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ECTOPIC PREGNANCY
Ectopic pregnancy is a serious complication of pregnancy that can result in maternal death. It is a condition where a pregnancy develops outside of its normal position within the uterus, such as in the fallopian tube. Approximately 1 in 60 pregnancies results in ectopic pregnancy. About 9% of pregnancy-related deaths are related to ectopic pregnancy.
Q. What is an ectopic pregnancy?
A. The normal site of a pregnancy is inside the uterus. When a woman becomes pregnant, the fertilized egg travels through the fallopian tube and progresses into the uterus. If the fallopian tube is damaged or the contractions of the fallopian (which allows for progression of the egg through the tube) are inadequate, the fertilized egg may get stuck in the fallopian tube and cause an ectopic pregnancy.
An ectopic pregnancy can be a life threatening condition. The fallopian tube is small, thin, and has a constricted area in which the pregnancy can grow. If an ectopic pregnancy is undiagnosed, the growing embryo could burst through your fallopian tube. If this happens, you will bleed internally and this may ultimately lead to death.
Q. Who is at risk of having an ectopic pregnancy?
A. There are several risk factors associated with ectopic pregnancy. Anything that may have caused prior tubal damage, which may obstruct flow of the egg through the fallopian tube, would increase the risk of having an ectopic pregnancy. Some of the common conditions associated with an increased risk of ectopic pregnancy include a history of pelvic inflammatory disease (PID). The inflammation that accompanies this pelvic infection can lead to permanent scarring of the fallopian tubes. A prior history of ectopic pregnancy will increase risk of a subsequent ectopic pregnancy. The reason? Whatever caused the first ectopic pregnancy is most likely still present. Women with a prior history of ectopic pregnancy that has been surgically corrected have a 15% risk of subsequent ectopic pregnancy. History of infertility is associated with an increased risk of ectopic pregnancy. Whenever a patient is seeing a physician for infertility and pregnancy ensues, she should be evaluated for the location of the pregnancy. Any pelvic surgeries will put you at risk of an ectopic pregnancy due to the risk of adhesions or scar tissue from the surgery. Of specific concern is a prior history of a ruptured appendix with which there is often significant inflammation and scarring. Finally, a patient with a history of a prior tubal ligation or the use of progesterone contraceptives such as the Norplant implants is at increased risk of ectopic pregnancy should she become pregnant while using these methods.
Q. How is an ectopic pregnancy diagnosed?
A. There are several signs and symptoms of an ectopic pregnancy that may be helpful in making an early diagnosis. Women with abdominal cramping and vaginal bleeding early in pregnancy should be suspected of having an ectopic pregnancy until proven otherwise. Therefore, if you have the abovementioned symptoms, contact your physician immediately. If you notice severe abdominal pain, shoulder pain (which can be referred pain if you have an ectopic pregnancy that has already burst through the tube), or experience dizziness and fainting, contact your physician immediately and go to the nearest emergency room.
Your physician will run several tests to diagnose an ectopic pregnancy. Initially he or she will confirm pregnancy with a pregnancy test. He or she may then order certain other blood tests, including a quantitative human chorionic gonadotropin level (hCG), which is a measure of the amount of this hormone in your blood. Your physician may measure several of these hormone levels at 48-hour intervals. Your physician is looking for the increase in this hormone level that is normally seen in pregnancy. If the level does not increase normally, you may have an ectopic pregnancy.
Your physician may also order ultrasound studies to determine if you have an ectopic pregnancy. By approximately 5 to 6 weeks, the radiologist should be able to see your pregnancy on ultrasound evaluation. Certain findings are expected on ultrasound examination based on hCG levels. To get the most accurate ultrasound evaluation, your physician/radiologist may need to do the ultrasound evaluation through your vagina (known as a transvaginal ultrasound).
With the above information, your physician may be able to diagnose an ectopic pregnancy. If it is still unclear after the above tests, and especially if you are still having pain, your physician may need to do surgery to further diagnose (and sometimes to treat) your problem. He or she may suggest a dilitation and curettage (where the intrauterine contents are scraped out and sent to the pathologist) to determine if you are having a miscarriage rather than an ectopic pregnancy. The physician may suggest laparoscopy. A small incision is made under your navel and a small camera is placed within the abdomen. This allows your physician to directly examine your fallopian tubes.
Q. How is an ectopic pregnancy treated?
A. Once you have been diagnosed with an ectopic pregnancy, there are several treatment options that may be recommended by your physician. There are both medical (drug therapy) options and surgical options for the treatment of ectopic pregnancy. Regardless of what type of treatment you and your doctor choose, the most important thing to remember is that some form of treatment must undertaken.
Your physician may recommend drug treatment of the ectopic pregnancy with methotrexate. This medicine is normally used to treat cancer and arthritis. The dose will be much lower than that used to treat cancer, therefore there will be very few side effects. This medicine is administered by injection and works by preventing cell division. Your physician will then closely follow your hormone levels to make sure that the pregnancy is resolving. If the levels do not decrease appropriately, you may need a second injection or surgery.
If you do not meet the criteria for methotrexate, your physician may recommend surgery to treat your ectopic pregnancy. Two approaches to surgery can be used depending on the seriousness of the situation, and whether your ectopic has already burst through the tube. The first option is laparoscopy, where a small incision is made under your navel and a small light inserted into your abdomen. Your fallopian tube can then be examined. Your physician will then make a few other small incisions lower on your abdomen through which he or she can insert instruments. The physician will then be able to either remove the ectopic pregnancy by making an incision on the fallopian tube, or remove the entire fallopian tube.
The second surgical approach is called a laparotomy. This involves making a larger incision lower on your abdomen and removing the ectopic pregnancy or fallopian tube. If your ectopic pregnancy has already ruptured (burst through the tube) this will be the quickest way to remove your fallopian tube and stop the bleeding.
After surgery, you will be monitored closely by your physician, and if only the ectopic pregnancy was removed, hormone levels will be followed to make sure that all of the pregnancy was removed.
Subsequent Pregnancies
Should you decide to get pregnant in the future, it is imperative that you consult a physician as soon as you get a positive pregnancy test. The risk of subsequent ectopic pregnancy is significantly higher after you have already had one.
Thomas G. Stovall, M.D.
Dr. Stovall is a Clinical Professor of Obstetrics and Gynecology at the University of Tennessee Health Science Center in Memphis, Tennessee and Partner of Women's Health Specialists, Inc.
Date Published: 2004-03-05
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