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Ectopic Pregnancy

Ectopic Pregnancies

Ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity.


Presentation

The classical clinical trio of ectopic pregnancy is: amenorrhoea, abdominal pain and vaginal bleeding. However, not all patients present with these symptoms. Many of them present with nausea, fever and breast fullness as well. In absolute emergency situations, a patient may present with severe tenderness, abdominal rigidity, involuntary guarding and signs of hypovolemic shock as well [8].

On examination of the pelvis, the physician may notice the following changes: the uterus may be enlarged and slightly soft, signs of peritoneal inflammation may be present and a mass may also be palpated.

Fever
  • Abstract A 34-year-old woman without any medical history presented to our hospital emergency unit with a history of 4 days of progressively increasing pain in the left iliac fossa, fever and vaginal bleeding for the past 3 weeks.[ncbi.nlm.nih.gov]
  • […] pregnancy could be ectopic If you are pregnant, or think you could be, and you are showing any of the symptoms below, you should seek immediate medical advice: Vaginal bleeding Abdominal pain, especially if it is just on one side Pain in your shoulder A fever[bounty.com]
  • You have a fever. You have questions or concerns about your condition or care. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated.[drugs.com]
  • Many of them present with nausea, fever and breast fullness as well. In absolute emergency situations, a patient may present with severe tenderness, abdominal rigidity, involuntary guarding and signs of hypovolemic shock as well.[symptoma.com]
Pallor
  • There were 87.8% patients was had pallor, 9.4% were admitted with features of shock. Cervical motion tenderness (82.2%) was the most frequent sign. Urinary beta-hCG was positive in 96.1% cases.[ncbi.nlm.nih.gov]
  • Pallor. Abdominal distension. Enlarged uterus. Tachycardia and/or hypotension. Shock or collapse.[patient.info]
Anemia
  • At examination on admittance, our patient had a bad general condition with clinical anemia. She had an occlusive syndrome that had been evolving for 3 days.[ncbi.nlm.nih.gov]
  • Blood and Bone marrow: MTX may cause anemia (low red blood cell count), leukopenia (low white blood cell count), and or thrombocytopenia (low platelet count). Low platelet counts can result in spontaneous bleeding.[ivf1.com]
Abdominal Pain
  • CASE REPORT: A 34-year-old patient with a history of subtotal hysterectomy for postpartum hemorrhage consulted for acute abdominal pain. The diagnosis of ectopic pregnancy was made using blood pregnancy test and transvaginal ultrasound.[ncbi.nlm.nih.gov]
  • The presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum hCG testing.[ncbi.nlm.nih.gov]
  • The presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum hCG testing. Full Text[doi.org]
  • CASE PRESENTATION: A 25-year-old African woman was referred to our clinic with 6 weeks' delay of menstruation, frequent increasing abdominal pain and 3 days of vaginal bleeding. Her general condition was good and her vital signs were normal.[ncbi.nlm.nih.gov]
  • Abstract Splenic ectopic pregnancies are a rare cause of abdominal pain in reproductive-age women.[ncbi.nlm.nih.gov]
Lower Abdominal Pain
  • A case of a 30 years-old woman admitted for lower abdominal pain is reported.The level of hCG was 659.2 mU/mL and transvaginal ultrasound reveled a fluid collection in the pouch of Douglas.[ncbi.nlm.nih.gov]
  • She had amenorrhea, left lower abdominal pain, but no vaginal bleeding. Her urine human chorionic gonadotropin (HCG) test was positive and blood HCG level was 1880 m-international units per milliliter (mIU/mL).[ncbi.nlm.nih.gov]
  • The patient presented with intermittent lower abdominal pains on a 20 weeks gestation associated with mild epigastralgia and 2 previous episodes of mild pervaginal bleeding (2 and 1 months ago respectively before consultation) managed with injectable[ncbi.nlm.nih.gov]
  • The most common symptoms and findings of ectopic pregnancy are: an overdue period (suggesting pregnancy) bleeding from the vagina positive pregnancy test lower abdominal pain fainting .[netdoctor.co.uk]
