An ectopic pregnancy is a condition in which the embryo is implanted in any tissue other than the uterus. Most ectopic pregnancies occur in Fallopian Tubes, but implantation can also occur in the abdomen, ovaries or the cervix. The fetus produces enzymes that allow it to implant in varied types of tissues, and thus an embryo implanted elsewhere than the uterus can cause great tissue damage in its efforts to reach a sufficient supply of blood. An ectopic pregnancy is a medical emergency, and, if not treated properly, can lead to the death of the woman.
Causes
There are a number of risk factors for ectopic pregnancies. However, in as many as 50% of the ectopic pregnancies no risk factors can be identified.
Risk factors include:
Pelvic Inflammatory Disease(PID)
Infertility
Intro-uterus exposure to DES
tubal surgery
previous ectopic pregnancy
multiple sexual partners
current IUD
Tubal ligation
Symptoms
Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks.
The early signs are:
Pain in the lower abdomen
Pain while urinating
Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding
Pain while having a bowel movement
Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal:
External bleeding is due to the falling progesterone levels
Internal bleeding (is due to hemorrhage from the affected tube
The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID).
Diagnosis
An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test.
The use of vaginal ultrasound is essential.
An abnormal rise in blood β-hCG levels may also indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy today is around 1500 IU/ml of β-hCG.
Surgery can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion has occurred, or a tubal rupture has occurred, it is difficult to find the pregnancy tissue.
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.
Treatment
Medical treatment
Early treatment of an ectopic pregnancy with the Methotrexate has proven to be a viable alternative to surgical treatment. If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the end of a pregnancy.
Surgical treatment
If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss.
Surgeons use Laparoscopy or Laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy or remove the affected tube with the pregnancy.
Complications
The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare in women who have access to modern medical facilities. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.