Ectopic pregnancy is one in which the fertilized egg is implanted and develops outside the normal uterine cavity. It is a very life-threatening condition where pregnancy occurs outside the uterine cavity, somewhere in the tubes, ovary, cervix or abdomen and requires appropriate treatment.
In normal pregnancy, the ovary releases the egg and is collected by fimbriae of the fallopian tubes. Fertilization takes place in the ampullary region of the tubes. After 3 days, the fertilized egg moves into the uterus to get attached to the uterine lining. But due to some reasons, fertilized egg gets implanted outside the uterine cavity most often in the tubes and result in tubal pregnancy.
Nowadays, its incidence has increased and caused maternal morbidity and mortality. It occurs in 1 in 300 pregnancies. An ectopic pregnancy can’t progress normally and leads to rupture and bleeding, a very fatal condition. Its early diagnosis is very necessary to prevent or reduce women’s death due to ectopic pregnancy.
Sites of implantation
There are certain factors responsible for the fertilized egg to remain in the tubes are-
Factors that prevent or delay the migration of the fertilized egg to the uterine cavity, includes-
- Pelvic inflammatory diseases
- Narrow tubal lumen
- Loss of cilia of the lining epithelium
- Formation of tubal adhesions
- Infections such as salpingitis or chlamydia trachomatis
- Contraceptive failures can cause ectopic pregnancy such as the use of intrauterine devices, sterilization operations and use of progestin only pill
- Any tubal surgery to improve fertility can increase the risk of ectopic pregnancy
- Formation of adhesions after any pelvic surgery
- Use of assisted reproductive techniques to induce ovulation and in case of IVF or GIFT procedures
- Any previous ectopic pregnancy
- Hormonal factors
- Birth defects of the uterus and tubes
- There is an increased risk with induced abortions
Factors that facilitate implantation in the tubes-
- Increased decidual reaction
- Presence of tubal endometriosis
- Due to premature degeneration of the zona pellucida, the trophoblastic activity is resumed early and leads to nidation in the tubes.
Risk factors for ectopic pregnancy
- Advanced maternal age of 35 years or older
- Cigarette smoking can also increase the risk of ectopic pregnancy
- Any previous surgery done on the fallopian tubes to correct any abnormalities
- Previous history of ectopic pregnancy
A woman may not experience any typical symptoms other than pregnancy symptoms such as nausea and vomiting, missed period and breast tenderness. As pregnancy progresses beyond 8 weeks, a woman starts experiencing symptoms such as-
- Sharp abdominal pain due to distension of the tube by the fertilized egg. Initially, it is located in the lower abdomen on the affected side but gradually spreads all over the abdomen.
- Vaginal bleeding or spotting
- Shoulder pain due to bleeding into the peritoneal cavity
- Severe pelvic pain
- Dizziness and fainting
- Uneven abdominal distension
- Chest pain
- The woman looks more ill and presence of pallor.
If the tube ruptures, a woman may experience shock and collapse symptoms, fainting, low blood pressure and the condition becomes more fatal and leads to death if left untreated. Emergency treatment is required without any delay to prevent any complications.
The presence of sharp abdominal pain with fainting and collapse are suggestive of intra abdominal haemorrhage which points to a diagnosis of ectopic pregnancy. Without wasting any time, investigations are carried out which include-
- Blood examination should be done to check haemoglobin, ABO and Rh grouping, total WBC and ESR.
- Estimation of hCG helps to diagnose ectopic pregnancy because the level of hCG reduces in ectopic pregnancy as compared to normal pregnancy.
- Sonography not only helps to diagnose the pregnancy but is also helpful in finding the offending site of ectopic pregnancy. As trans vaginal sonography is more informative.
- Urine test
- Laparoscopy is done in case of confusion arises with other pelvic lesions. It is also helpful in removing ectopic mass using operative procedures at the same time.
- Dilatation and curettage to identify decidua without villi structure are very much suggestive of ectopic pregnancy.
- The level of serum progesterone less than 5 ng/ml suggests an abnormal or ectopic pregnancy.
- Laparotomy is also used in some cases.
There are numerous ways to treat an ectopic pregnancy. All cases of suspected ectopic are to be admitted as an emergency. After the admission procedure, the woman should be treated for shock(if develops) by starting the ringer’s solution and blood for transfusion is arranged. Depending on the severity of the condition, the woman can be treated by using the medication, laparoscopic surgery and laparotomy(abdominal surgery).
Women with stable conditions and no intra abdominal haemorrhage can be treated with methotrexate medication which helps to stop further cell growth.
Other than this, there are a number of chemotherapeutic agents which have been used as medical management of ectopic pregnancy such as Potassium Chloride, prostaglandins or actinomycin.
After the administration of medication, a doctor may order an hCG test. If the level of serum hCG is declining then it means the medication is working effectively, if there is no change then a second dose is required to get the desired effect.
The surgical procedures can be done either laparoscopically or by laparotomy depending on the location, severity and degree of damage to the organ. Some of the surgical procedures include-
- Salpingostomy– In this procedure, an incision is made directly on the ectopic pregnancy site and products are removed by keeping the incision line open to be healed later.
- Salpingotomy– It is done in the same way as salpingostomy but the incision line is closed with sutures. This is not commonly done.
- Salpingectomy– Involves removal of the damaged tube.
- Segmental resection– It is mainly done in isthmic pregnancy and involves end to end anastomosis.
If the tube ruptures due to ectopic pregnancy and causes heavy bleeding, then emergency surgery is done to save the life of the woman.
Is it possible to get pregnant after an ectopic pregnancy?
Yes, it is possible. Many women who have had ectopic pregnancy go on to have a normal pregnancy in the future. But there is an increased risk of recurrence of ectopic pregnancy in the future. In such cases, advice from the health care provider is very necessary throughout the pregnancy. For those who had one fallopian tube removal, another tube can help in the conception process. Otherwise, the IVF technique can help the woman to have children. One must wait for at least 6 months to have further pregnancy to allow the tubes to heal to prevent another ectopic pregnancy.
In the above post, we discussed ectopic pregnancy, its causes and risk factors, sites of implantation, symptoms, diagnosis and various treatment modalities.