Ectopic Pregnancy

Pregnancy is one of the beautiful phases in a woman's life. While some pregnancies sail through without any complications, others may suffer from mild to life-threatening conditions at some point. Ectopic pregnancy is one such complication which can pose serious risk to the mother and the fetus if not attended to, immediately. 

What is Ectopic Pregnancy?

According to the American Pregnancy Association, ectopic pregnancy happens to 1 in every 50 pregnant women, although it is reported to be 1 in 100 in the UK. In a normal pregnancy, after fertilization, the fertilized egg implants on to the inner wall of the uterus. As the name suggests (ectopic means ‘displaced’), in an ectopic pregnancy, however, the fertilized egg attaches itself to a location in the female reproductive tract other than the uterine wall. The potential sites of implantation are the fallopian tube, ovary, cervix, and abdomen. The most common ectopic pregnancy occurs in the fallopian tube, also referred to as tubal pregnancy, that is, the fertilized egg implants to the wall of the fallopian tube.

What causes Ectopic Pregnancy?

In an ectopic pregnancy, the normal passage of the fertilized egg through the fallopian tube is obstructed. Though the exact cause may not always be pinned down, the common causes are:

• Pelvic inflammatory disease (PID), a bacterial infection in the female reproductive organs including ovaries, fallopian tubes, uterus, and the cervix
• A previous abdominal or tubal surgery which resulted in scar tissue or an adhesion
• A birth defect which caused an abnormality in the fallopian tube
• Fibroids in the uterus
• Endometriosis, a condition in which the tissue lining the inner wall of the uterus grows outside the uterus.

What are the risk factors for Ectopic Pregnancy?

Women with the following conditions or lifestyle issues are prone to increased risk for ectopic pregnancy:

High-risk factors:

• Previous ectopic pregnancy
• History of pelvic inflammatory disease or pelvic surgery
• Past or present use of intrauterine devices (IUDs) for contraception
• Previous tubal ligation as a means of birth control

Sterilization and contraception procedures are aimed at the prevention of pregnancy. In spite of their use, if a sperm fertilizes the egg, it increases the risk of ectopic pregnancy. 

Moderate-risk factors:

• Risk factors for sexually transmitted diseases such as multiple sexual partners
• Smoking

Low-risk factor:

• Maternal age of more than 40, though some studies report 35+ years as a risk factor

What are the signs of Ectopic Pregnancy?

Many women would not be aware of their pregnancy in the very early stages. This can make ectopic pregnancy symptoms less distinct and less apparent in early pregnancy. Some symptoms of normal pregnancy like nausea, vomiting, and soreness of breasts can be present through at a milder level in ectopic pregnancy. However, the following are the common signs of ectopic pregnancy to look for:

• Consistent pain on one side of the abdomen or entire abdominal region; usually a sharp pain but, in some women, it can also be a vague pain like abdominal cramps.
• Abnormal vaginal bleeding which can be heavy or intermittent and dark red or brown in color
• Delay or abnormality in the menstrual period (when the pregnant women are not aware of her pregnancy, she may mistake vaginal bleeding for menstrual bleeding)
• Pain in the shoulders because of pooling of blood under the diaphragm

How is Ectopic Pregnancy diagnosed?

Pain associated with early pregnancy signs must be immediately reported to a doctor for early medical intervention. Diagnosis is usually carried over a few days or weeks involving learning previous history, physical examination, multiple scans and blood tests in order to confirm an ectopic pregnancy. 

It is highly difficult to conclude an ectopic pregnancy because the embryo usually gets ruptured even before diagnosis. Also, the diagnostic symptoms of ectopic pregnancy can overlap with that of a miscarriage, making it hard to differentiate between an ectopic pregnancy and an early miscarriage. Here are the various diagnosis steps your healthcare provider will perform to check for ectopic pregnancy:

• A pelvic examination, most frequently, shows a lump or tenderness, called as adnexal mass or adnexal tenderness respectively, in women with an ectopic pregnancy.
• A pregnancy test may be positive for both normal pregnancy and ectopic pregnancy in the very early stages. Yet, in an ectopic pregnancy, the level of hCG (Human Chorionic Gonadotropin) is lower than an intrauterine pregnancy. 
• One sure-shot diagnosis of an ectopic pregnancy is the presence of an embryo or yolk sac in the fallopian tube in an ultrasound. However, one cannot be always located because the time of the rupture of egg and the first ultrasound may greatly vary with pregnancies. 
• If a transvaginal ultrasound performed around 6 or 7 weeks after last period date does not show an embryo or yolk sac in the uterus but a blood test shows positive for pregnancy, it may indicate an ectopic pregnancy. However, it can also indicate an early miscarriage.

How is Ectopic Pregnancy treated?

Unfortunately, an embryo which attaches to a fallopian tube or anywhere outside the uterine wall cannot survive the pregnancy. It is mandatory to end the pregnancy in order to save the mother. The following medical interventions are carried out upon the diagnosis of ectopic pregnancy:

In the early stages when the embryo is small, a drug called methotrexate is administered in order to abort the pregnancy. Subsequent blood tests and ultrasound can confirm if the process was successful. 

Surgery becomes necessary under the following conditions:

• the Embryo has crossed the stage of abortion through drug administration
• emergency due to rupture of the fallopian tube
• acute pain
• severe internal bleeding

The type of surgery depends upon the extent of tubal damage and the preference about preserving the tubes for future pregnancies. 

• Laparoscopy is the most preferred type of surgery to remove the embryo and the connected tissue. It is less invasive and demands relatively lesser post-operative care. 
• In some adverse cases such as the rupture of the fallopian tube, the life of the pregnant mother is at high risk. Excessive loss of blood due to internal bleeding may result in death. A surgical procedure called laparotomy is performed in such situations. Laparotomy involves a larger incision under general anesthesia. 
• If tubal damage is severe, the fallopian tube has to be removed completely through a surgical procedure called salpingectomy. 

What is the probability of a future conception following an Ectopic Pregnancy?

In most cases where an ectopic pregnancy is aborted at an early stage, future conception is possible through careful monitoring of the hormonal cycles though the risk of recurrence of ectopic pregnancy might still be present. However, in cases where a part or entire fallopian tube has been surgically removed, the chances of getting pregnant again are either less or nil. Yet, pregnancy can still be made possible through assisted reproductive technologies such as IVF. 

References

Kumar, V., & Gupta, J. (2015). Tubal ectopic pregnancy. BMJ Clinical Evidence, 2015, 1406.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646159/