Ectopic Pregnancy

What is an ectopic pregnancy?
Ectopic pregnancy is any pregnancy that occurs outside the uterus. The vast majorities (95%) of these are in the fallopian tubes. Other possibilities are the ovary, cervix, or abdominal cavity. It occurs in about 1 out of 200 pregnancies. It is very serious because when the pregnancy grows in these abnormal areas, it can easily cause massive, rapid bleeding, which can result in a decrease in fertility and even death.

What causes ectopic pregnancy?
Usually, some sort of anatomical problem exists which traps the fertilized egg in the tube. Pelvic Inflammatory Disease (PID), which leads to scarring of the tubes, is the most common cause, comprising about 30%-50% of all ectopics. Pelvic infections include chlamydia and gonorrhea.

There are a number of other factors that will put a woman at risk for an ectopic. These factors include:

a) Congenital anatomical abnormalities
b) Tumors or cysts in the tubes
c) Fibroids in the uterus, which block the tube's entrance into the uterus
d) Endometriosis
e) Scar tissue from outside the tube, which causes constriction on the tube. This may be caused by other problems or surgery in the abdomen or pelvis, such as appendicitis
f) Previous tubal surgery: previous ectopic, tubal ligation, tubal rejoining
g) Delayed passage of the conceptus to the uterus. The conceptus may be fertilized in one tube but cause an ectopic in the opposite tube because it reaches that tube via passage through the abdominal cavity or through the uterus and back across into the other tube. Because of the increased amount of time required to travel these lenths, the conceptus becomes too big to complete its roundabout trip to the uterus.
h) Current use of progestin-only oral contraceptives
I) Infertility treatment

While there is a higher percentage of ectopic pregnancy in IUD users, the IUD does not cause ectopic pregnancies. Rather, it functions to prevent uterine pregnancies, so the only ones that can result are ectopic. The same sort of relationship exists between the use of emergency contraceptives and ectopic pregnancy. This type of contraception prevents implantation of the fertilized egg in the uterus; therefore, only ectopic pregnancies can result. Three weeks after a woman takes an emergency contraceptive, she should see her doctor for a follow-up so that, if she does develop an ectopic, it can be caught early.

Early Symptoms
Here are the common symptoms that a woman may experience early in an ectopic pregnancy:

a) Abdominal pain (especially one-sided and/or low)
b) Late or missed period (although a woman can start experiencing the symptoms of the ectopic before she misses a period)
c) Vaginal bleeding
d) Tissue passage from the vagina (the woman should try to save any passed tissue so the doctor can analyze it)
e) Pregnancy symptoms

Late Symptoms
These are the symptoms that a woman may experience as her ectopic pregnancy continues to develop into a larger embryo and causes bleeding or rupture:

a) Dizziness and fainting (because of the loss of blood)
b) Shoulder pain (the blood irritates the diaphragm; the diaphragms nerves are felt in the shoulder)
c) Weakness
d) Heart racing
e) Bloated and hard abdomen

The woman should not wait until she notices these late symptoms to go to the emergency room. The importance of calling her doctor right away after noticing the early symptoms cannot be stressed enough. Early detection of an ectopic is imperative for saving a woman's fertility and her life. The treatments are more effective when used early on in the pregnancy.

In the Emergency Room
Here are the tests that the woman will have when she gets to the emergency room:

a) Urine pregnancy test (a blood test will have to be done if it is too early to be detected through the urine)
b) Transvaginal ultrasound
c) Pelvic exam

The doctor will also perform many other tests in order to make sure it is an ectopic instead of one of many other conditions that present the same types of symptoms.

Treatments for Ectopic Pregnancy
The options for treatment depend largely on how developed the embryo is when the woman goes in for treatment, as the size of the embryo is a main factor for determining treatment-type. An ectopic pregnancy starts out in the unruptured state, which is when the mass is still small enough to fit in the fallopian tube. However, if left untreated for too long, the mass will continue to grow until it eventually gets so large that it will rupture the tube. All these treatments are forms of abortion. A woman's chances of survival if she does not abort are very, very slim.

Medical Treatment
If the pregnancy is discovered in the unruptured state and the patient is stable (no major bleeding problems), a drug called methotrexate can be used if the mass is less than 3.5 cm in diameter. This drug cannot be used if the embryo is too developed because it works by preventing the rapid division of cells in the early embryo; the embryo is then reabsorbed. Methotrexate can either be injected by means of a shot, IV, or transvaginally into the fallopian tube. Either single or multiple doses can be used. Side effects of methotrexate use are very minimal, including nausea and fatigue. Contraindications to the use of methotrexate include:

a) active lung disease
b) cardiac problems
c) pelvic pain
d) early indications of shock
e) white blood cell count less than 3,000

Surgical Treatment
If the mass is greater than 3.5 cm and the woman is experiencing signs of blood loss and shock, surgical treatment will be required. This procedure is usually done laparoscopically, which takes 60 minutes on average (although it can range from 13-240 minutes). There are 2 different types that can be performed:

Salpingostomy: this conservative procedure involves removal of the part of the fallopian tube that contains the conceptus. It is done to maximize the preservation of the tube for subsequent fertility. The 2 ends of the cut tube are rejoined after healing has taken place. The woman should be informed that rejoining the tubes results in a decreased fertility and thus a higher rate of recurrent ectopic pregnancy.
Salpingectomy: this procedure involves the removal of the whole fallopian tube on the side where the ectopic occurred. It is done if conservative surgery is not possible, like when the tube is damaged or deformed. This procedure decreases fertility even more than salpingostomy; there is the chance of subsequent ectopic pregnancy, but not as much as with salpingostomy. It is important to understand that this surgery itself does not cause more ectopics. It is simply that women who had an ectopic because of one abnormal tube are more likely to have the same abnormality in the other tube, and thus more chance of an ectopic.

The goal of treatment is to use the least invasive method that has the highest success rate and will preserve the woman's subsequent fertility. Here is a table that provides some useful information regarding the success rates and benefits of methotrexate versus laparoscopy.

TreatmentSuccess RatePost-op stayTime for HCG back to normalSubsequent pregnancy ratesFertility Differences
Methotrexate 88.2% 24 hours29 days 50-79%Use of methotrexate results in lower rate of repeat ectopic pregnancy
Laparoscopy (salpingotomy 95.9% 46 hours13 days 50-85% 
How will this affect my fertility?
Here are some statistics that are useful for a woman to know following an ectopic pregnancy:

a) Chance of subsequent pregnancy: 50%
b) Chance of another ectopic: 15%
c) Chance of spontaneous abortion during next pregnancy: 15-20%

There are some factors that will decrease a womans chance of getting pregnant again following an ectopic pregnancy, including:

a) Over age 35
b) Previous problems with fertility

Women who cannot get pregnant again after an ectopic pregnancy should try using various fertility techniques, such as in vitro fertilization.

After an Ectopic
After a woman has an ectopic pregnancy, her HCG (human chorionic gonadotropin) levels need to be monitored. She will need to have her levels checked 48 hours after her treatment and then once a week until they go back to being negative. The woman does not need to make a separate doctor's appointment for each of these tests; usually, she can simply walk into the doctor's office in the morning to get her blood tested. If these levels do not become negative, surgery or additional methotrexate treatment will be required. The woman will also need to use contraception for at least 3 months after her ectopic to allow the fallopian tubes time to heal (unless her tube was removed altogether). The next time she does miss a period, she needs to see a doctor right away to make sure it is not another ectopic. Her doctor will measure HCG levels and perform an ultrasound.

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