Disease: Ectopic Pregnancy

What Is an Ectopic Pregnancy?

An ectopic pregnancy can be a serious medical concern that requires prompt treatment.

A pregnancy begins when a sperm cell makes its way through the cervix and uterus and into the fallopian tube, where it meets a mature egg cell that has recently been released by the ovary.

The sperm cell merges with the egg cell, and the resulting zygote begins to divide, from one cell to two to four, etc.

In a normal pregnancy, as the cells divide, the zygote moves through the fallopian tube to the uterus, where it becomes a hollow structure called a blastocyst. The blastocyst implants in the lining of the uterus, called the endometrium.

Some of the cells of the blastocyst become the embryo, and some become the placenta, the organ that delivers oxygen and nutrients from mother to fetus and waste products from fetus to mother.

What Can Go Wrong

Occasionally, the fertilized egg implants somewhere other than the uterus. This is called an ectopic pregnancy, or sometimes, a tubal pregnancy.

One to 2 percent of pregnancies in the United States are an ectopic pregnancy, according to a report in the journal American Family Physician.

In the vast majority of ectopic pregnancies, the fertilized egg implants in the fallopian tube. However, it can also implant in the uterine muscle, the abdomen, the ovaries, or the cervix.

In virtually all cases, an ectopic pregnancy is not viable, meaning it cannot result in a healthy baby. This is because the tissues in which the egg implants cannot supply the blood and other support that the uterus normally provides for the fetus to survive.

Dangers of Ectopic Pregnancy

Any ectopic pregnancy carries the risk of catastrophic internal bleeding.

When the pregnancy is located in a fallopian tube, as it is in most cases, there’s a high risk that the fallopian tube will rupture.

That’s because unlike the uterus, which can expand in size as the embryo and then fetus grows, the fallopian tube cannot expand much at all.

As the growing embryo presses against the sides of the fallopian tube, it can cause sharp, stabbing pains in the abdomen, pelvic area, shoulder, and neck.

A ruptured fallopian tube is a medical emergency that requires immediate surgery to remove the embryo and ruptured fallopian tube.

Risk Factors for Ectopic Pregnancy

Anything that can block the passage of a fertilized egg through the fallopian tube—such as scar tissue—raises the risk of the egg implanting in the fallopian tube.

Some possible causes for such blockages include:

  • Infection or inflammation of the fallopian tube
  • Abnormally shaped fallopian tube
  • Previous ectopic pregnancy
  • Previous pelvic surgery or surgery on the fallopian tube
  • Previous pelvic surgery, including a Cesarean section (This raises the risk of an ectopic pregnancy in locations other than the fallopian tubes.)
  • Pelvic inflammatory disease (PID)
  • Endometriosis, or growth of patches of endometrial tissue outside the uterus
  • A tubal ligation, a form of permanent birth control in which the fallopian tubes are cut or blocked, that fails or is reversed

Women who smoke and women whose mothers used DES (diethylstilbestrol) during pregnancy are also at higher risk for an ectopic pregnancy. DES is a synthetic form of estrogen prescribed to women between 1940 and 1971 to prevent miscarriage, premature labor, and related pregnancy complications.

In addition, the use of fertility drugs and assisted reproductive technology has been associated with a small increase in the risk of an ectopic pregnancy.

Preventing Ectopic Pregnancy

Many ectopic pregnancies cannot be prevented, but some of those caused by PID may be preventable. That’s because an important cause of PID is chlamydia, the most common sexually transmitted bacterial disease in the United States.

Chlamydia is readily treated with antibiotics, but many women with a chlamydial infection have few or no symptoms, so they don’t seek treatment.

Women who are sexually active should discuss their need to be screened for sexually transmitted infections with their gynecologists or primary care physicians.

Quitting smoking may also lower the risk of an ectopic pregnancy.

Sources:

  • The Merck Manual Home Health Handbook, Merck Research Laboratories, Whitehouse Station, NJ, 2009.
  • Lozeau, Anne-Marie. Diagnosis and Management of Ectopic Pregnancy. American Family Physician, 2005.
  • Ectopic Pregnancy; Mayo Clinic.
  • Salpingostomy; Encyclopedia of Surgery.

What Is an Abdominal Pregnancy?

Abdominal pregnancy is extremely rare, but poses significant health risks when it occurs.

Pregnancy begins at fertilization, when a sperm cell that has made its way through the cervix and uterus and into the fallopian tube meets and merges with a mature egg cell.

Once fertilized, the egg begins to divide — from one cell to two to four, etc. — and to move through the fallopian tube to the uterus, where it implants in the lining of the uterus (the endometrium).

