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What You Should Know About an Ectopic Pregnancy

When a woman learns she is pregnant with her first baby, her life changes.The very thought of nurturing a life within her can be pretty overwhelming! One minute she will be overjoyed at the news, the next minute her feelings might be that of doubt and anxiety. Soon she settles down and embraces motherhood, the growing bump and the idea of having a child.

She starts planning her future life with her baby. She's not concerned about having any pregnancy complication because nothing seems out of place initially, but somewhere within she may start feeling something is just not right. Just as she's starting to enjoy the thought of motherhood, she feels pain, an excruciating pain. 

And before it dawns on her, there arises a possibility of a major surgery or medical treatment. She is diagnosed with ‘Ectopic Pregnancy’. The ending of an ectopic pregnancy is a form of miscarriage – and the feelings that a woman and her partner go through can be very depressing.

Ectopic pregnancy is a common life-threatening condition. It is the major cause of maternal mortality and morbidity in the first trimester. Ectopic pregnancy is usually diagnosed unexpectedly and is often physically and emotionally traumatic. Many women may have only recently discovered they were pregnant when they are given the diagnosis. 

Some women diagnosed with an ectopic pregnancy don't even know they are pregnant and are suddenly asked to think of the possibility of undergoing a major surgery or an urgent medical treatment.

8 What is an Ectopic Pregnancy

An ectopic pregnancy occurs when a fertilized egg implants itself outside of the womb/uterus, usually in one of the fallopian tubes. Over 95% of ectopic pregnancies implant in one of the fallopian tubes (Varma and Gutpa 2009), this is why it is also known as a ‘Tubal Pregnancy’.

The fallopian tubes are a pair of 4-inch (10 cm) long narrow tubes connecting the ovaries to the uterus and are not designed to hold a growing embryo. As the fallopian tube is not large enough to support the growing embryo, the embryo cannot develop normally into a baby in tubal pregnancy and this can be really devastating for a pregnant woman to accept. 

In very few cases, sometimes it is seen that an ectopic pregnancy shows no noticeable symptoms and only gets detected during a routine pregnancy test or when the woman is in pain. However, for many, symptoms do become apparent between 5th and 14th week of pregnancy. 

As the pregnancy continues, it causes pain and bleeding. If not diagnosed and treated in time, the tube can rupture and cause internal bleeding. This then becomes a medical emergency and can be fatal. Sadly, such pregnancies do not survive, and can't be transferred to your uterus. A doctor will have to remove the pregnancy tissues and sometimes even the affected fallopian tube.

An early diagnosis and treatment is indispensable to prevent life-threatening bleeding and if possible, to save the tubes and preserve fertility. An ectopic pregnancy happens in 1 out of 60 pregnancies. Rarely (in around 2 out of 100 pregnancy cases), an ectopic pregnancy can occur in an ovary, in the abdominal space or in the cervix (neck of the womb) and/or at the joint between the tube and the womb. 

An ectopic pregnancy is said to rarely occur in both the womb and the tube at the same time (known as heterotopic pregnancy). 

7 Differing Types of Ectopic Pregnancy

Tubal Pregnancy: The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimabrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%). 

Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal bleeding.

Non-tubal Ectopic Pregnancy:2% of ectopic pregnancies are intra-abdominal and occur in the ovary or the cervix. In this kind of pregnancy, the placenta sits on the intra-abdominal organs or the peritoneum as it finds sufficient blood supply. 

The diagnosis is most commonly made at 16 to 20 weeks of gestation and hence the fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extra-uterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from where it is attached. 

This is extremely rare. However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of bleeding.

Heterotopic Pregnancy: A very rare case of ectopic pregnancy is aheterotopic pregnancy, where two fertilized eggs--one outside the uterus and the other inside the uterus--gets implanted. Generally, quite often, the intrauterine pregnancy is discovered much later than the ectopic pregnancy because of the painful nature and emergency it projects. 

Ectopic pregnancies are therefore, normally discovered and removed very early in the pregnancy and the additional pregnancy inside the uterus generally goes unnoticed even with an ultrasound. If hCG levels are checked and a continuous surge in the levels are seen even after the removal of the ectopic pregnancy, then a pregnancy inside the uterus becomes viable, normally confirmed by an ultrasound. 

Although rare, heterotopic pregnancies are becoming more common, most likely due to increased use of IVF treatment. The survival rate of the uterine fetus of an ectopic pregnancy is considered to be around 70%.

Persistent Ectopic Pregnancy: A persistent ectopic pregnancy refers to the continuation of trophoblastic growth, which involves abnormal growth of cells inside a woman's uterus, after a surgical intervention to remove an ectopic pregnancy. 

