What is Ectopic Pregnancy?

What is Ectopic Pregnancy?

Ectopic means “out of place.” In an ectopic pregnancy, the fertilized egg settles and grows in any location other than the inner lining of the uterus.  The majority of ectopic pregnancies occur in the fallopian tube (95%) that is why ectopic pregnancies are commonly called “tubal pregnancies”.  However, they can occur in other locations, such as the ovary, cervix, and abdominal cavity. The major health risk of this condition is internal bleeding. Although the survival rate from ectopic pregnancies is improving, the incidence is increasing. The major reason for a poor outcome is failure to seek early medical attention.

How does one know if she has ectopic pregnancy?
Symptoms of an ectopic pregnancy can often be vague, and include vaginal bleeding, abdominal or pelvic pain (usually more severe on one side), shoulder pain, weakness, or dizziness.  These symptoms can also occur in other conditions such as ovarian cysts, miscarriages, or even in normal pregnancy. Weakness, dizziness, and a sense of passing out upon standing can represent serious internal bleeding, thus, requiring immediate medical attention.

What are the risk factors?
The greatest risk factor for an ectopic pregnancy is a prior history of an ectopic pregnancy. The recurrence rate is 15 % after the first ectopic pregnancy, and 30 % after the second.

Infection in the pelvis is another leading cause. Pelvic infections are usually caused by sexually transmitted organisms, such as chlamydia or gonorrhea. However, non-sexually transmitted bacteria can also cause pelvic infections and increase the risk for ectopic pregnancy. Infection causes damage to the lining of the fallopian tubes resulting in damage and obstruction or scarring and partial blockage of the lumen of the tubes, thereby disrupting the transport of the fertilized egg into the uterus. The egg then settles into the fallopian tube without reaching the uterus, thus, becoming an ectopic pregnancy.

Like pelvic infections, conditions such as endometriosis, myoma, or pelvic scar tissue (pelvic adhesions), can cause narrowing of the lumen and kinking of the fallopian tube which disrupts egg transport resulting in ectopic pregnancy.

Prior surgeries involving the fallopian tubes or other pelvic organs are other risk factors.  In their desire to conceive, some women undergo surgery to repair damaged fallopian tubes or to reverse prior tubal ligation. Any such procedure increases the risk for ectopic pregnancy.

Approximately 50% of pregnancies in women using intrauterine devices (IUDs) will be located outside of the uterus. However, the number of women becoming pregnant while using IUDs is extremely low, therefore the overall risk of ectopic pregnancies related to it is very low.

An increased incidence of ectopic pregnancy has also been reported with the use of progestin – only oral contraceptives; after using “morning after pill” (high dose estrogen pill used during mid cycle to prevent pregnancy).

What happens when you have ectopic pregnancy?
Normally, the inner lining of the fallopian tubes are coated with small hair – like projections called cilia. These cilia are important to transport the egg smoothly from the ovary through the fallopian tube, and once fertilized into the uterus.  If these cilia are damaged (by infection or prior surgery), egg transport becomes disrupted. The egg then settles in the fallopian tube without reaching the uterus, thus, becoming an ectopic pregnancy. The egg can also implant in the ovary, abdomen, or the cervix. None of these areas has as much space or nurturing tissue as the uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it, resulting in severe internal bleeding that endangers the mother's life.  A classical ectopic pregnancy never develops into a live birth.

How is ectopic pregnancy diagnosed?
When / Who do you consult?
The first step in the diagnosis is an interview and examination by the doctor. If you arrive in the emergency room complaining of abdominal pain, you will likely be given a urine pregnancy test. This test can easily determine if you are pregnant, and speed can be crucial in treating ectopic pregnancy.  A referral to an obstetrician follows.  The obstetrician, after a brief interview, does the pelvic examination to locate the areas causing pain, to check for any enlarged, pregnant uterus,  or to find any masses in your abdomen.  You will probably also have an ultrasound examination, which will show whether the uterus contains the developing fetus or if masses are present elsewhere in the abdominal area which may represent the ectopic pregnancy. Even with the best equipment, it is difficult to see pregnancy especially those less than 6 weeks.  If the obstetrician cannot diagnose ectopic pregnancy but cannot rule it out as well, he/she may ask you for a serial blood test to determine the levels of the hormone human chorionic
gonadotropin (â – hCG). This hormone appears in the blood and urine as early as 10 days after conception, and its levels double every 2 days for the first 10 weeks of pregnancy. If the â – hCG levels are lower than expected for your stage of pregnancy, the obstetrician is one step closer to diagnosing ectopic pregnancy.  A repeat ultrasound may likewise be requested. A pulsed Doppler ultrasound may also be done to confirm the diagnosis by demonstrating the characteristic ring – of – fire and a high-velocity low-impedance blood flow pattern along the periphery of the ectopic pregnancy.

What is the health risk of an ectopic pregnancy?
Some women spontaneously absorb their ectopic pregnancy with no apparent ill effects, and can be observed without treatment.  The most feared complication of an ectopic pregnancy is internal bleeding, causing pelvic and abdominal pain, shock, and even death. Therefore, bleeding in an ectopic pregnancy may require immediate surgical attention. Internal bleeding results from the rupture of the fallopian tube, or from blood leaking from the end of the tube as the growing placenta penetrates the wall of the fallopian tube.  Blood coming from the tube irritates other tissues and organs in the pelvis and abdomen resulting in significant pain.

What are the available treatment options?
Treatment options for ectopic pregnancy include observation, laparoscopy, laparotomy, and medication.  Selection of these options is individualized.  Some ectopic pregnancies will resolve on their own without the need for any intervention, while others will need urgent surgery due to life – threatening bleeding.

For those who require intervention, the most common treatment is surgery.  Two surgical options are available: laparotomy and laparoscopy.  Laparotomy is an open procedure whereby an incision is made across the lower abdomen.  Laparoscopy involves inserting viewing instruments into the pelvis through tiny incisions in the skin.

Some patients can be monitored by their symptoms and blood levels of â – hCG hormone without surgical intervention.  Changes in the hormone level can signal a spontaneous resolution of the pregnancy.  This approach requires very close communication with the obstetrician so that should problems occur, intervention can be prompt.

Another treatment method involves the use of an anti – cancer drug called methotrexate. This drug acts by killing the cells of the placenta, thereby inducing miscarriage of the ectopic pregnancy.  Some patients may not respond to methotrexate, and will require surgical treatment.

In The Medical City, what are the related services available?
The different laboratory tests that evaluate the blood picture of the patient (hemoglobin, hematocrit, and leukocyte count), including the hormone human chorionic gonadotropin assays (urine and serum), are all being offered at The Medical City. The Women's Health Care Center is equipped with OB-GYN sonologists who are competent in diagnosing ectopic pregnancy using the gray scale and the pulsed Doppler ultrasound.  Treatment options, namely laparotomy and laparoscopy are readily available once deemed necessary by the clinician to be performed immediately on the patient. Furthermore, the department of OB – GYN includes consultant staff with subspecialty training in the use of methotrexate (on selected patients) as a treatment alternative for ectopic pregnancy.

Note:   This information is not intended to be used as a substitute for professional medical advise, diagnosis or treatment.   If you or someone you know have any of the symptoms mentioned above, it is advisable to seek professional help.

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