It means implantation of the fertilized egg outside the uterus. The placenta
and fetus begin to develop there.
The most common site in fallopian tube commonly called tubal pregnancy and represent
95% of cases.
Ectopic pregnancy can also rarely occur in the ovary, in the abdomen "abdominal
pregnancy" and in the lower portion of uterus in the cervix referred to as cervical
pregnancy. Ectopic pregnancy occurs from 1-2% in all pregnancies. Ectopic pregnancy
is an importatn cause of maternal mortality in the first trimester
Symptoms
In ectopic pregnancy, there are symptoms, which are similar to those that happen
in normal early pregnancy like headache, nausea, vomiting and breast tenderness.
But there are other symptoms that occur in most cases.
1. pain: lower abdominal pain sometimes may localize to one iliac fossa. Pain
present in 95% of cases
2. Delayed period or irregular menses occur in 75% of cases
3. Vaginal bleeding or brown discharge, and syncope. This is not heavy usually
as spotting. The vaginal bleeding or discharge is due to shedding of the decidua
or "decidual cast" when the pregnancy fails
Causes
1. PID "pelvic inflammatory disease". 50% of women with ectopic pregnancies
have a medical history of salpingitis or PID. Mostly caused by infection with
such organisms as gonorrhea and Chlamydia, tuberculoses and other infections,
including appendictis also cause increased incidence of ectopic pregnancy. The
inflammation causes damage to the ciliated epithelium in the fallopian tube,
which is important in transport of fertilized ovum to the uterus
2. Obstruction or blockage in the fallopian tube. Result from previous tubal
surgery like tubal sterilization. The risk of an ectopic pregnancy occurring
in this situation may reach to 60%
Also congenital tubal abnormalities, endomertriosis and tubal scarring caused
by ruptured appendix or by previous pelvic surgery can cause ectopic pregnancy.
3. Contraceptive methods: like using progesterone only oral contraceptives and
progesterone bearing IUCD. Can increase risk of ectopic pregnancy. Although
these methods are close to 99% effective in preventing pregnancy but when pregnancy
occur in this situation. There is increased incidence of ectopic pregnancy.
The progesterone impairs peristalsis movement of tubes and slow down transport
of fertilized egg result in implantation in the tube.
Risk factors
1. maternal age between 35-40. have higher rates of ectopic
2. Previous ectopic pregnancy increase the risk of recurrence to 10-15%
3. Few studies suggest increased risk for ectopic pregnancy in smoker women
4. Documented previous salpingitis resulting in tubal damage.
5. History of infertility
6. Previous pelvic surgery including sterilization.
9. Exposure to diethylstilboestrol in utero Complications
1. Rupture ectopic pregnancy with resulting hemorrhage leading to shock. This
is most common complication
2. infertility:- occurs in 10-15% of women with history of ectopic pregnancy.
Prevention
There is no known way to prevent ectopic pregnancy but there are important points
that should be considered to decrease the incidence of (PID) which as we mentioned
before increases the incidence of ectopic pregnancy
1. avoiding multiple sexual partners
2. Using condom during intercourse when one of the partners is infected with
(STD)
3. early diagnosis and adequate treatment for (STD)
4. early diagnosis and treatment for (PID) Diagnosis
1. vaginal examination: may reveal uterine adenexal tenderness
2. blood test:- to check level of pregnancy hormone (HCG). If the hormone level
is high enough to suggest pregnancy but is not within the normal levels of that
stage of pregnancy, it may be ectopic and should be repeated every 3 days.
3. Ultrasound: by using transvaginal ultrasound the physician can detect embryo
in the fallopian tube. But in most cases the embryo die early in the process
and too small for the sonographer to find. By transvaginal ultrasound, we can
detect blood clots as well as tissue that remain from the embryo. Such diagnostic
strategies have greatly reduced the use of laproscopy, but this diagnostic surgical
procedure is likely to remain the final diagnostic test if interpretation of
the test results is uncertain.
- Absence of intrauterine gestational sac and the pregnancy test with level
of hormone above 1000 iu/l more likely it is ectopic pregnancy.
4. Culdocentesis (historical) this test less commonly performed is used to look
for internal bleeding and it is not useful in detecting an early ectopic pregnancy
Treatment
Conservative management
By monitoring ectopic pregnancy in it's early stage. When its size is small
and cannot be detected in vaginal u/s and level of HCG very low.
This pregnancy can resolve spontaneously "spontaneous miscarriage through fallopian
tube" without any medical or surgical intervention.
Medical treatment
The success rate of medical treatment is 80-90%; approximately two-thirds have
patent tubes after the procedure. In the absence of a history of infertility,
the subsequent conception rate is 80% and the recurrent ectopic pregnancy rate
is 11%
This method is safer than surgical treatment. Used when embryo is still small
and HCG level not high by using drug (methotrexate) I.M injection and the dose
according to BMI and body weight. This drug reaches the embryo through blood
stream, where it ends the pregnancy by stopping the cells of placenta from growing.
Overtime, The tiny embryo is reabsorbed into your body.
The patient need blood testing for HCG level to make sure that the pregnancy
has been terminated.
Side effect of metrotrexate
1.abdominal pain or cramps
2. nausea And vomiting
3. Some times diarrhoea.
Note:
Avoid alcohol and multivitamins that contain folic acid which can interfere
with action of methotrexate
* You can take paracetamol only as analgesia
* Preferable to use contraceptives pills for 3-6 months after medical treatment
with methotrexate
Surgical treatment
Laparoscopy: - is the most common surgical treatment used in
non-emergency cases and when the patient is in stable condition. This method
is less invasive and requires minimal hospitalization. After this operation
patient need one week to recuperate. Laproscopic treatment of tubal pregnancy
offers numerous advantages: reduced operating time, hospital stay and cost,
earlier return to activity and improved cosmetic result.
Surgical Laparotomy
Used in cases in which rupture has already occurred and when there is severe
internal bleeding and patient is in shock state. Or when the embryo is too large.
After the operation patient need six weeks to recuperate.
Surgical methods include removal of product of conception and the tube may be
preserved or may need to be removed depending on the situation.
3. Vaginal bleeding or brown discharge, and syncope. This is not heavy usually
as spotting. The vaginal bleeding or discharge is due to shedding of the decidua
or "decidual cast" when the pregnancy fails
