Any pregnancy that implants and develops outside of the endometrial cavity is called an ectopic pregnancy. There has been a fourfold increase in incidence over the last two decades but mortality has reduced by almost 80 per cent.
By Dr Shahshikala Hande
In a normal pregnancy, the fertilised egg implants and develops in the uterus. In most ectopic pregnancies, the egg settles in the fallopian tubes. This is why ectopic pregnancies are commonly called “tubal pregnancies”. In other words any pregnancy that implants and develops outside of the endometrial cavity is called an ectopic pregnancy. There has been a fourfold increase in incidence over the last two decades but mortality has reduced by almost 80 per cent.
When the ovary has released an egg into the fallopian tube, it stays there for about 24 hours. Once it comes in contact with a sperm, it gets fertilised. The fertilised egg remains in the fallopian tube for about three to four days and after that moves to the uterus. Once it is in the womb, it sticks or attaches itself to the uterus lining until the baby grows and is born. Nausea and vomiting with pain, sharp abdominal cramps, pain on one side of the body, dizziness or weakness, pain in the shoulder, neck or rectum are common symptoms of ectopic pregnancy.
What causes an ectopic pregnancy?
Increased prevalence of pelvic inflammatory disease
Contraception failure
Use of intrauterine device
Tubal reconstructive surgery
History of infertility
Assisted Reproductive Therapy (ART)
Endometriosis
Post tubectomy
Previous ectopic pregnancy
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Symptoms
An ectopic pregnancy takes place within the first few weeks of the pregnancy, mostly unknown to the mother. Signs of such a pregnancy are:
Amenorrhea and history of delayed period or history of vaginal spotting of blood
Pelvic pain
Vaginal bleeding
Vomiting, fainting attack
Extreme abdominal cramps
Pain on one side of the abdomen
Dizziness
Weakness
Shoulder pain
Neck pain
Pain in the rectum
An ectopic pregnancy might lead to fallopian tube rupture or damage. In such a case, there might be internal bleeding, the patient can go into shock and require urgent intervention.
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Diagnosis
A transvaginal ultrasound is the diagnostic tool of choice. TVS has a sensitivity of 87-99 per cent for diagnosing ectopic pregnancy. Sometimes even a TVS cannot diagnose an ectopic pregnancy in early stages and then serial ß-hCG levels may help in diagnosing a pregnancy but cannot determine its location. A combination of ß-hCG in blood and a sonography is used to diagnose ectopic pregnancies. In case of confusion, laparoscopy offers a benefit both in confirmation and removal of the pregnancy. If it is confirmed, the doctor shall guide the family regarding the best treatment to be taken depending upon the patient’s condition.
Treatment and management of an ectopic pregnancy
The type of treatment must be individualised depending upon the condition of the patient. A fertilised egg cannot survive outside the uterus, hence the matter needs to be addressed immediately, and medication or surgeries are the next option.
Treatments can be conservative, medical or surgical
Conservative or expectant management involves no immediate treatment and involves close monitoring of the patient. But this is an option only for clinically stable women with an ultrasound diagnosis of unruptured ectopic pregnancy and when ß-hCG level is initially less than 1500 IU/ L and decreasing.
Medical treatment involves giving the methotrexate injection when a clear diagnosis of unruptured ectopic pregnancy is made and viable intrauterine pregnancy has been excluded and ß-hCG level is between 1500 and 5000 IU/ L. These patients have to be monitored with serial Serum ß-hCG levels. When the patient is given methotrexate, she has to avoid pregnancy for three months in order to prevent subsequent foetal malformations.
If the patient does not respond, then surgical treatment is the option. Laparoscopy is preferred over open abdominal surgery. At the time of surgery, removing the tube with the pregnancy is preferred (salpingectomy). In women with a history of previous ectopic pregnancy with contralateral tubal damage, salpingotomy is performed where the tube is conserved and only the pregnancy is removed. However, there is a risk of persistent trophoblast and so serum ß-hCG levels should be checked to confirm complete resolution. They may require a methotrexate injection or even a salpingectomy. Early diagnosis is essential in saving a woman’s life. Adequate blood replacement and surgery is essential in reducing mortality. In case there is massive bleeding and damage in the fallopian tube, a procedure called laparotomy is performed wherein larger incisions are made as compared to a laparoscopy.
The chance of recurrence is approximately one in 10. Whenever a woman misses her period, a pregnancy test is mandatory by ß-hCG and a TVS to confirm IUP. This will help in diagnosing ectopic pregnancies early and timely intervention can save the woman’s life. The treatment of a pregnancy following an ectopic one should be a normal one. However, following the suggestions of the doctor with regards to when to try conceiving again is advised. The doctor may suggest a period of three to six months before trying again for a baby.
(The writer is Consultant – Obstetrician & Gynaecologist, Cloudnine Group of Hospitals, Bengaluru.)
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