Ectopic Pregnancy

09Jan, 2023

Ectopic Pregnancy

What is an ectopic pregnancy?

An ectopic pregnancy is when a pregnancy starts to grow outside the uterus (womb) (Ectopic-misplaced) It could occur in the uterine tube, ovary, the mouth of the uterus (cervix) and rarely, in the abdominal cavity; which is of course abnormal.

Why is an ectopic pregnancy abnormal?

Normally, the sperm and egg fuse in the uterine tube and after fertilization form the zygote (the fertilized egg) which moves into the uterus and implants there. The pregnancy can grow and develop as the uterus has the capacity to enlarge greatly as the pregnancy progresses. However if the egg gets implanted in other places or even stuck within the tube which has no capacity to expand as pregnancy progresses, then the tube stretched and finally ruptures resulting in a catastrophe.

How is an Ectopic pregnancy diagnosed?

Most often, the symptoms appear about 5-6 weeks after the last normal period. The symptoms are very varied and may vary from abnormal, irregular bleeding over several days to sudden collapse without any warning symptoms. Some women may have absolutely no symptoms and only an alert obstetrician can pick up the ectopic before any untoward event.

What are the symptoms of an ectopic pregnancy?

Abnormal bleeding, pain lower abdomen and sudden collapse are the common symptoms.

What is an abnormal bleeding?

The expected period may be missed or it may be light. Some women may have an almost normal period, which is then followed by bleeding after a few days. There may be spotting over several days, without missing a period at all. Women who usually have delayed cycles may be unaware that they could be pregnant, attributing the delayed period as a usual occurrence for them.

What is the nature of pain in ectopic pregnancy?

Pain may not be a feature initially. It can come on suddenly or may be present in the lower abdomen over several days. Sudden pain may be associated with giddiness. Lower abdominal pain could be one sided or generalized.

Also, blood leaking from the ruptured tube into the abdomen can be an irritant and cause referred pain on the shoulder tip. This pain may worsen on lying down and may not be relieved with painkillers.

What are other symptoms of an ectopic pregnancy?

Diarrhoea or difficulty in moving bowels can occur. Nausea and vomiting can also exist.

An ectopic pregnancy is a serious health risk, which must be treated as an emergency. Any of the above symptoms must prompt the woman to seek medical help immediately.

Who is at an increased risk of ectopic pregnancy?

The following women are at a higher risk of ectopic:

  • 1) Women who had a previous ectopic pregnancy
  • 2) Women with a damaged fallopian tube which is often due to previous surgery on the fallopian tubes (includes tubectomy- sterilization operation)
  • 3) Previous pelvic infection.
  • 4) Pregnancy with an existing intrauterine contraceptive device (Copper-T/ IUD)
  • 5) Patients on progesterone –only contraceptive pills (mini-pill)
  • 6) Pregnancy after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) pregnancy (Test-tube baby)
  • 7) Women over 40 years old or those who smoke.

How is an ectopic pregnancy diagnosed?

Though the symptoms may be vague, an alert medical person always has her/his ante up for the possibility of an ectopic pregnancy. Medical history and examination (may include internal examination) and a positive urine pregnancy test indicate a probable diagnosis of an ectopic pregnancy. A transvaginal scan (where a probe is gently inserted into vagina) to look at the uterus, ovaries and fallopian tubes often clinches the diagnosis.

Sometimes, when the diagnosis is not too obvious, blood tests for human chorionic gonadotrophin hormone (hCG) and/or progesterone may be done, even serially.

If the diagnosis is still unclear, an operation called a laparoscopy (button hole/key hole surgery) may be necessary. This operation is done under anaesthesia. If an ectopic pregnancy is detected, treatment may take place during the same operation.

What are the options for treatment?

As an ectopic pregnancy cannot result in the birth of a baby, all available options aim to end the pregnancy. The options depend on duration of pregnancy, symptoms and general condition of the woman, scan findings, hCG values and amount of bleeding inside the abdomen. Also, the preferences of the woman, her future fertility plans and an informed consent is necessary before deciding on the modalities of treatment.

What are the possible treatment options for an ectopic pregnancy?

The options that are available are Expectant management, medical management and surgical management.

What is Expectant management?

Expectant management implies a policy of wait and watch. If the pregnancy in tube has not ruptured it, it could simply resolve or abort completely within the abdominal cavity. Such situations are not potentially harmful. If the woman is compliant and follows her doctor’s instructions, she could be managed with watchful expectancy, with intentions to interfere only if necessary.

Expectant management is not an option for all women. The attending gynaecologist must assess the patient, symptoms and reports before deciding whether the expectant management can be offered.

Women undergoing expectant management may require additional medical or surgical management during their course of observation.

What is Medical management?

Again, after proper evaluation, some women may be offered medication to treat the ectopic pregnancy. Methotrexate (an anti-cancer drug) has been used to prevent the ectopic from growing and allows gradual resolution.

This management also requires stringent supervision and serial evaluation with hCG and vaginal scans. Admission for a 1-3 days and regular follow up as advised thereafter is mandatory for this management to be successful.

What is the Surgical management?

AThe aim of surgery is to remove the ectopic pregnancy. This can be achieved by either laparoscopy (key hole surgery) or laparotomy (Open surgery through a larger cut in the lower abdomen.)

Laparoscopy is done when the woman’s general condition is favourable and laparotomy when the internal bleeding is suspected to be very heavy and her condition is unstable.

To have the best chance of a future pregnancy inside the uterus, and to reduce the risk of having another ectopic pregnancy, the fallopian tube removed may need removal (Salpingectomy).

However, if there is only a single tube or if the other tube is unhealthy and hopelessly damaged, then the future fertility of the woman is greatly affected. In such situations, various types of operations are done to try to retain the tube. This type of operation depends on the woman’s desire for future fertility and the findings at surgery.

Salpingotomy (tube conserving surgery) is done in such cases. Salpingotomy aims to remove the pregnancy within, without removing the tube. However, it carries a higher risk of a future ectopic in the same tube.

What is the risk in surgical management of ectopic?

Surgery is often done under general anaesthesia and at times under spinal anaesthesia. Apart from the risks of a ruptured ectopic itself, the anaesthetic risk is also present. The individual risks are discussed by the surgeon and the anaesthetist prior to surgery.

What about future pregnancies?

For most women, an ectopic pregnancy is an isolated chance happening and the possibility of having a successful pregnancy in future is high. There is only a small reduction in the chance of conceiving even with only one tube present.

However, the chance of a repeat ectopic pregnancy is 7-10% and depends on the type of previous surgery and that of the existing tube.

In a future pregnancy, an ultrasound scan at 6 to 8 weeks can confirm a healthy intrauterine pregnancy (pregnancy inside the uterus)

If however, the woman does not plan for a future pregnancy, she is offered the appropriate contraception.

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