If this growth goes unnoticed then after a few weeks it may lead to new clinical symptoms including bleeding. This calls for monitoring of the hCG levels even after the removal of an ectopic pregnancy and checks for its complete disappearance. The best preventive method is to administer the drug methotrexate at the time of surgery.

Pregnancy of Unknown Location: Pregnancy of Unknown Location (PUL) is the term used for a pregnancy where a test shows positive but cannot be detected using trans-vaginal ultrasound. Specialized early pregnancy departments have estimated that between 8-10% of women who get assessed for early pregnancy through ultrasound are classified as having a PUL. This pregnancy could be one of a viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.

In a persisting PUL, the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy can be established through a trans-vaginal sonography. A persisting PUL could either be an early ectopic pregnancy that has not been established, or a trophoblastic growth in the endometrial cavity. When a potentially viable intrauterine pregnancy is ruled out, only then treatment should be considered. 

6 Causes

Ectopic/Tubal pregnancy is generally caused by conditions which slows down or obstructs the movement of the fertilized egg down the fallopian tube into the womb/uterus. 

Or any condition which may have damaged the fallopian tubes and increasing the risk of an ectopic pregnancy. A review published in 2010 supports the hypothesis that “tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur”. 

Some of the possible causes include past damage to the uterus, diseases and illness, or abnormalities. A history of Endometriosis can cause an ectopic pregnancy. Endometriosis is a disease where tissue usually found in the uterus starts developing in other areas of the body and may impede the movement of the eggs trapping them in the fallopian tubes or in other parts where an ectopic pregnancy can occur.

Adhesions caused by previous surgery of the pelvic area or on the tubes can cause an ectopic pregnancy. This can be cause by tissue that has healed improperly and has causes the fallopian tubes to become either partially blocked or blocked entirely. Pelvic inflammatory disease is an infection of the female reproductive organs which can cause scarring of the organs. The scarred tissue might cause constriction of the fallopian tube and result in an etopic pregnancy.

An abnormality in the tube's shape can be caused by abnormal growths or a birth defect. If the tube's shape doesn't allow the egg to flow down into the uterus, but remain in the tubal area or rest in another area, when the egg becomes fertalized it can result in an ectopic pregnancy because the egg was not fertalized in the uterus.

Multiple induced abortions can also result in ectopic pregnancies. The reason being that multiple forced abortions cause scarring inside the uterus and can effect the ability of the egg to attach securely and remain on the wall of the uterus. If an egg fertalizes elsewhere and can't be found, it can become a pregnancy of unknown location.

5 Why an Ectopic Pregnancy

You might never know what might have caused Ectopic Pregnancy; but you are at a higher risk if you have had a previous occurrence of ectopic pregnancy in a fallopian tube, you increase your risk of having another such pregnancy by about 1 in 90 to 1 in 10;

Smoking is believed to cause damage to the fallopian tubes' ability to move the fertilized egg into the uterus, and thus resulting in an ectopic pregnancy. If you're using a birth control method, you'll still need to contact your doctor if you become pregnant and suspect you have an ectopic pregnancy. An intrauterine device may not stop an ectopic pregnancy which can be troublesome for the woman.

Pelvic Inflammatory Disease (PID), or a sexually-transmitted disease such as chlamydia or gonorrhea can also cause an ectopic pregnancy. These issues can cause scar tissues to form on the fallopian tubes and stop the egg from travelling into the uterus. Sometimes a surgery performed on the pelvic area, for example having your appendix removed or an unsuccessful fallopian tube surgery and even surgical sterilization (tubal ligation) or reversal of tubal ligation can result in an ectopic pregnancy.

The use of fertility drugs can cause the ovaries to release multiple eggs (superovulation). In this case one of the eggs released from the same ovary might not make it down into the uterus and become fertalized in the fallopian tube. Women who become pregnant after taking infertility treatment such as In Vitro Fertilization (IVF) need to go for an early ultrasound check to see where the embryo has implanted to avoid a pregnancy of unknown origin.

Women over the age of 40 who become pregnant are at higher risk for an ectpoic pregnancy as well. Although pregnancy becomes rare with an intrauterine device (IUD) or after a tubal ligation, those pregnancies that do progress in spite of all these risk factors may have an increased chance of being ectopic.

4 Ectopic Pregnancy Symptoms

Up to 10% of women with ectopic pregnancy have no symptoms, and one-third have no medical signs. In many cases the symptoms have no distinction as they seem similar to those of other gastrointestinal-genitourinary disorders like urinary tract infection, appendicitis, salpingitis (an infection and inflammation of the fallopian tubes), miscarriage, ovarian torsion (OT) or rupture of a corpus luteal(CL)cyst – ovarian cyst

Clinically, ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 4 to 8 weeks. Symptoms that can possibly help recognize a potential risk of ectopic/tubal pregnancy are:

  • - One-sided abdominal or pelvis pain you may experience a persistent to severe pain, typically on one side of your abdomen (tummy) or pelvis, which may come and go at regular intervals; and
  • - Vaginal bleeding unusual vaginal bleeding which may be heavier or lighter from your regular period. Some women tend to mistake this bleeding for a normal period and do not realise of being pregnant as the bleeding often starts and stops, and can be bright or dark red in colour than usual or watery.