  • The most common symptoms and findings of ectopic pregnancy are: an overdue period (suggesting pregnancy) bleeding from the vagina positive pregnancy test lower abdominal pain fainting.[netdoctor.co.uk]
Severe Abdominal Pain
  • On Valentine’s Day morning, 12-week pregnant Avila woke up complaining of severe abdominal pain.[medicaldaily.com]
  • Severe abdominal pain and heavy vaginal bleeding are signs of a ruptured fallopian tube and should be reported immediately to your doctor.[everydayhealth.com]
  • Those symptoms include severe abdominal pain and blood loss leading to lightheadedness and dangerously low blood pressure. There's no way for an ectopic pregnancy to continue because the fertilized egg can't survive outside of the uterus.[refinery29.com]
  • Call your doctor immediately if you have heavy vaginal bleeding that causes lightheadedness, fainting, or shoulder pain , or if you have any severe abdominal pain, especially if it is on one side of the belly.[webmd.com]
  • Symptoms of this life-threatening event include extreme lightheadedness, fainting, severe abdominal pain and shock.[mayoclinic.org]
Acute Abdomen
  • More than half of all women with ectopic pregnancy presented with acute abdomen and required emergency laparotomy.[ncbi.nlm.nih.gov]
  • The second patient is also 16 years old and presented with an acute abdomen. She was diagnosed as a ruptured luteal cyst and underwent partial oophorectomy.[ncbi.nlm.nih.gov]
  • Peritonism and signs of an acute abdomen may occur. Women with a positive pregnancy test and any of the following need to be referred immediately to hospital: Pain and abdominal tenderness. Pelvic tenderness. Cervical motion tenderness.[web.archive.org]
  • A patient with spotting, no abdominal pain, and a low initial beta–human chorionic gonadotropin (β-HCG) level that is falling may be managed expectantly, whereas a patient who presents with hemodynamic instability, an acute abdomen, and high initial β-HCG[emedicine.medscape.com]
Pelvic Mass
  • CT scan showed a left pelvic mass compatible with a tubo-ovarian abscess. After transfer to our gynaecology unit, transvaginal ultrasound revealed an empty uterus with a heterogeneous mass in the left adnexal area.[ncbi.nlm.nih.gov]
  • The current pregnancy represents a chronic tubal pregnancy (a tubal pregnancy in which the tubal wall gradually disintegrates, with slow and/or repeated episodes of hemorrhaging leading to the formation of a pelvic mass).[merckmanuals.com]
  • Tenderness on pelvic exam is the most common physical exam finding, but few patients will have a palpable pelvic mass.[cdemcurriculum.com]
Hypotension
  • Systemic hypotension is a late marker of shock after trauma: a validation study of ATLS principles in a large national sample. Am J Surg 2006; 192:727. PMID: 17161083 Rana P et al. Ectopic pregnancy: a review. Arch Gynecol Obstet. 2013;288:747-57.[coreem.net]
  • If the tube has ruptured, the patient may present in shock with tachycardia and hypotension. Shoulder pain from diaphragmatic irritation is a late sign and is seldom seen in current practice.[web.archive.org]
  • Transfusion of O negative blood should be strongly considered in the setting of hypotension.[cdemcurriculum.com]
Tachycardia
  • If the tube has ruptured, the patient may present in shock with tachycardia and hypotension. Shoulder pain from diaphragmatic irritation is a late sign and is seldom seen in current practice.[web.archive.org]
  • Tachycardia and/or hypotension. Shock or collapse.[patient.info]
Shoulder Pain
  • Signs of ectopic pregnancy include abdominal pain shoulder pain vaginal bleeding feeling dizzy or faint get medical care right away if you have these signs. Doctors use drugs or surgery to remove the ectopic tissue so it doesn't damage your organs.[icd9data.com]
  • Signs of ectopic pregnancy include Abdominal pain Shoulder pain Vaginal bleeding Feeling dizzy or faint Get medical care right away if you have these signs. Doctors use drugs or surgery to remove the ectopic tissue so it doesn't damage your organs.[medlineplus.gov]
  • pain, and rectal pressure.[my.clevelandclinic.org]
  • ., if the tube ruptures, a weak pulse, clammy skin and fainting are common because of internal bleeding) Shoulder pain Feeling of rectal pressure Diagnosis A pregnancy test is done first.[healthcentral.com]
Vaginal Bleeding
