Ectopic Pregnancy: What to Know
11 Jan 2023
by Dr. Oybek Rustamov in Fertl Edu
An ectopic pregnancy is a type of pregnancy where the fertilized egg implants outside of the uterus, usually in the fallopian tube. In a normal pregnancy, the fertilized egg is transported through the fallopian tube and implants in the uterus 3 to 4 days after fertilization.
However, if the fallopian tube is blocked or damaged, the fertilized egg may implant in the tube instead of the uterus. The fallopian tube is not able to support the growing embryo and the pregnancy cannot continue normally. If left untreated, the fallopian tube can rupture and cause serious bleeding. Although the most common site for ectopic pregnancy is the fallopian tube, it can also occur in the cervix, ovary, or even within the abdomen.
What are the causes of an ectopic pregnancy?
There are several risk factors that can increase a woman’s likelihood of having an ectopic pregnancy.
Women who have damaged fallopian tubes are more at risk, and around 50 percent of ectopic pregnancies are associated with some degree of tubal damage. Tubal damage can be caused by a variety of factors, including pelvic infections, such as gonorrhea or chlamydia, endometriosis, appendicitis, and previous pelvic surgery.
Additionally, women who conceive while using an intrauterine device (IUD), have had a tubal ligation for sterilization, or have undergone reversal of a tubal ligation or other tubal surgery are also at a higher risk for ectopic pregnancy. Women who conceive with the help of fertility drugs or in vitro fertilization (IVF) also have a slightly higher risk of ectopic pregnancy.
Future Pregnancies
Sometimes, there is no clear reason for why an ectopic pregnancy has occurred. However, it is known that women who have had an ectopic pregnancy are at higher risk for having another one in the future, and should be monitored carefully if another pregnancy is attempted or suspected.
How is an ectopic pregnancy diagnosed?
It’s important for women to be aware of the signs and symptoms of ectopic pregnancy and to seek medical attention if they are experiencing any of them. Early diagnosis and treatment can help prevent serious complications.
An ectopic pregnancy can be indicated by a number of different signs.
- Pelvic pain
- Abnormal levels of human chorionic gonadotropin (hCG) in the first few weeks of pregnancy
- Delayed or abnormal bleeding
It is crucial to see a doctor right away if you are pregnant and suffering any of these symptoms. If you have a history of tubal injury or other diseases that increase your chance of ectopic pregnancy, this is very crucial.
There are several tests that can be used to diagnose an ectopic pregnancy. These include measuring hCG and progesterone levels in the blood, ultrasound, and laparoscopy.
Human chorionic gonadotropin (hCG)
This is a hormone produced by the placenta during pregnancy. In a healthy pregnancy, the level of hCG in the blood should double approximately every 48 hours. If the hCG level does not double, it could indicate a problem with the pregnancy, such as an ectopic pregnancy or miscarriage. Doctors may repeat hCG tests every 48 hours to help make a diagnosis.
Progesterone
Progesterone is another hormone produced during pregnancy. Its levels in the blood rise early in pregnancy. Low levels of progesterone can indicate an abnormal pregnancy. However, progesterone levels alone are not always reliable for diagnosing ectopic pregnancy and are not routinely used for this purpose.
Ultrasound
These exams can be used to determine whether a pregnancy is inside the uterus in the first 3 to 5 weeks after conception (1 to 3 weeks after a missed period). A transvaginal ultrasound is more sensitive than abdominal ultrasound for this purpose. An ultrasound can also show fluid or blood in the abdomen, which could indicate bleeding from an ectopic pregnancy.
In some cases, the combination of ultrasound, hCG, and progesterone blood level measurements, can confirm the diagnosis of an ectopic pregnancy without the need for further procedures like laparoscopy. However, sometimes it is not possible to see an ectopic pregnancy with an ultrasound, and the diagnosis is made when a pregnancy is not seen in the uterus but hCG levels are present.
What are the treatment options?
