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| ECTOPIC PREGNANCY BY STEPHANIE BLACK |
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| Transvaginal pelvis ultrasound demonstrating an ectopic pregnancy-Image courtesy of Mario Ernesto Libardi |
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ABSTRACT
Ectopic pregnancy is defined as any pregnancy that occurs outside the uterine cavity. Approximately 97% of ectopic pregnancies occur in a fallopian tube, with 55% of these occurring in the ampulla, 25% in the isthmus, and 17% in the fimbria. The remaining 3% of ectopic pregnancies are located in ovarian, cervical, abdominal, and interstitial (corneal) sites. Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. It is the leading cause of pregnancy related death in the first trimester, And accounts for 10% to 15% of all maternal deaths. During the last 2 decades, the incidence of ectopic pregnancies has risen. This may be due, in part, to known risk factors, such as pelvic inflammatory disease (PID), the use of intrauterine devices (IUD), and smoking. Based on hospital discharge data, the incidence of ectopic pregnancy increased from 4.5 cases per 1000 pregnancies in 1970 to 19.7 cases per 1000 pregnancies in 1992. |
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Endometriosis, Culdocentesis, Methotrexate, Pelvic inflammatory disease, hormone HCG, Progesterone intrauterine device, and ectopic pregnancy
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| left tubal ectopic pregnancy demonstrated with power doppler |
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An ectopic pregnancy results from a fertilized egg’s inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube may have partially or entirely blocked the pathology. Pelvic inflammatory disease is the most common of these infections. Endometriosis (when cells from the lining of the uterus detach and grow elsewhere in the body) or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg’s progress. |
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| This image demonstrates a left tubal ectopic pregnancy with decidual cast in the uterus. |
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Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. The most common clinical presentations of an ectopic pregnancy are pelvic pain, vaginal spotting, and amenorrhea. These usually present after 5 to 9 weeks of amenorrhea. Other classic symptoms are dizziness, pregnancy symptoms, and vaginal passage of tissue. Pain usually results from the stretching of the peritoneum over the tube. After the tube ruptures, pain usually decreases or disappears. The diagnosis can be difficult unless the condition is suspected; it may be confused with miscarriage, an ovarian accident, or PID. The most common classic finding on physical examination is adnexal tenderness. Other typical signs include abdominal tenderness, uterine enlargement, and orthostatic changes. 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. If someone arrives in the emergency department complaining of abdominal pain, they will likely be given a urine pregnancy test. Although these tests are not sophisticated, they are fast and speed is crucial in treating an ectopic pregnancy. If someone already knows they are pregnant, or if the urine test comes back positive, they will then be given a quantitative HCG test. This blood test measures levels of human chorionic gonadotropin (HCG), a hormone produced by the placenta. HCG appears in the blood and urine as early as 10 days after conception, and its levels double every 2 days for the first 10 weeks of pregnancy. If HCG levels are lower than expected for the patient’s stage of pregnancy, doctors are one step closer to diagnosing ectopic pregnancy. The doctor will also give the patient a pelvic exam to locate the areas causing pain, to check for an enlarged, pregnant uterus, or to find masses in the abdomen. The patient will probably also get an ultrasound examination, which shows whether the uterus contains a developing fetus or if masses are present elsewhere in the pelvic area. However ultrasound may not be able to detect an ectopic pregnancy. A less commonly performed test, a culdocentesis, may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found there likely comes from a ruptured ectopic pregnancy. Even with the best equipment, it is hard to see a pregnancy that is less than 6 weeks old. If the doctor cannot diagnose ectopic pregnancy but can rule it out, he or she may ask the patient to return every 2 days to measure HCG levels. If these levels do not rise as quickly as they should, the doctor will continue to monitor the patient carefully until 6 weeks gestational age, when an ultrasound can be used.
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The risk of ectopic pregnancy is highest for women who are between 35 and 44 years old and have had:
• PID
• Previous ectopic pregnancy
• Surgery on a fallopian tube
• Medication to stimulate ovulation
Some birth control methods can also increase the risk of an ectopic pregnancy. If someone gets pregnant while using progesterone-only oral contraceptives, progesterone intrauterine devices, or the morning-after pill, then risk of an ectopic pregnancy will increase.
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TREATMENT FOR RECURRENT ECTOPIC PREGNANCIES |
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| 3D ultrasound demontstrating cervical ectopic pregnancy-Image courtesy of Saied Mohamed Tohamy |
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Treatment of an ectopic pregnancy varies, depending on its size and location and whether the patient wants to conceive again. An early ectopic pregnancy can sometimes be treated with an injection of methotrexate, which dissolves the fertilized egg and allows the body to reabsorb it. This nonsurgical approach minimizes scarring of the pelvic organs. If the pregnancy is advanced, the patient will likely need surgery to remove it. In the past, this was a major operation, requiring general anesthesia and a large incision across the pelvic area. This may still be necessary in cases of emergency or extensive internal injury. However, the pregnancy may sometimes be removed using laparoscopy, a less invasive surgical procedure. In this case, the surgeon makes a small incision in the lower abdomen and then inserts a laparoscope. This long, hollow tube has a lighted end which allows the doctor to view internal organs and insert other instruments. The ectopic pregnancy is then surgically removed and any damaged organs are repaired or removed. General or reginal anesthesia is used. Whatever the treatment, the doctor will want to see the patient regularly afterward to make sure the HCG levels return to zero. This may take up to 12 weeks. A continually elevated HCG could mean that some ectopic tissue was missed. This tissue may have to be removed with methotrexate or additional surgery. |
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Approximately 30% of women who have had ectopic pregnancies will have difficulty becoming pregnant again. The prognosis depends mainly on the extent of the damage and the type of surgery that was done. If the fallopian tube has been spared, the chances of a future successful pregnancy are 60%. Even if one fallopian tube has been removed, the chances of having a successful pregnancy with the other tube can be greater than 40%. The likelihood of a repeat ectopic pregnancy increases with each subsequent ectopic pregnancy. Once you have had an ectopic pregnancy, you face an approximate 15% chance of having another.
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An ectopic pregnancy results from a fertilized egg’s inability to work its way quickly enough down the fallopian tube into the uterus. Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. Treatment of an ectopic pregnancy varies, depending on its size, location and whether the patient wants to conceive again. Approximately 30% of women who have had an ectopic pregnancy will have difficulty becoming pregnant again. Nothing can be done to prevent ectopic pregnancy, but we can make sure it is detected early.
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