What Can Go Wrong

In the United States, one to two percent of pregnancies are ectopic pregnancies, caused when the fertilized egg implants somewhere other than the uterus. Of those, about 1.4 percent are abdominal pregnancies. (In most cases, the fertilized egg implants in a fallopian tube.)

In an abdominal pregnancy, the fertilized egg may implant on any number of organs or tissues within the abdomen.

Dangers of Abdominal Pregnancy

Abdominal pregnancies are dangerous for both the mother and the fetus.

For the mother, the danger is heavy internal bleeding if the placenta detaches from the abdominal organ or tissue to which it is attached.

For the fetus, the dangers include not receiving adequate blood and nutrients to support healthy growth, and not being protected by the amniotic sac and fluid (as would normally happen in the uterus).

Those fetuses that do survive an abdominal pregnancy often have malformations.

Symptoms of Abdominal Pregnancy

A woman with an abdominal pregnancy may initially have the same signs and symptoms as those of a normal pregnancy:

  • Missed period
  • Nausea and occasional vomiting
  • Breast tenderness
  • Fatigue

However, she may also have abdominal pain and/or vaginal bleeding, which should be checked out by a doctor.

Diagnosing Abdominal Pregnancy

Many abdominal pregnancies are missed or go undiagnosed until a late stage.

A doctor may suspect an abdominal pregnancy if a woman reports abdominal pain or pain with the fetus’s movements, or if the growing fetus does not seem to be in the right place in the mother’s body.

Blood tests that measure the level of human chorionic gonadotropin (hCG) can also indicate a problem if levels of the hormone are not rising normally as the pregnancy progresses.

Usually, ultrasound is used to diagnose abdominal pregnancy. Ultrasound uses sound waves to create images of internal structures. Ultrasound is used to confirm the location of the gestational sac.

In some cases laparoscopy — the insertion of a very small viewing instrument into the abdomen — is used to confirm the diagnosis.

Treatment of Abdominal Pregnancy

In very rare cases, an abdominal pregnancy has resulted in a live birth. Most abdominal pregnancies, however, are terminated medically or surgically.

If caught early, an abdominal pregnancy may be ended with a dose of methotrexate, a drug that stops cells from dividing and is toxic to the placenta.

When an abdominal pregnancy is ended surgically, the surgeon must take steps to prevent heavy bleeding at the place of implantation.

In some cases, the placenta is left in the woman’s body and treated with methotrexate to prevent such bleeding and allow the body to reabsorb the placenta.

Sources:

  • Molinaro et al. (2007). “Ectopic Pregnancies in Unusual Locations.” Seminars in Reproductive Medicine.
  • Salpingostomy; Encyclopedia of Surgery.

Symptoms of Ectopic Pregnancy

Abdominal pain and abnormal bleeding may be symptoms of an ectopic pregnancy.

The initial symptoms of an ectopic pregnancy are the same as those of a normally progressing pregnancy:

  • Missed period
  • Nausea and occasional vomiting
  • Breast tenderness
  • Fatigue

Signs of Trouble

If the pregnancy is in the fallopian tube, as most are, the following sign and symptoms develop as the growing embryo presses against the inflexible walls of the fallopian tube:

  • Sharp, stabbing pain in the pelvis, abdomen, and possibly shoulder and neck. The pain may come and go and may vary in intensity.
  • Vaginal bleeding
  • Nausea
  • Dizziness and light-headedness

Ectopic pregnancies that are not in the fallopian tube may cause more generalized abdominal pain.

When to Seek Help

An ectopic pregnancy can be life-threatening, so it’s important to seek medical help if you notice any of the signs and symptoms of an ectopic pregnancy.

Any type of ectopic pregnancy can cause heavy internal bleeding. An ectopic pregnancy located in the fallopian tube can rupture the tube, affecting future fertility.

Virtually all ectopic pregnancies are not viable, meaning they cannot result in a healthy baby, and need to be ended to protect the health of the pregnant woman.

Diagnosing Ectopic Pregnancy

When an ectopic pregnancy is suspected, the first step may be to do a pregnancy test, or qualitative hCG test, if the woman has not already had a positive pregnancy test.

A qualitative hCG detects human chorionic gonadotropin (hCG) in the mother’s urine or blood. The hormone is produced in the placenta starting shortly after implantation of the fertilized egg.

A pregnancy test can detect hCG within 10 days of a missed period, and some tests can detect it even earlier, within a week of conception.

