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Ectopic Pregnancy

What Is An Ectopic Pregnancy?

Ectopic pregnancy is derived from the Greek word ‘ektopas’ which means ‘out of place’. It is a pregnancy that implants outside the uterine cavity or womb. It occurs in 1% to 2% of all pregnancies and of these about 98% implants in the fallopian tube (figure 1). Other sites for ectopic pregnancy include abdominal cavity, ovaries, cornu of the uterus and cervix.

A ruptured ectopic pregnancy is a life threatening condition. Ectopic pregnancy is the number one cause of death in women who are in the first 3 months of pregnancy. The number of ectopic pregnancies is increasing, so it is important to understand more about it.

Who are at risk?

We don’t always know why women have ectopic pregnancies but there are certain factors that increases their risk and include :

  • Previous ectopic pregnancies
  • Pelvic Inflammatory Disease (PID) or Salpingitis(pelvic infection)
  • Subfertility (difficulty in conceiving)
  • Previous abdominal or pelvic surgery
  • Previous tubal sterilization or ligation
  • Pelvic endometriosis
  • Using Intrauterine Contraceptive Device (IUCD)
  • Undergoing assisted conception (fertility treatment)

Why is it dangerous?

In most ectopic pregnancy, the embryo does not reach the uterine cavity or womb, but instead it implants into the lining of the fallopian tube. The implanted embryo then burrows into the tubal lining and this will cause bleeding. As the embryo increases in size, the fallopian tube is stretched and it may rupture. This may cause very heavy bleeding into the abdominal cavity and threaten the life of the woman. Early diagnosis and treatment in a hospital is necessary.

What are the signs & symptoms?

Most ectopic pregnancy starts to have signs and symptoms between the fifth and eighth weeks of pregnancy. If you suspect that you are pregnant and have the following signs and symptoms then you should see a doctor without delay :

  • Lower abdominal pain which may be more one-sided, either to the left or right
  • Abnormal vaginal bleeding and it is usually slight with ‘dark coloured’ blood
  • Shoulder-tip pain which may indicate there is intra-abdominal bleeding
  • Occasionally may present with diarrhoea or pain on defecation

Failure to diagnose the ectopic pregnancy early may cause the rupture of the fallopian tube, resulting in excessive bleeding. At this stage you may have the following symptoms :

  • Sudden severe abdominal pain
  • Dizziness, ‘fainting spells’, sweating and feeling weak
  • Collapse due to the excessive bleeding
  • Distended abdomen
  • Pale appearance

If you have the above signs and symptoms then you should get to the Accident & Emergency Department of the nearest hospital as soon as possible for treatment. Either you call for an ambulance or someone should drive you there.

How to diagnose an ectopic pregnancy? Diagnosing an ectopic pregnancy is not easy. It may require a few days particularly if you have very few symptoms. The doctor will initially confirm if you are pregnant by performing a urine pregnancy test (UPT). Then an abdominal and vaginal examination would be carried out.

An ultrasound scan of the pelvis should follow, preferably a trans-vaginal ultrasound scan (TVS) as this would allow the doctor to see the pelvic organs more clearly (figure 2). The doctor would look for a pregnancy within the uterus or womb. If a uterine pregnancy is confirmed then the chance of ectopic pregnancy is rare. There are however, a very rare chance of a ‘heterotopic pregnancy’, a condition where there is an intrauterine pregnancy as well as an ectopic pregnancy. The doctor will also look for a gestational sac outside the uterus, which is not easy and more often than not would be unable to locate it. The presence of free fluid (blood) in the pelvis may also be suggestive of an ectopic pregnancy. In very early pregnancy, intrauterine pregnancy may not always be visible on ultrasound scan and the doctor may want to repeat it in a week or two.

Blood tests to check serum beta-hCG levels may be ordered by the doctor in certain circumstances and usually needs to be repeated 2 days later. This may be able to assist the doctor in assessing the pregnancy and if a pregnancy is an ectopic or not.

The above examinations and investigations may not be able to confirm an ectopic pregnancy and you may have to undergo a laparoscopic or an open surgery to visually confirm it. Sometimes when a tubal abortion (when the gestational sac is expulsed from the fallopian tube into the abdominal cavity) has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy occasionally shows a normal looking fallopian tube.

What are the possible treatments?

The treatment for ectopic pregnancy depends on the clinical presentation. This may include: if the ectopic has ruptured or not, whether you are clinically stable (normal blood pressure and pulse rate), the size of the ectopic gestational sac, and the presence of blood in the pelvis and the level of serum beta-hCG. How far away you live from the nearest hospital may be one of the factors that the doctor will consider before deciding which treatment is the right one for you.

There are several ways ectopic pregnancy can be treated :

  • Conservative treatment

In a carefully selected group of women with ectopic pregnancy, conservative management may be acceptable. Women with non-viable tubal pregnancy who are asymptomatic, not ruptured and without evidence of bleeding into the pelvis may not require any intervention besides monitoring. These women should be counseled appropriately. Additional serum beta-hCG confirming a decreasing level is reassuring.

  • Medical treatment

Medical treatment with intramuscular injection of a drug called Methotrexate, can be considered for a selected group of women who fulfill certain criteria. These include: an ectopic pregnancy which is not ruptured, a gestational sac less than 3cm in diameter, a serum beta-hCG level less than 3000 IU and the absence of blood in the pelvis on ultrasound scan. Serial estimations of serum beta-hCG levels would be required to assess if this mode of treatment is effective.

  • Surgical intervention

In the majority of ectopic pregnancies, this would be the recommended modality of treatment. The preferred method is through a laparoscopic surgery (key hole surgery), but it would be dependent on the availability of surgical equipment and expertise. If it is a tubal pregnancy, the doctor will then decide to either remove the pregnancy and still leave the fallopian tube intact or remove the entire tube. This is usually based on how healthy the other tube looks.

In cases where the tubal pregnancy has ruptured and the woman’s condition is not stable, open surgery would be preferred over laparoscopic surgery as it would be faster to perform. In cases where blood loss is considerable, blood transfusion will be necessary.

Will I be able to get pregnant again?

There is still a good chance that you would be able to get pregnant in the future, but this would be dependent on how healthy the other tube was and several other factors such as: your age, and/or if you had difficulty getting pregnant before. If the other tube is not blocked or damaged then the chances of getting pregnant is good irrespective whether the tube affected by ectopic was left intact or completely removed during the surgery.

In general, some 65% to 70% of women with a previous history of ectopic pregnancy will conceive again within 18 months. However, if both the fallopian tubes are damaged or ruptured then you may have to undergo infertility treatment (IVF) to be able to conceive in the future.

What are my chances of getting another ectopic pregnancy?

The chances of getting another ectopic pregnancy are between 12% to 20% depending on several factors. Your doctor would be able to inform you of your risks.

What should I do when I get pregnant again?

Once you suspect you are pregnant, please confirm the pregnancy by doing a urine pregnancy test or by going to your doctor early. An early assessment by ultrasound should be able to confirm if it is a normal pregnancy or another ectopic pregnancy.

How long should I wait before trying to get pregnant again?

This is dependent on when you feel you are physically and emotionally ready to try for another pregnancy. The general advice is to wait for 3 to 6 months to recover from the surgery, 3 months if it is by laparoscope and 6 months if it is by open surgery.

 

Last Reviewed : 20 June 2014
Writer : Dr. Haris Njoo Suharjono
Accreditor : Dr. Aza Miranda Abdul Rahman
Reviewer : Dr. Hj. Mohamed Hatta Mohamed Tarmizi