Ectopic Preg

An ectopic pregnancy is a complication of pregnancy in which the fertilized ovum is developed in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. 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.

Overview

Oviduct with an ectopic pregnancy (tubal pregnancy) showing an embryo of approx. 6-7 menstrual weeks

Another example of a tubal pregnancy (fetus is 8 weeks gestational age, 6 weeks from conception) In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.[1] In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding (hematosalpinx) expels the implantation out of the tubal end as a tubal abortion. Some women thinking they are having a miscarriage are actually having a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity,

which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

Causes There are a number of risk factors for ectopic pregnancies. However, in as many as one third [2]to one half [3] of ectopic pregnancies, no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, those who have been exposed to DES, tubal surgery, smoking, previous ectopic pregnancy, and tubal ligation. [4]

Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Damage to the cilia or blockage of the Fallopian tubes is likely to lead to an ectopic pregnancy. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia. If however both tubes were occluded by PID, pregnancy would not occur and this would be protective against ectopic pregnancy. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy. Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of ectopic pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound.

Other Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies; this is speculative. Women exposed to diethylstilbestrol (DES) in utero (aka "DES Daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women.

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. Later presentations are more common in communities deprived of modern diagnostic ability. The early signs are: • • • •

•

Pain in the lower abdomen, and inflammation (Pain may be confused with a strong stomach pain, it may also feel like a strong cramp) Pain while urinating Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. 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. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. 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 and has two discrete pathophysiologic mechanisms. • •

External bleeding is due to the falling progesterone levels. Internal bleeding (hematoperitoneum) 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). The most common misdiagnosis assigned to early ectopic pregnancy is PID. More severe internal bleeding may cause: • • • •

•

Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse. Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.

Diagnosis An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. An abnormal rise in blood βhCG levels may also indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy today is around 1500 IU/ml of βhuman chorionic gonadotropin (βhCG). A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for βhCG has been reached. An empty uterus with levels lower than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work and ultrasound. If the βhCG falls on repeat examination, this strongly suggests an abortion or rupture. Free fluid which is non-echogenic is a normal finding in the late menstrual cycle and early normal pregnancy. This is a transudate and is not presumptive evidence of bleeding. Echogenic free fluid suggests the presence of blood clot and is suggestive of free blood in the peritoneum. A laparoscopy or laparotomy 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 laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. 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. Cullen's sign can indicate a ruptured ectopic pregnancy.

Nontubal ectopic pregnancy Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[5] While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been salvaged from an abdominal pregnancy. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is

generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports.[6][7][8] However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of hemorrhage. On 19 April 2008 an English woman, Jayne Jones (age 37) who had an ectopic pregnancy attached to the omentum, the fatty covering of her large bowel, gave birth. The baby was delivered by a laparotomy at 28 weeks gestation. The surgery, the first of its kind to be performed in the UK, was successful, and both mother and baby survived.[9] On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via Caesarean section. She had no problems or complications during the 38 week pregnancy.[10][11]

Heterotopic pregnancy In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. Although rare, with the continual increase of IVFs, heterotopic pregnancies are becoming more and more common. However, these pregnancies are still considered moderate to high risk. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%. [3] Successful pregnancies have been reported even from burst tubal pregnancy continuing by the placenta implanting on abdominal organs or on the outside of the uterus. The case of Olivia, Mary and Ronan had an extrauterine fetus (Ronan) and intrauterine twins. All three survived. The intrauterine twins were taken out first. [12]

Treatment

] Nonsurgical treatment Early treatment of an ectopic pregnancy with the antimetabolite methotrexate has proven to be a viable alternative to surgical treatment[13] since 1993[citation needed] (though the literature dates back to at least 1989).[14] If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy.

] Surgical treatment If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.[15]

Chances of future pregnancy The chance of future pregnancy depends on the status of the adnexa left behind. The chance of recurrent ectopic pregnancy is about 10% and depends on whether the affected tube was repaired (salpingostomy) or removed (salpingectomy). Successful pregnancy rates vary widely between different centuries, and appear to be operator dependent. Pregnancy rates with successful methotrexate treatment compare favorably with the highest reported pregnancy rates. Often, patients may have to resort to in vitro fertilisation to achieve a successful pregnancy. The use of in vitro fertilisation does not preclude further ectopic pregnancies, but the likelihood is reduced.

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.

Ectopic pregnancy and Moral theology In Catholic moral theology, the event of an ectopic pregnancy is one of the only cases where the foreseeable death of a child in the womb is allowed, since it is categorized as an indirect abortion. In the 1968 encyclical Humanae Vitae, Paul VI writes that "the Church does not consider at all illicit the use of those therapeutic means necessary to cure bodily diseases, even if a foreseeable impediment to procreation should result there from

—provided such impediment is not directly intended for any motive whatsoever". This view was also advocated by Pius XII in a 1953 address to the Italian Association of Urology. [16]

Ectopic means "out of place." In an ectopic pregnancy, a fertilized egg has implanted outside the uterus. The egg settles in the fallopian tubes in more than 95% of ectopic pregnancies. This is why ectopic pregnancies are commonly called "tubal pregnancies." The egg can also implant in the ovary, abdomen, or the cervix, so you may see these referred to as cervical or abdominal pregnancies. None of these areas has as much space or nurturing tissue as a uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding and endanger the mother's life. A classical ectopic pregnancy does not develop into a live birth.