  • She felt tenderness in an abdominal examination and had a small amount of vaginal bleeding. Transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary.[ncbi.nlm.nih.gov]
  • The presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum hCG testing.[ncbi.nlm.nih.gov]
  • The only other independent marker of risk of EP was duration of vaginal bleeding; the risk of EP increased by 20% (95% CI, 14%-27%) for every 1-day increment in duration (P 0.001).[ncbi.nlm.nih.gov]
  • The presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum hCG testing. Full Text[doi.org]
  • A 38-year-old woman presented with light vaginal bleeding at approximately 8 weeks gestation.[ncbi.nlm.nih.gov]
Pelvic Pain
  • The prevalence of EP was low when there was no pelvic pain, no diarrhea and the duration of bleeding was 3 days, with an EP rate of 2% (6/391).[ncbi.nlm.nih.gov]
  • We included for our study only women in their first trimester of pregnancy experiencing acute pelvic pain and/or vaginal bleeding who were hospitalized (262 patients).[ncbi.nlm.nih.gov]
  • MATERIALS AND METHODS: A 29-year-old woman with vaginal bleeding and pelvic pain was admitted to the current clinic. She had secondary amenorrhea for nine weeks.[ncbi.nlm.nih.gov]
  • Abstract Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound.[ncbi.nlm.nih.gov]
Adnexal Mass
  • Abstract A positive urine pregnancy test (UPT) with adnexal mass in ectopic pregnancy is not the ultimate diagnosis. The incidence of ectopic pregnancy is about 27 per 1000 pregnancies [1].[ncbi.nlm.nih.gov]
  • CONCLUSION: This is the first study to report that in women with ectopic pregnancies after IVF, higher hCG-though well below treatment failure thresholds previously described in spontaneous pregnancies-fewer embryos transferred, and adnexal masses are[ncbi.nlm.nih.gov]
  • The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography (LR 111; 95% CI, 12-1028; n 6885), and the physical examination findings of cervical motion tenderness (LR 4.9; 95% CI, 1.7-14; n 1435), an adnexal[ncbi.nlm.nih.gov]
  • However, the diagnosis is often not that simple, especially when the patient presents early, has minimal pain, is haemodynamically stable, and TVS shows an empty uterus but no obvious adnexal mass.[ncbi.nlm.nih.gov]
Salpingitis
  • […] diagnosis* Salpingitis/parasitology Salpingitis/pathology Salpingitis/surgery Sequence Analysis, DNA Young Adult Substance DNA, Helminth[ncbi.nlm.nih.gov]
  • Abstract Tubal pathology, smoking, pelvic inflammatory disease, miscarriage, medical or surgical abortion, usage of intrauterine devices (IUDs) for women with salpingitis latent injuries, older than 40 years, are risk factors for ectopic pregnancy.[ncbi.nlm.nih.gov]
  • Etiology The main cause of ectopic pregnancy is salpingitis. The morphologic sequelae of acute salpingitis can be observed in approximately 50% of women with ectopic pregnancies. No pathologic changes can be found in approximately 40%.[web.archive.org]
  • Intrauterine contraceptive device (IUCD), salpingitis, infertility, and assisted reproductive techniques are the important risk factors. Approximately, 75% terminate in first trimester and are often misdiagnosed as corpus luteum haemorrhage.[ncbi.nlm.nih.gov]
  • As discussed above, obstruction of the fallopian tube could result from PID, salpingitis or tubal endometriosis all of which are non-anatomical causes.[symptoma.com]
Cervical Motion Tenderness
  • Cervical motion tenderness (82.2%) was the most frequent sign. Urinary beta-hCG was positive in 96.1% cases. Ultrasonography revealed diagnosis in 2/3rds cases among 129 patients.[ncbi.nlm.nih.gov]
  • The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography (LR 111; 95% CI, 12-1028; n 6885), and the physical examination findings of cervical motion tenderness (LR 4.9; 95% CI, 1.7-14; n 1435), an adnexal[ncbi.nlm.nih.gov]
  • Early symptoms and signs include pelvic pain, vaginal bleeding, and cervical motion tenderness. Syncope or hemorrhagic shock can occur with rupture. Diagnosis is by measurement of the beta subunit of human chorionic gonadotropin and ultrasonography.[msdmanuals.com]
  • Haemodynamic instability and cervical motion tenderness may indicate rupture or imminent rupture. If the patient is haemodynamically stable, transvaginal ultrasound is the initial test of choice.[bestpractice.bmj.com]