If your ectopic pregnancy is not diagnosed early, your tube may get stretched by your growing embryo, and rupture causing internal bleeding and these signs and symptoms further show up:

  • - Shoulder tip and/or neck painshoulder tip pain usually occurs when you are lying down and is a sign that the ectopic pregnancy is ruptured and is causing internal bleeding. The bleeding is thought to irritate the phrenic nerve, which is found in your diaphragm (the muscle used during breathing that separates your chest cavity from your abdomen);
  • - Bowel pain you may experience pain when passing urine or stools;

Sweating and feeling light-headed, weak and dizzy;

  • - Diarrhoea and vomiting an ectopic pregnancy can cause similar symptoms to a gastrointestinal disease and is often associated with diarrhoea and vomiting; and/or

Shock, or collapsing, due to severe internal bleeding.

Hence, it is very important for you as a pregnant woman to seek emergency care if you are experiencing sharp stabbing pain or is bleeding and do ask your physician for a diagnosis. 

3 Ectopic Pregnancy Diagnosis

Soon after you visit your hospital, when you may probably be in pain or bleeding, the medical practitioner/physician may perform a pregnancy test, a pelvic exam, and an ultrasound test to view the condition of the uterus and fallopian tubes; to locate the pain, tenderness or a mass in the abdomen; and to see if there is any developing fetus in the uterus. If an ectopic pregnancy gets confirmed, the physicianmay then decide on the best possible treatment based on your medical condition at that particular time.

Your physician might want to do a Culdocentesis on you. It is a medical procedure/ diagnostic procedure involving the extraction of fluid from the rectouterine pouch, posterior to the vagina through a needle. The presence of blood in this area may indicate bleeding from a ruptured fallopian tube and helps identify ectopic pregnancy.

Another method is through the measurement of the hormone Human Chorionic Gonadotropin (better known as hCG) levels, which is produced during pregnancy. If an hCG level is lower than what is expected, then it can be one reason to suspect the pregnancy to be an ectopic pregnancy. The low levels of progesterone also help in indicating the pregnancy to be abnormal.

Lastly, a perfect method could be ‘Laparoscopy’ in which a telescope is inserted through a small incision in the woman's abdomen after being administered anaesthesia in an operating theatre. This method allows the doctor to see the fallopian tubes and other organs. 

7. Treatment

Leaving an ectopic pregnancy to develop and grow is fatal and life-threatening as the process of the fertilised egg would cause the fallopian tube to rupture (split open) and cause internal bleeding. 

An ectopic pregnancy may be treated in any of the following ways:

  • If your ectopic pregnancy happens to be detected at an early stage, a drug called ‘Methotrexate’ may be injected by your doctor into your thigh or bottom to stop the egg from developing further. The pregnancy tissue is then absorbed into the woman’s body by this medication which may also help save the fallopian tubes. You may need more than one injection of methotrexate. In more than half of the cases, the egg dies before it can develop further and as such “Methotrexate’ is of no use.
  • Another scenario could be: your ectopic pregnancy is detected very early on and you are feeling well, with no symptoms as such then you may be given the option of having no treatment (PRODIGY 2010, RCOG 2010b, RCOG 2004: 5) which is known as expectant management, or "wait and see".

    Sometimes, in such cases where there is no evidence of a sac and your pregnancy hormonal levels are very low, your ectopic pregnancy would naturally lead to miscarriage.(Varma and Gupta 2009) However, about a third of women may further have to go for a treatment with methotrexate or surgery (RCOG 2010b), if this expectant management or miscarriage does not happen to work out.

  • In most of the cases, the fallopian tube gets ruptured and starts bleeding internally. In such cases, all or part of the fallopian tube may have to be removed. Emergency surgery is recommended to reduce further blood loss. Signs of a ruptured fallopian tube are a sudden, severe, sharp pain in the abdomen; dizziness; feeling sick; diarrhoea and shoulder tip pain. Ruptured fallopian tube is a medical emergency. If you are pregnant and have these symptoms then call 000 and ask for an ambulance.
  • If ectopic pregnancy is detected at a more advanced stage then it will require surgery to remove the pregnancy sac. Your doctor may perform a ‘laparoscopic surgery’ under general anaesthesia. The doctor/surgeon would have to remove the ectopic pregnancy and repair or remove the affected fallopian tube.

If ectopic pregnancy cannot be removed by a laparoscope procedure, then another surgical procedure called ‘Laparotomy’ may have to be performed. An ectopic pregnancy can also be removed from a fallopian tube by using salpingostomy or salpingectomy.