Signs and Symptoms Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. These can include missed periods, breast tenderness, nausea, vomiting, or frequent urination. The first warning signs of an ectopic pregnancy are often pain or vaginal bleeding. You might feel pain in your pelvis, abdomen, or, in extreme cases, even your shoulder or neck (if blood from a ruptured ectopic pregnancy builds up and irritates certain nerves). Most women describe the pain as sharp and stabbing. It may concentrate on one side of the pelvis and come and go or vary in intensity. Any of the following additional symptoms can also suggest an ectopic pregnancy:

• • • •

vaginal spotting dizziness or fainting (caused by blood loss) low blood pressure (also caused by blood loss) lower back pain

What Causes an Ectopic Pregnancy? 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 might have partially or entirely blocked it. Pelvic inflammatory disease (PID), which can be caused by gonorrhea or chlamydia, is a common cause of blockage of the fallopian tube. Endometriosis (when cells from the lining of the uterus implant 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.

Diagnosis If you arrive in the emergency department complaining of abdominal pain, you'll likely be given a urine pregnancy test. Although these tests aren't sophisticated, they are fast — and speed can be crucial in treating ectopic pregnancy. If you already know you're pregnant, or if the urine test comes back positive, you'll probably be given a quantitative hCG test. This blood test measures levels of the hormone human chorionic gonadotropin (hCG), which is produced by the placenta and appears in the blood and urine as early as 8 to 10 days after conception. Its levels double every 2 days for the first several weeks of pregnancy, so if hCG levels are lower than expected for your stage of pregnancy, one possible explanation might be an ectopic pregnancy. You'll probably also get an ultrasound examination, which can show whether the uterus contains a developing fetus or if masses are present elsewhere in the abdominal area. But the ultrasound might not be able to detect every ectopic pregnancy. The doctor may also give you a pelvic exam to locate the areas causing pain, to check for an enlarged, pregnant uterus, or to find any masses. Even with the best equipment, it's hard to see a pregnancy less than 5 weeks after the last menstrual period. If your doctor can't diagnose ectopic pregnancy but can't rule it out, he or she may ask you to return every 2 or 3 days to measure your hCG levels. If these levels don't rise as quickly as they should, the doctor will continue to monitor you carefully until an ultrasound can show where the pregnancy is.

Options for Treatment

Treatment of an ectopic pregnancy varies, depending on how medically stable the woman is and the size and location of the pregnancy. An early ectopic pregnancy can sometimes be treated with an injection of methotrexate, which stops the growth of the embryo. If the pregnancy is further along, you'll likely need surgery to remove the abnormal pregnancy. In the past, this was a major operation, requiring a large incision across the pelvic area. This might 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. The surgeon makes small incisions in the lower abdomen and then inserts a tiny video camera and instruments through these incisions. The image from the camera is shown on a screen in the operating room, allowing the surgeon to see what’s going on inside of your body without making large incisions. The ectopic pregnancy is then surgically removed and any damaged organs are repaired or removed. Whatever your treatment, the doctor will want to see you regularly afterward to make sure your hCG levels return to zero. This may take several weeks. An elevated hCG could mean that some ectopic tissue was missed. This tissue may have to be removed using methotrexate or additional surgery.

What About Future Pregnancies? Some women who have had ectopic pregnancies will have difficulty becoming pregnant again. This difficulty is more common in women who also had fertility problems before the ectopic pregnancy. Your prognosis depends on your fertility before the ectopic pregnancy, as well as the extent of the damage that was done. The likelihood of a repeat ectopic pregnancy increases with each subsequent ectopic pregnancy. Once you have had one ectopic pregnancy, you face an approximate 15% chance of having another.

Who's at Risk for an Ectopic Pregnancy? While any woman can have an ectopic pregnancy, the risk is highest for women who are over 35 and have had: • • • •

PID a previous ectopic pregnancy surgery on a fallopian tube infertility problems or medication to stimulate ovulation

Some birth control methods can also affect your risk of ectopic pregnancy. If you get pregnant while using progesterone-only oral contraceptives, progesterone intrauterine

devices (IUDs), or the morning-after pill, you might be more likely to have an ectopic pregnancy. Smoking and having multiple sexual partners also increases the risk of an ectopic pregnancy.

When to Call Your Doctor If you believe you're at risk for an ectopic pregnancy, meet with your doctor to discuss your options before you become pregnant. You can help protect yourself against a future ectopic pregnancy by not smoking and by always using condoms when you're having sex but not trying to get pregnant. Condoms can protect against sexually transmitted infections (STDs) that can cause PID. If you are pregnant and have any concerns about the pregnancy being ectopic, talk to your doctor — it's important to make sure it's detected early. You and your doctor might want to plan on checking your hormone levels or scheduling an early ultrasound to ensure that your pregnancy is developing normally. Call your doctor immediately if you're pregnant and experiencing any pain, bleeding, or other symptoms of ectopic pregnancy. When it comes to detecting an ectopic pregnancy, the sooner it is found, the better.