Workup

Early diagnosis of ectopic pregnancy helps to reduce the rate of female morbidity and mortality. As the risk factors do not necessary help in establishing a prompt diagnosis, screening of a female patient in her reproductive years who presents with cramping, abdominal pain and vaginal bleeding for pregnancy will help for the same.

Serum as well as urine assays for the presence of the beta human chorionic gonadotropin hormone (bhCG) that have been produced to identify a pregnancy even before the 1st missed menstrual cycle, can also help in the early detection for ectopic pregnancy. Ultrasonography is the most important tool for diagnosing an extrauterine pregnancy [8]. Endovaginal ultrasonography or transvaginal ultrasonography can be used to confirm intrauterine pregnancy 38 days after the menstrual period. Absence of a conceptus inside the uterine cavity with a high beta HCG level confirms the presence of an ectopic pregnancy. Colour-flow Doppler ultrasonography improves the specificity of a transvaginal ultrasonography. Laproscopy is also one of the methods used for diagnosis.

Chlamydia
  • KEYWORDS: Chlamydia trachomatis; Ectopic pregnancy; Embryo implantation; Fallopian tube; Integrins[ncbi.nlm.nih.gov]
  • What they have found is that the ectopic rates reduced at the same rate as chlamydia."[theguardian.com]
  • All identified risk factors are maternal: pelvic inflammatory disease, Chlamydia trachomatis infection, smoking, tubal surgery, induced conception cycle, and endometriosis.[ncbi.nlm.nih.gov]
  • The epidemiological risk factors for tubal ectopic pregnancy are well established and include: tubal damage as a result of surgery or infection (particularly Chlamydia trachomatis), smoking and in vitro fertilization.[ncbi.nlm.nih.gov]
  • 10 Things To Know About Your Menstrual Cycle," 6 Sep. 2018 If left untreated, chlamydia and gonorrhea can lead to infertility, ectopic pregnancy and chronic pelvic pain. — Harriet Rowan And Alex Leeds Matthews, Washington Post , "California’s Deadly STD[merriam-webster.com]

Treatment

Ectopic pregnancy can be treated. Methotrexate is the treatment of choice for an unruptured ectopic pregnancy [9]. For a patient to receive methotrexate treatment, she should be haemodynamically stable, having no severe or persisting abdominal pain, normal liver function and renal function tests and should be able to follow up multiple times.

If the patient has evidence of an intrauterine pregnancy, is breastfeeding, has severe anaemia, immunodeficiency, sensitivity to methotrexate, etc. methotrexate should not be the first treatment of choice.

Laparoscopy is the recommended surgical mode of treatment [10]. Laparotomy is usually carried out on patients who are haemodynamically unstable or for those having a cornual ectopic pregnancy.

