly is generally good. However, these are diagnosed late, and progressing to complications can have a poor prognosis and increased mother mortality.

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 there is heavy bleeding with abdominal pain or pelvic pain at any time during pregnancy, seeking immediate medical attention is warranted.

Indications for hospitalization if required

Hospitalization is required for surgical management or in some when who have methotrexate and are in pain.

Suggested clinical specialists/ Departments to consult for this condition

Specialists from the Department of Gynaecology will attend to an Ectopic Pregnancy.