Ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity.
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 .
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.
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 . 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.
Ectopic pregnancy can be treated. Methotrexate is the treatment of choice for an unruptured ectopic pregnancy . 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 . Laparotomy is usually carried out on patients who are haemodynamically unstable or for those having a cornual ectopic pregnancy.
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.
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 . 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 . 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.
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 . 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% .
The exact pathophysiology of ectopic pregnancy is unknown. However, there are four main possibilities as to why it happens:
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 . 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.
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.
Ectopic pregnancy is defined as pregnancy that occurs outside the uterine cavity which ultimately leads to the death of the fetus . It refers to the product of conception being implanted in the fallopian tubes, cervix, or ovary or at times even in the abdominal cavity .
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.
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 . 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.