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Ectopic Pregnancy: causes and treatment
An ectopic pregnancy (also called a tubal
pregnancy) occurs when
a fertilized egg is implanted outside the uterus, typically in one of the
Fallopian tubes. Sometimes the embryo can also occur in the cervical canal, one
of the ovaries or the pelvic or abdominal cavity (abdominal pregnancy).
Once conception occurs, the fertilized egg usually takes about four to five days
to travel down the tube from the ovary to the uterus. If the tube is damaged or
blocked, or fails to propel the egg toward the uterus, the egg may become
implanted in the wall of the tube and continue to develop there. Occasionally it
may implant in another part of the abdomen, in an ovary, or in the cervix. If an
ectopic pregnancy is not recognized and treated in time, the embryo will grow
until it causes the tube to rupture, resulting in severe abdominal pain,
bleeding, and sometimes even death.
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Pelvic inflammatory disease (PID), gonorrhea, or
chlamydia (which may be
symptomless) - Rate of ectopic pregnancy in women with previous known PID is
increased 6-10 times higher than in women with no previous history of PID. A
published study of 745 women with one or more episodes of PID that attempted to
conceive showed that 16% were infertile from tubal occlusion. Of those that
conceived, 6.4% had ectopic pregnancies.
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You've had a previous ectopic pregnancy
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You have an
intrauterine device (IUD) in place when you get pregnant. (IUDs are
about 99 percent effective at preventing pregnancy, but if you do get pregnant
while using one, the pregnancy is likely to be ectopic. Having used an IUD in
the past will not increase your risk for ectopic pregnancy.)
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Your tubes were damaged by a previous infection or surgery.
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You're being evaluated or treated for
infertility. (Infertility is often caused
by damaged tubes, and if you get pregnant while being treated for infertility,
there's a higher than average chance that the pregnancy will be ectopic.)
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You've had previous pelvic or abdominal surgery, such as the removal of an
ovarian cyst or fibroids, an appendectomy, or a
cesarean section.
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A few studies suggest you may also have a slightly increased risk for ectopic
pregnancy if you smoke cigarettes or douche regularly.
Ectopic pregnancies are most commonly discovered at six or seven weeks but
may be found as early as four weeks.
Common symptoms of ectopic pregnancy are sharp abdominal cramps or pains on
one side. The pains may start out as a dull ache that gets more severe with
time. Neck pains and shoulder pains are also common. While cramping and bleeding
can mean many things, pain in the shoulder, particularly when you lie down, is
specifically characteristic of a ruptured ectopic pregnancy. The pain is caused
by internal bleeding that irritates nerves that happen to go to the shoulders,
but may not be felt in all cases. You may also have a menstrual type of bleeding
along with the pain, but the pain is the most obvious sign.
If the ectopic is ruptured, you may also have signs of shock like a weak,
racing pulse; pale, clammy skin; and dizziness or fainting. You'll need to get
medical attention right away.
Ectopic pregnancy can be tricky to diagnose. If a woman tests positive for
pregnancy ( hCG levels test ), or has missed her period but the uterus does not
display the typical signs associated with pregnancy, an ectopic pregnancy is
suspected. An ultrasound scan can be useful in identifying that the uterus is
indeed empty and that blood has accumulated in the pelvic or abdominal cavity. A
culdocentesis may also be then performed to confirm a diagnosis of an ectopic
pregnancy. A laparoscope may also be employed to directly view the ectopic
pregnancy.
If the pregnancy is clearly ectopic and the embryo is still relatively
small, you may be given the drug methotrexate. This is the best way to terminate
the pregnancy without damaging your tube. The drug is injected into a muscle and
reaches the embryo through your bloodstream, killing the cells that are building
the placenta and causing the embryo to be reabsorbed into your body, as it would
be if you had a miscarriage. You may feel some cramping during this process as
the embryo swells. You may bleed for a week or two afterward as you shed the
lining of your uterus, which should feel like a regular menstrual period. You'll
need to come back in for blood testing to make sure that the pregnancy has
really been terminated.
If the embryo is too large for methotrexate to be used or you're in severe pain
or bleeding internally, you'll need surgery. The possible procedures for ectopic
pregnancy can all be done by laparoscopy (same day surgery) or by laparotomy
(bigger incision).
Different Procedures used:
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Salpingotomy (or -ostomy): Making an incision on the tube and
removing the pregnancy.
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Salpingectomy: Cutting the tube out.
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Segmental resection: Cutting out the affected portion of the
tube.
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Fimbrial expression: "Milking" the pregnancy out the end of the
tube.
In general, the procedure of choice will be salpingectomy if future
fertility is of no concern, if the tube is ruptured, if there is significant
anatomic distortion, or if there is overt hemorrhage.
Abdominal Surgery- In this case, you'll be given general anesthesia and a
surgeon will open your abdomen and remove the embryo as well as the ruptured
tube, if necessary. You may need a blood transfusion to replace lost blood if
you were bleeding heavily before surgery. Afterward, you'll need about six weeks
to recuperate. You may feel bloated, and have sore breasts and abdominal pain or
discomfort as you heal.
Overall, your chances of having another ectopic pregnancy are about 10
percent, depending on what caused the first one and what type of treatment you
had. That means that your chances of having a normal pregnancy next time are
still very high — at least 90 percent. If your first ectopic pregnancy was the
result of damage to the tube from an infection, tubal ligation, or DES exposure,
there's a greater chance that the other tube is damaged as well.
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