Prognosis

If diagnosed early, ectopic pregnancy has a good prognosis in terms on the effects on maternal health. However, late diagnosis leads to tubal or uterine rupture which in turn causes haemorrhage, shock, disseminated intravascular coagulation (DIC) and eventually death.

Ectopic pregnancy is considered to be the chief cause of maternal deaths in the first 3 months amongst all pregnancy related deaths. However, death is rare because usually ectopic pregnancies are diagnosed in the first trimester itself. If diagnosed and treated surgically, it is important to know the surgical complications as well. Infertility can result as a secondary complication as a result of the loss of reproductive organs which may occur during surgery in cases of advanced ectopic pregnancy.

Etiology

For an ectopic pregnancy to occur, two events are needed: the fertilization of the ovum and the abnormal implantation of the product at a site away from the uterine cavity. A risk factor that affects both the events is: a history of major tubal infection which reduces the fertility of a woman and increases abnormal implantation [2]. Other risk factors include tubal damage which could be the result of infections such as pelvic inflammatory disease (PID), cervicitis or salpingitis caused due to micro-organisms such as Chlamydia trachomatis or Neisseria gonorrhoea. A history of previous ectopic pregnancy is also a major risk factor wherein a patient has a 7-13 fold increase i.e. a 50-80% possibility of another ectopic pregnancy.

Smoking is believed to decrease tubal motility by damaging the ciliated cells in the fallopian tubes [3]. Intrauterine contraceptive devices and progesterone pills have also been found to increase the risk of tubal pregnancies. Infertility which has not been treated for two years or more also contributes to an increased risk of tubal pregnancy. Infertility patients having defects with the luteal phase have higher rates of ectopic pregnancy than those suffering from infertility due to anovulation.

History of multiple sexual partners, in a way also becomes a risk factor. Pregnancy that occurs post a tubal ligation has high chances of developing into an ectopic pregnancy. A high rate of ectopic pregnancy occurs in women between the ages of 35-44 years most probably because aging might lead to progressive reduction in myoelectrical activity of the fallopian tubes which brings about tubal motility. Other risk factors associated with of ectopic pregnancy include congenital anatomical abnormalities of the uterus such as a bicornuate or septate etc.

Epidemiology

Around, 85-90% of ectopic pregnancies occur amongst multigravid women. The incidence of ectopic pregnancy is reported to be as the number of ectopic pregnancies per 1000 conceptions [4]. Since the 1970, in the United States, the rate was 4.5 cases per 1000 pregnancies but has been increasing ever since, presently accounting for 1-2% of all pregnancies and has been estimated as 1 in 40 pregnancies or around approximately 25 cases per 1000 pregnancies. In the United Kingdom, the incidence of ectopic pregnancy is 11.1 per 1000 pregnancies and in Africa 1.1-4.6% [5].

Sex distribution
Age distribution

Pathophysiology

The exact pathophysiology of ectopic pregnancy is unknown. However, there are four main possibilities as to why it happens:

  • There could be an anatomical obstruction to the passage of the zygote.
  • It could be an abnormal conceptus.
  • Abnormalities of the fallopian tube with regards to tubal motility.
  • Transperitoneal migration of the zygote [6].

Anatomical abnormalities and obstruction of the fallopian tube are most frequently responsible for ectopic pregnancies. As discussed above, obstruction of the fallopian tube could result from PID, salpingitis or tubal endometriosis all of which are non-anatomical causes. Once the endosalpinx is scarred, it could lead to the formation of diverticuli in which the zygote could be trapped.

It is believed that tubal motility is influenced by the functioning of the hormones. Some cases of ectopic pregnancy may arise due to endocrine abnormalities which may be seen in patients using progesterone only pills, intra-uterine devices and gonadotropins for the induction of ovulation all of which interfere with tubal motility [7]. Superovulation also results in an increased risk of ectopic implantation. It has been theorised that abnormal levels of progesterone in the luteal phase of the menstrual cycle leads to impaired motility thereby giving rise to an ectopic pregnancy. Women undergoing an embryo transfer during in-vitro fertilization are also at high risk for the same.