Expectant Observation
One option for treatment is observation alone, also known as “expectant management.” This is typically limited to women with early ectopic pregnancies that have no symptoms and low hCG levels (usually less than 1,000 IU/L) that are decreasing without treatment. Observation alone is only an option for women who can dependably return for hCG level checks. Women who are being treated with observation alone should avoid intercourse and strenuous exercise.
If hCG levels are less than 1,000 IU/L and dropping, and an ultrasound cannot determine the location of the pregnancy, it is sometimes referred to as a “biochemical pregnancy.” Approximately half of these are actually ectopic pregnancies, and the rest are intrauterine pregnancies that will end in miscarriage.
Most of these will resolve without incident within a month with observation alone. If they experience pain or other symptoms, or if the hCG levels do not drop or rise appropriately, treatment with the medication methotrexate or surgery may be necessary.
Medical Treatment
In some cases, an ectopic pregnancy can be treated with the drug methotrexate.
To be eligible for this treatment, a woman must be in stable condition with no evidence of internal bleeding or severe pain. She must also be able to communicate with her doctor during treatment and follow-up with blood tests after treatment.
Methotrexate is a drug originally used to treat certain types of cancer that are related to placental tissue. It is effective at destroying ectopic pregnancy tissue, which is then reabsorbed by the body. However, it can also destroy normal pregnancy tissue, so it is not an option for women with a heterotopic pregnancy (one in the uterus and one in the fallopian tube).
It is given as a single injection or a series of injections over several days. It is successful in treating most early ectopic pregnancies, although the chances of success depend on the size of the ectopic pregnancy as seen on ultrasound and the hCG level in the blood. Women with large ectopic pregnancies or rapidly rising or high hCG levels (over 10,000 IU/L) are less likely to respond to a single dose of methotrexate. These women may need multiple doses of methotrexate or surgical treatment.
During treatment, women should avoid sun exposure as methotrexate can cause sensitivity to sunlight and increase the risk of sunburn. They should also avoid alcohol and vitamins with folic acid.
Surgical Treatment
Laparoscopy is used to do most surgeries for ectopic pregnancies today.
Laparotomy is usually only done when an ectopic pregnancy has ruptured and caused a lot of internal bleeding or when the abdomen and pelvis have a lot of scar tissue.
A laparoscopic salpingostomy can be done if the ectopic pregnancy is found early, before the tube bursts. During this procedure, the fallopian tube is opened and the pregnancy tissue is removed. The tube is left in place. The tube will then heal itself. Some of the ectopic tissue may stay and keep growing in about 5 to 15 percent of cases. This can be treated by removing the tube through surgery or by giving them methotrexate.
A salpingectomy is a common method of surgical treatment of ectopic pregnancy. The salpingectomy involves removal of the tube which contains the ectopic pregnancy. When the ectopic pregnancy is in the ovary, which is rare, part or all of the ovary may need to be taken out.
Summary
When an ectopic pregnancy goes untreated, complications might arise. Because of the potential benefits of a reduced risk of complications and the availability of additional treatment choices, early diagnosis is crucial. Blood tests, ultrasound scans, and laparoscopy are all viable methods for diagnosing an ectopic pregnancy.
The medicine methotrexate may be used to treat some ectopic pregnancies, while monitoring and surgery may be necessary for others. Laparoscopy is the procedure of choice for treating ectopic pregnancies. Laparotomy is a more extensive abdominal surgery that may be required in unusual circumstances.
It is crucial to closely monitor women who have had an ectopic pregnancy in the past and who subsequently become pregnant again due to the increased risk of another ectopic pregnancy. The emotional pain of an ectopic pregnancy is common, and many women find it beneficial to talk about their experiences in a support group or with a therapist.
References
| 1. | Ectopic pregnancy. (2017). acog.org/Patients/FAQs/Ectopic-Pregnancy |
| 2. | Mayo Clinic Staff. (2015). Ectopic pregnancy. mayoclinic.com/health/ectopic-pregnancy/DS00622 |
| 3. | Perkins KM, et al. (2015). Risk of ectopic pregnancy associated with assisted
reproductive technology in the United States, 2001-2011. ncbi.nlm.nih.gov/pmc/articles/PMC4315158/ |
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