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Ectopic pregnancy

Alternative Names:

  • abdominal pregnancy;
  • cervical pregnancy;
  • tubal pregnancy

What is Ectopic Pregnancy?

A pregnancy in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there.

The most common site is within a Fallopian tube, however, ectopic pregnancies can occur in the ovary, the abdomen, and in the lower portion of the uterus (the cervix).

Ectopic Pregnancy: Causes, Incidence and Risk Factors

Ectopic pregnancies are usually caused by conditions that obstruct or slow the passage of a fertilized ovum (egg) through the Fallopian tube to the uterus. This may be caused by a physical blockage in the tube, or by failure of the tubal epithelium to move the zygote down the tube and into the uterus. Most cases are a result of scarring caused by previous tubal infection.

Up to 50% of women with ectopic pregnancies have a medical history inclusive of salpingitis or PID (pelvic inflammatory disease).

Some ectopic pregnancies can be traced to congenital tubal abnormalities, endometriosis, tubal scarring and kinking caused by a ruptured appendix, scarring caused by previous tubal surgery and prior ectopic pregnancies. In a few cases, the cause is unknown.

On occasion, a woman will conceive after elective tubal sterilization. The risk of an ectopic pregnancy occurring in this situation may reach 60%. Women who have had surgery to reverse previous tubal sterilization in order to become pregnant also have an increased risk of ectopic pregnancy (when reversal is successful).

Ectopic pregnancy symptoms and risks

The administration of hormones (specifically estrogen and progesterone) can alter the normal ciliary movement of the tubal epithelium. Slow movement of the fertilized egg down the fallopian tube can result in tubal implantation. Women who become pregnant despite using the progesterone-only oral contraceptives have a 5 fold increase in the ectopic rate. Progesterone-bearing IUDs increase the risk of ectopic pregnancy from 5% (in nonmedicated IUDs) to 15%, and the “morning after pill” is associated with a 10 fold increase in risk (when its use fails to prevent a pregnancy).

The incidence data for ectopic pregnancies ranges from 1 in every 40 to 100 pregnancies. In any case, the incidence of ectopic pregnancy is on the rise (the rate nearly tripled from 1970 to 1980 and continues to increase). Increased risk is associated with women who have a history of salpingitis and/or PID, tubal surgery of any type (including tubal ligation and reversal of), or prior ectopic pregnancy. The incidence in the U.S. is higher in black women than in Caucasian women.

Ectopic Pregnancy: First sings and Symptoms

  • lower abdominal or pelvic pain
  • mild cramping on one side of the pelvis
  • amenorrhea (cessation of regular menstrual cycle)
  • abnormal vaginal bleeding – usually scant amounts, spotting
  • breast tenderness
  • nausea
  • back pain, low.

If rupture and hemorrhaging occurs before successfully treating the pregnancy, symptoms may worsen and include:

  • Severe, sharp, and sudden pain in the lower abdominal area
  • feeling faint or actually fainting
  • referred pain to the shoulder area

Ectopic Pregnancy diagnostics and tests

Ectopic pregnancy symptoms and risks

A pelvic examination may reveal uterine adnexal (Fallopian tube or ovary region) tenderness.

  • There is usually a positive pregnancy test.
  • Urine HCG (qualitative) tests may be falsely negative in up to 17.5% of them.
  • In contrast, serum HCG (quantitative) tests have only a 2% incidence of false negative results.
  • A hematocrit test may be normal or decreased.
  • The white blood count may be normal or increased.
  • A culdocentesis may be performed to determine if free blood is present in the abdomen.
  • An ultrasound (transvaginal ultrasound or pregnancy ultrasound) illustrates an empty uterus. Products of conception may be evident elsewhere.
  • A laparoscopy and or a laparotomy may be necessary for adequate diagnosis.
  • A D&C may be indicated to rule out a nonviable intrauterine pregnancy.

This disease may also alter the results of the following tests:

  • serum progesterone (found to be less than 15 ng/ml in 80% of women with ectopic pregnancies, to greater than 15 ng/ml in 90% of women with normal intrauterine pregnancies)
  • amylase
  • urine amylase

Ectopic pregnancy Treatment

In the event that pelvic-organ rupture has occurred because of the ectopic pregnancy, internal bleeding and/or hemorrhage may lead to shock. Nearly 20% of ectopic pregnancies present themselves in this manner. This is an emergency condition. Therefore, initial treatment may be to address shock by keeping the woman warm, elevating her legs, and administering oxygen. A blood transfusion is performed as soon as possible.

Laparotomy and ectopic pregnancy

Surgical laparotomy is performed to stop the immediate loss of blood (in cases in which rupture has already occurred), or to confirm the diagnosis of ectopic pregnancy, remove the products of conception, and repair surrounding tissue damage as much as possible.

Ectopic pregnancy treatment with laparoscopy

In nonemergency cases, mini-laparotomy or laparoscopy may be alternative surgical methods. Such alternatives have similar outcomes, however, they are less invasive and are available at a lower cost because they require minimal hospitalization or outpatient treatment.

Nonsurgical treatment of ectopic pregnancy

Nonsurgical (medical) management is being implemented in some medical centers for very early ectopic pregnancies without suspected immediate danger of rupture. In such cases, methotrexate is administered with careful outpatient monitoring of the woman and serial quantitative HCGs and CBCs.

Ectopic pregnancy: Expectations (Prognosis)

About 50% of the women who have experienced an ectopic pregnancy are later able to achieve a normal pregnancy. A subsequent ectopic pregnancy may occur in 10 to 20 % of cases. Some women fail to become pregnant again, while others become pregnant and spontaneously abort during the first trimester. The maternal death rate from ectopic pregnancy in the U.S. is 1 to 2%. Fetal death rate is nearly 100%.

Complications of ectopic pregnancy

Rupture, with resulting hemorrhage leading to shock and possible death, is the most common complication.
Infertility occurs in nearly 50% of women who have experienced an ectopic pregnancy with surgical treatment.

Calling Your Health Care Provider

Call for an appointment with your health care provider if symptoms occur in a woman who has the opportunity to become pregnant. Ectopic pregnancy can occur in any woman who is sexually active, regardless of contraceptive use.

Prevention

Forms of ectopic pregnancy, other than tubal, are probably not preventable, however, tubal pregnancies, which make up the majority of ectopic pregnancies, may be prevented in some cases by avoiding those conditions that might cause scarring of the Fallopian tubes. Such prevention may include:

  • avoiding risk factors for PID (multiple partners, intercourse without a condom, and contracting sexually transmitted diseases [STDs])
  • early diagnosis and adequate treatment of STDs
  • early diagnosis and adequate treatment of salpingitis and pelvic inflammatory disease (PID).




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