In Salpingostomy, the ectopic growth is removed through a small, lengthwise cut in the fallopian tube (linear salpingostomy) but the tube, as such, is not removed. The cut is left to close on its own or is stitched up to close. A segment of the fallopian tube is removed, and the remaining healthy fallopian tube may be reconnected. This is needed when the fallopian tube gets stretched and may rupture due to the ectopic pregnancy or when it has already ruptured or is completely damaged.

Both salpingostomy and salpingectomy can be done either through a small incision using laparoscopy or through a larger open abdominal incision called laparotomy. Laparoscopy takes less time than laparotomy. And the hospital stay is shorter. But for an abdominal ectopic pregnancy or an emergency tubal ectopic removal, a laparotomy is generally suggested and performed.

2 Future Pregnancies

Those women who have an ectopic pregnancy can have normal pregnancies and births in the future, even if one of their fallopian tubes is removed. Getting pregnant with just one normal working fallopian tube is quite possible. The chances of having a successful pregnancy after an ectopic pregnancy may be lower than normal, and this all depends on your medical history and why you had an ectopic pregnancy. 

If your ectopic pregnancy was caused by a sexually transmitted disease then you can try for a successful pregnancy again by getting yourself treated for it, but however, it may have some impact on your fertility.

The scarring that occurs due to the infection is what causes ectopic pregnancy and not the infection. Getting treated for the infection does not eliminate the damage already done.C heck on your hCG level regularly to see if it reaches zero. If the levels reach zero then you won't have your entire fallopian tube removed. 

If your hCG level remains high, it simply indicates that the ectopic tissue was not entirely removed and hence would require you to get it removed surgically or by taking the drug methotrexate.

The outlook for future pregnancies depends on whether the fallopian tube turns out to be normal or not. That is, if your fallopian tubes are undamaged after your ectopic pregnancy, your chances of conceiving won't be reduced. If one of your tubes was badly damaged or ruptured, your chances of conceiving are only reduced slightly (EPT you’re your one healthy fallopian tube can give you a good chance of conceiving again as you can still ovulate with one healthy working tube. 

You have about a 1 in 10 risk of having another ectopic pregnancy (PRODIGY 2010, RCOG 2010a). But again, on a much brighter side, about 6 out of 10 women who have had an ectopic pregnancy are able to conceive again and do have a successful pregnancy within 18 months (PRODIGY 2010).

Talk with your doctor and get advice on how long to wait after an ectopic pregnancy before trying to conceive again. Some doctors ideally suggest waiting 3 to 6 months as keyhole surgery requires you to wait for 3 months before trying to conceive again.  

An adominal surgery would require you to wait for 6 months to allow the scarring to heal; and if you were administered the drug methotrexate, then you will need to also wait for about 3 months before trying for a baby as you can be rest assured that the drug is out of your system completely.

If you do become pregnant again, see your doctor immediately, who will then refer you to get an ultrasound done to check that your pregnancy is developing in the right place.

1 Counselling and Support

After going through the ordeal of an ectopic pregnancy and the loss, take time out to relax and let your mind and body heal. Don't blame yourself for the loss. You will find many counselling and/or pregnancy loss ‘Support Groups’ to help you and your partner and your family cope with your pregnancy loss.

At a support group you can hear or read about the experiences of other women who too have faced the same situation, and/or talk to your friends. So, ask your doctor about such support groups near you.

You could possibly go into depression due to the hormonal changes after the loss of the pregnancy. Check for the symptoms of postpartum depression and talk to your doctor, friends, a psychologist or a clinical social worker to help deal with your depression.

Ectopic pregnancy is a common and serious problem, with a significant morbidity rate and the potential for maternal death. It's a terrifying ordeal and the impact of this kind of pregnancy can be very hard to deal with. Try to rest & relax, and take it easy for a while. Ectopic pregnancy is a physically and emotionally traumatic experience, regardless of when you actually lost it.

In addition to experiencing the loss of a pregnancy, women tend to fear the loss of fertility. Feelings of grief and loss mount and turn into sadness, anger, even feelings of guilt and self blaming. These need to be acknowledged and expressed. Remember that the ectopic pregnancy was not your fault.

It can be helpful to share these feelings with your partner, in a support group, or through counselling. Time plays a very important factor in healing both physically and emotionally before pursuing another pregnancy. Allow yourself time to grieve and heal before trying to conceive again.

Beware, the symptoms of an ectopic pregnancy act like a miscarriage. If you suspect an ectopic pregnancy, don’t wait to call your practitioner. With a timely diagnosis and care, you stand a good chance of having a healthy pregnancy in the future.

Don’t be disheartened! You will definitely have a baby in-utero and a healthy one!

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