A negative pregnancy test does not absolutely rule out pregnancy or ectopic pregnancy; it may simply be too early to detect hCG in the mother’s urine or blood.

A doctor may also order one or more quantitative hCG tests to help diagnose (or rule out) an ectopic pregnancy. A quantitative hCG test measures the level of hCG in the blood.

In an ectopic pregnancy, the blood level of hCG is usually lower than in a normally developing pregnancy and also rises at a slower-than-normal rate.

Using Ultrasound for Diagnosis

Another step in diagnosing a suspected ectopic pregnancy is using ultrasound to locate the implanted embryo.

Sometimes a transvaginal ultrasound, in which a thin probe is introduced into the vagina and sound waves are used to create images of internal structures, is performed.

If an embryo is located outside the uterus, a treatment plan is made based on the mother’s overall health, where the embryo is located, and the mother’s hCG levels (a falling level can indicate that the pregnancy is resolving on its own).

If an embryo is not located, doctors continue to monitor the pregnancy until a diagnosis can be made.

In some cases the diagnosis will be confirmed by inserting a laparoscope—a very small viewing instrument—into the abdomen through a small incision below the navel.

Sources:

  • The Merck Manual Home Health Handbook, Merck Research Laboratories, Whitehouse Station, NJ, 2009.
  • Ectopic Pregnancy; Mayo Clinic.
  • hCG; LabTestsOnline.

Ectopic Pregnancy Treatment

Prompt treatment of an ectopic pregnancy is needed to protect the health of the pregnant woman.

In all but very rare cases, an ectopic pregnancy is not viable, meaning it cannot result in a healthy baby.

In addition, most ectopic pregnancies represent a serious threat to the pregnant woman’s health.

If a woman’s body does not expel or reabsorb the embryo on its own, medical or surgical intervention is almost always necessary to end the pregnancy.

Watchful Waiting

If an ectopic pregnancy is caught very early, a doctor may elect to wait and see if the woman’s body expels or reabsorbs the pregnancy on its own.

This approach is only recommended if the woman has no symptoms, such as abdominal pain or vaginal bleeding, and declining blood levels of the hormone human chorionic gonadotropin (hCG), which would indicate the pregnancy may be ending on its own.

Methotrexate

Another possible treatment option for an ectopic pregnancy that is caught early is the drug methotrexate, which is also used to treat some forms of cancer as well as severe psoriasis and rheumatoid arthritis.

For treatment of an ectopic pregnancy, the drug may be given as a single injection or as multiple injections. Methotrexate interrupts cell division, preventing the embryo from developing any further.

Methotrexate is not a safe option for women who are breastfeeding and wish to continue doing so.

Within two to three days of injection with methotrexate, a woman can expect to experience increased abdominal pain that lasts for 24 to 48 hours, and vaginal bleeding or spotting.

Severe abdominal pain and heavy vaginal bleeding are signs of a ruptured fallopian tube and should be reported immediately to your doctor.

Other side effects of methotrexate can include nausea, vomiting, diarrhea, stomach upset, inflammation of the mouth and lips, and dizziness.

Following an injection of methotrexate, a woman must return to her medical provider’s office several times for blood tests to measure her hCG level. Falling hCG levels indicate that the pregnancy is ending. Stable or rising levels indicate that further treatment is necessary, either with another injection of methotrexate or with surgery.

Surgery

If taking methotrexate is not an option or isn’t working, the embryo must be removed surgically.

A variety of surgical techniques and approaches can be used, depending on where the embryo is implanted and, if it is implanted in a fallopian tube, whether the tube has ruptured.

Laparoscopy, surgery using very small instruments, inserted into the body through small incisions, is often the preferred approach. It is less painful and requires less healing time than laparotomy, which involves an abdominal incision.

If the fallopian tube has not ruptured, it may be possible to remove the embryo while preserving the fallopian tube.

If the fallopian tube has ruptured, however, that portion of the fallopian tube will be removed along with the embryo.

After Treatment

Having an ectopic pregnancy can take an emotional toll, so a woman and her partner will likely need time to grieve the loss of the baby.

A woman who has experienced the trauma of surgery also requires time to heal physically.

Having a normal pregnancy following an ectopic pregnancy is possible. But women who have had an ectopic pregnancy are at higher risk of having another one and should talk to their doctor about how and when it’s safe to try conceiving again.

Sources:

  • The Merck Manual Home Health Handbook, Merck Research Laboratories, Whitehouse Station, NJ, 2009.
  • Salpingostomy; Encyclopedia of Surgery.

Source: http://www.everydayhealth.com

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