What is ectopic pregnancy, symptoms, screening, risk, treatment?

What is ectopic pregnancy, symptoms, screening, risk, treatment?

An ectopic pregnancy is a pregnancy that happens outside of your uterus. This occurs when a fertilized egg i.e.  embryo implants in a location that can’t support its growth. An ectopic pregnancy most often happens in your fallopian tube (a structure that connects your ovaries and uterus). Ectopic pregnancies more rarely can occur in your ovary, abdominal cavity or cervix. Pregnancies can’t continue if they’re ectopic because only the uterus is meant to carry a pregnancy. 90% of ectopic pregnancies happen in the fallopian tubes. Abdominal pregnancies are the rarest.

Physiology of fertilization: 

Normally after sexual contact the sperms traverse the vagina and the uterine cavity and then the fallopian tube. In the fallopian tube they wait for 24 hours for the egg to come which generally happens in the mid cycle after ovulation. The egg is released from the ovary and caught by the finger like projections of the fallopian tube, and it’s here that the fertilization of egg and sperm takes place. After fertilization the embryo divides rapidly and by the peristaltic movements of the tube it’s pushed towards the uterine cavity traversing through a very narrow opening called uterine Ostia. After it reaches the cavity implantation occurs inside the uterine cavity near 21st day of the cycle. This normal physiological mechanism may get disrupted if the tube is blocked partially thus allowing only the sperms to pass but not the embryo which is bigger than sperm. This leads to implantation of the embryo inside the tube itself. Since the tube was not designed to hold a pregnancy, it bursts if the pregnancy starts increasing in size. 

The commonest cause of tubal blockage is Pelvic inflammatory disease caused by bacterial infections, commonest being tuberculosis

Sexually transmitted disease can also cause tubal blockage due to fibrosis of tubes

Symptoms:

Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks of pregnancy. Some women don't have any symptoms at first. They may not find out they have an ectopic pregnancy until an early scan shows the problem or they develop more serious symptoms later on.

Main symptoms

You may have an ectopic pregnancy if you miss a period, have a positive pregnancy test, and have other signs of pregnancy.

Vaginal bleeding: Vaginal bleeding tends to be a bit different to your regular period. It often starts and stops, and may be watery and dark brown in color. Some women mistake this bleeding for a regular period and don't realize they're pregnant. Vaginal bleeding during pregnancy is relatively common and isn't necessarily a sign of a serious problem, but you should seek medical advice if you experience it.

Tummy pain: You may experience tummy pain, typically low down on one side. It can develop suddenly or gradually, and may be persistent or come and go. Tummy pain can have lots of causes, including stomach bugs and trapped wind, so it doesn't necessarily mean you have an ectopic pregnancy.

Shoulder tip pain: Shoulder tip pain is an unusual pain felt where your shoulder ends and your arm begins. It's not known exactly why it occurs, but it can be a sign of an ectopic pregnancy causing some internal bleeding, so you should get medical advice right away if you experience it.

Discomfort when going to the toilet: You may experience pain or pressure in your bottom when going for a poo pain when going for a pee

Diarrhea: Some changes to your normal bladder and bowel patterns are normal during pregnancy, and these symptoms can be caused by urinary tract infections and stomach bugs. But it's still a good idea to seek medical advice if you experience these symptoms and think you might be pregnant.

Symptoms of a rupture:

In a few cases, an ectopic pregnancy can grow large enough to split open the fallopian tube. This is known as a rupture. Ruptures are very serious, and surgery to repair the fallopian tube needs to be carried out as soon as possible.

Signs of a rupture include a combination of a sharp, sudden and intense pain in your tummy feeling very dizzy or fainting, feeling sick

Diagnosis

It can be difficult to diagnose an ectopic pregnancy from the symptoms alone, as they can be similar to other conditions. If you have the symptoms of an ectopic pregnancy and a positive pregnancy test, you may be referred to an early pregnancy assessment service for further testing.

Some of the tests you may have include:

•  vaginal ultrasound
• blood tests
• keyhole surgery

Vaginal ultrasound:

An ectopic pregnancy is usually diagnosed by carrying out a transvaginal ultrasound scan. This involves inserting a small probe into your vagina. The probe is so small that it's easy to insert and you won't need a local anesthetic. The probe emits sound waves that bounce back to create a close-up image of your reproductive system on a monitor. This will often show whether a fertilized egg has become implanted in one of your fallopian tubes, although occasionally it may be very difficult to spot.

Blood tests: Blood tests to measure the pregnancy hormone human chorionic gonadotropin (hCG) may also be carried out twice, 48 hours apart, to see how the level changes over time. This can be a useful way of identifying ectopic pregnancies that aren't found during an ultrasound scan, as the level of hCG tends to be lower and rise more slowly over time than in a normal pregnancy. The results of the test can also be useful in determining the best treatment for an ectopic pregnancy.