Prevention

There is no known way to prevent ectopic pregnancy. However, the modifiable risk factors, if known by an individual, can be taken care of. For e.g.: smoking, abstaining from having multiple sexual partners, taking precautions at the time of intercourse so as to prevent chlamydial infections which can cause PID and avoiding a late pregnancy may help to prevent it as it is a known factor that chances of ectopic pregnancy increase with age.

Summary

Ectopic pregnancy is defined as pregnancy that occurs outside the uterine cavity which ultimately leads to the death of the fetus [1]. It refers to the product of conception being implanted in the fallopian tubes, cervix, or ovary or at times even in the abdominal cavity [1].

If not diagnosed at the right time, it can prove to be fatal resulting in the death of the mother. Once the embryo is implanted at a particular site, it enlarges and creates a potential for organ rupture at that site thereby leading to massive haemorrhage, infertility in the long run or ultimately death.

Patient Information

Ectopic pregnancy is referred to as pregnancy that occurs outside the womb. It is generally seen in women who are pregnant above the age of 35-40 years, who maybe chronic smokers and those who suffer from pelvic inflammatory disease (PID). It may be caused due to a defect in the shape and structure of the uterus or a disturbance in the functioning of the fallopian tubes.

Precautions must be taken by those women who are undergoing IVF treatments as they stand a higher chance for the same and so do women who use intra-uterine contraceptive devices. Ectopic pregnancy needs immediate medical attention because severe complications may lead to death because of the massive hemorrhage.

A patient typically presents with: absence of periods, abdominal pain and vaginal bleeding. Some patients also present with nausea and dizziness [11]. As there are no specific diagnostic tools for the diagnosis of ectopic pregnancy, it is important to screen women in the reproductive age group who present with the classical triad of symptoms. Ultrasonography is one of the ways of diagnosing ectopic pregnancy as well as the levels of beta HCG which are indicative of the same.

Ectopic pregnancy has safe treatments available without the risk of permanent damages. However, in advanced stages it can rupture and prove to be fatal to the life of the mother. Surgery (laparoscopy) is the treatment of choice where a section of the uterine tubes is removed.

It is important to bear in mind, that ectopic pregnancy needs to be detected at the earliest. Therefore, regular pelvic check-ups are recommended to all sexually active females in their reproductive years. Earlier the diagnosis, better the prognosis.

References

Article

  1. Farquhar CM. Ectopic pregnancy. Lancet. Aug 13-19 2005;366(9485):583-91.
  2. Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996 June;65(6):1093-9.
  3. Strandell A, Thorburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction. Fertil Steril. 1999 Feb;71(2):282-6
  4. Calderón JL, Shaheen M, Pan D, Teklehaimenot S, et al. Multi-cultural surveillance for ectopic pregnancy: California 1991-2000. Ethn Dis. Autumn 2005;15(4 Suppl 5):S5-20-4.
  5. Goyaux N, Leke R, Keita N, Thonneau P. Ectopic pregnancy in African developing countries. Acta Obstet Gynecol Scand. 2003 Apr;82(4):305-12.
  6. Alan H. DeCherney, William O. Agel. Ectopic Pregnancy. Gynecology and Obstetrics. Vol 1. 2004 Edition. Retrieved from: https://www.glowm.com/resources/glowm/cd/pages/v1/v1c069.html.
  7. Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002 Dec;17(12):3224-30.
  8. Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol. 2010 Mar;115(3):495-502.
  9. Stovall TG, Ling FW, Gray LA. Single-dose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol. 1991 May;77(5):754-7
  10. Maymon R, Shulman A, Halperin R, Michell A, Bukovsky I. Ectopic pregnancy and laparoscopy: review of 1197 patients treated by salpingectomy or salpingotomy. Eur J Obstet Gynecol Reprod Biol. 1995 Sep;62(1):61-7.
  11. Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol. 1994 Dec;84(6):1010-5.

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Last updated: 2018-06-22 07:01