Keyhole surgery or diagnostic laparoscopy:

If it's still not clear whether you have an ectopic pregnancy or the location of the pregnancy is unknown, a laparoscopy may be carried out. This is a type of keyhole surgery carried out under general anaesthetic (where you're asleep) that involves making a small cut (incision) in your tummy and inserting a viewing tube called a laparoscope.

Your doctor uses the laparoscope to examine the womb and fallopian tubes directly.

If an ectopic pregnancy is found during the procedure, small surgical instruments may be used to remove it to avoid the possible need for a second operation later on.

Risk factors: 

There are several risk factors that could increase your chance of developing an ectopic pregnancy. You may be at a higher risk of developing an ectopic pregnancy if you’ve had:

• A previous ectopic pregnancy: A history of pelvic inflammatory disease (PID), an infection that can cause scar tissue to form in your fallopian tubes, uterus, ovaries and cervix.

   

• Surgery on your fallopian tubes (including tubal ligation) or on the other organs of your pelvic area.

• A history of infertility.

   

• Treatment for infertility with in vitro fertilization (IVF).

• Endometriosis.

• Sexually transmitted infections (STIs).

• An IUD in place at the time of conception.

• A history of smoking tobacco.

If you realize that you’re pregnant and have an IUD (intrauterine device) in place, or have a history of a tubal ligation (having your tubes tied), contact your healthcare provider right away. Ectopic pregnancy is more common in these situations.

Your risk can also increase with age. Women over age 35 have a higher risk than those under 35.

Up to 50% of women who experience an ectopic pregnancy don’t have any of the above risk factors.

Treatment:

Unfortunately, the foetus (the developing embryo) cannot be saved in an ectopic pregnancy. Treatment is usually needed to remove the pregnancy before it grows too large.

The main treatment options are:

• expectant management – your condition is carefully monitored to see whether treatment is necessary
• medicine – a medicine called methotrexate is used to stop the pregnancy growing
• surgery – surgery is used to remove the pregnancy, usually along with the affected fallopian tube

These options each have advantages and disadvantages that your doctor will discuss with you.

They'll recommend what they think is the most suitable option for you, depending on factors such as your symptoms, the size of the foetus, and the level of pregnancy hormone (human chorionic gonadotropin, or hCG) in your blood.

Expectant management

If you have no symptoms or mild symptoms and the pregnancy is very small or can't be found, you may only need to be closely monitored, as there's a good chance the pregnancy will dissolve by itself.

This is known as expectant management.

The following is likely to happen: 

You'll have regular blood tests to check that the level of hCG in your blood is going down – these will be needed until the hormone is no longer found.

You may need further treatment if your hormone level doesn't go down or it increases.

You'll usually have some vaginal bleeding – use pads or towels, rather than tampons, until this stops.

You may experience some tummy pain – take paracetamol to relieve this.

You'll be told what to do if you develop more severe symptoms.

The main advantage of monitoring is that you won't experience any side effects of treatment.

A disadvantage is that there's still a small risk of 1 of your fallopian tube splitting open (rupturing) and you may eventually need treatment.

Medicine

If an ectopic pregnancy is diagnosed early but active monitoring isn't suitable, treatment with a medicine called methotrexate may be recommended.

This works by stopping the pregnancy from growing. It's given as a single injection into your buttocks.

You won't need to stay in hospital after treatment, but regular blood tests will be carried out to check if the treatment is working.

A second dose is sometimes needed and surgery may be necessary if it doesn't work.

You need to use reliable contraception for at least 3 months after treatment.

This is because methotrexate can be harmful for a baby if you become pregnant during this time.

It's also important to avoid alcohol until you're told it's safe, as drinking soon after receiving a dose of methotrexate can damage your liver.

Surgery

In most cases, keyhole surgery (laparoscopy) will be carried out to remove the pregnancy before it becomes too large.

During a laparoscopy:

you're given general anesthetic, so you're asleep while it's carried out

small cuts (incisions) are made in your tummy

a thin viewing tube (laparoscope) and small surgical instruments are inserted through the incisions

the entire fallopian tube containing the pregnancy is removed if your other fallopian tube looks healthy – otherwise, removing the pregnancy without removing the whole tube may be attempted

Removing the affected fallopian tube is the most effective treatment and isn't thought to reduce your chances of becoming pregnant again.

Your doctor will discuss this with you beforehand, and you'll be asked whether you consent to having the tube removed.

Most women can leave hospital a few days after surgery, although it can take 4 to 6 weeks to fully recover.

If your fallopian tube has already ruptured, you'll need emergency surgery.

The surgeon will make a larger incision in your tummy (laparotomy) to stop the bleeding and repair your fallopian tube, if that's possible.

After either type of surgery, a treatment called anti-D rhesus prophylaxis will be given if your blood type is RhD negative (see blood groups for more information).