INTRODUCTION

The diagnosis of an ectopic pregnancy is usually a surprise and is often emotionally traumatic. Many women are in the midst of planning for the birth of their child when they receive the diagnosis. Some women diagnosed with an ectopic pregnancy do not even know they are pregnant and suddenly must contemplate the possibility of surgery or medical treatment.

Ectopic pregnancy constitute one to two percent of all conceptions. An ectopic pregnancy is an early pregnancy that has implanted outside of the uterus, the normal site for implantation. In normal conception, the egg is fertilized by the sperm in the fallopian tube. The resulting embryo travels through the tube and reaches the uterus three to four days later. However, if the fallopian tube is blocked or damaged and unable to transport the embryo to the uterus, the embryo may implant in the lining of the tube, resulting in an ectopic pregnancy. The fallopian tube cannot support the growing embryo. After several weeks the tube may rupture and bleed, resulting in a potentially serious situation.

Ninety-five percent of ectopic pregnancies implant in the fallopian tube, but they can also occur in the cervix, ovary, or even within the abdomen. Abdominal pregnancies are extremely rare and may often progress quite late into the pregnancy before they are discovered.

A commonly asked question from women who have ectopic pregnancies, particularly if they have been attempting to conceive for a long period of time, is whether the pregnancy can be removed from the tube and then transplanted into the uterus where it might grow normally. Unfortunately, this is not possible with present medical science.

Causes

Women with pre-existing tubal damage are more likely to develop an ectopic pregnancy. In fact, 50 percent of ectopic pregnancies are associated with some degree of tubal disease. Fallopian tube damage commonly results from prior pelvic infection. Tubal disease may also occur as a result of endometriosis, appendicitis, previous pelvic surgery, and DES exposure. Women who conceive after having a tubal ligation for sterilization, reversal of a tubal ligation, or any other type of tubal surgery also have a higher risk of having an ectopic pregnancy. Women who conceive as a result of fertility drugs or in vitro fertilization (IVF) have a slightly higher risk of having an pregnancy.

Sometimes there is no apparent explanation for why an ectopic pregnancy has occurred. However, it is known that once a woman has had an ectopic pregnancy, she has a higher chance of having another one and should be monitored carefully if another pregnancy is attempted or suspected.

Symptoms

Delayed or abnormal menstruation can be early sign of an ectopic pregnancy. If pregnancy is confirmed, pelvic pain, and/or irregular bleeding later in the pregnancy can indicate an ectopic pregnancy. If a woman knows or suspects she is pregnant and has experienced pelvic or lower abdominal pain, she should consult her physician even if the pain decreases in severity or stops altogether. Sometimes an ectopic is suspected when an ultrasound does not show a pregnancy inside the uterus.

Until recently, ectopic pregnancies were often not diagnosed until six to eight weeks into the pregnancy, when the patient was experiencing pelvic pain, irregular vaginal bleeding, possible internal bleeding, and tender feeling in the pelvis. Under these circumstances, this represented a life-threatening emergency, and major surgery (laparotomy) was required to remove the pregnancy and control bleeding. Fortunately, most ectopic pregnancies are now identified much earlier, often before the patient is even aware of an acute problem. This is largely due to the availability of sensitive hormonal testing and ultrasound examinations

The tests that are often used to diagnosis an early ectopic pregnancy include the measurement of human chorionic gonadotropin (hCG) levels in the bloodstream, ultrasound or laparoscopy.

In a normal pregnancy, the blood level of hCG, a hormone produced by the placental tissue, should approximately double every 48 hours. If an appropriate increase does not occur, this suggests that the pregnancy may not be healthy and may result either in a miscarriage or an ectopic pregnancy.

Ultrasound Examinations

Ultrasound can be used very early in determining whether or not a pregnancy is inside the uterine cavity. Transvaginal ultrasound is much more sensitive than abdominal ultrasound for this purpose. Ultrasound scans can also show fluid or blood in the abdominal cavity, suggesting a bleeding ectopic. Use of ultrasound, combined with hCG, can confirm the diagnosis of an ectopic pregnancy without the need for a laparoscopy.

In many cases a laparoscopy is required to confirm the diagnosis of an ectopic pregnancy. Laparoscopy can also be used to treat the ectopic. Laparoscopy is an outpatient surgical procedure requiring general anesthesia. A small telescope called a laparoscope is placed into the abdominal cavity through an incision in the navel. If necessary, the doctor can usually remove the ectopic pregnancy by placing special instruments through the laparoscope or through small incisions above the pubic area.

TREATMENT

For many years, the treatment of a tubal ectopic pregnancy was laparotomy to remove the effected tube and sometimes the nearby ovary. If diagnosed early, many ectopic pregnancies can now be removed while preserving the fallopian tube and/or ovary. A procedure called salpingostomy can save the fallopian tube containing the ectopic. In this procedure, the fallopian tube is opened and the pregnancy tissue is removed. The tube subsequently heals on its own. There is one drawback to using this procedure; some of the ectopic pregnancy tissue may remain and continue to grow. This occurs in 5 to15 percent of cases and may be treated by surgically removing the tube or by using methotrexate therapy. If the part of the tube containing the ectopic pregnancy cannot be saved, the doctor may perform a partial salpingectomy. In this operation, only the part of the tube containing the ectopic pregnancy is removed. If only a small portion of the tube removed, the tube may be rejoined later using microsugery.

If the fallopian tube is extremely damaged, the ectopic pregnancy is large and must be removed quickly, or future fertility is not an issue, a total salpingectomy is done. Some unusual types of ectopic pregnancy, such as cervical pregnancies, occasionally require hysterectomy for treatment

Medical Treatment

Recently, new advances have been made in the treatment of ectopic pregnancy. Because of the trend toward early diagnosis, medical (non-surgical) treatment is now available. A drug called methotrexate may be used to treat ectopic pregnancy. This drug was initially used to treat unique cancers usually derived from placental tissue. It is very effective in destroying ectopic pregnancy tissue and allowing it to be reabsorbed by the body. Methotrexate may be given as either a single intramuscular shot or as a multi-dose regimen with shots or pills for several days. A large number of early ectopics can be successfully treated with methotrexate therapy, often leaving the tube open. Patients who have liver and/or kidney disease are generally not candidates for Methotrexate therapy.

There are no known long-term side effects from methotrexate use. The short-term side effects are few. The drug can cause temporary ulcers in the mouth and other gastrointestinal sites, and can cause temporary liver function problems. Additionally, because methotrexate can cause sensitivity to sunlight, sun exposure should be limited during treatment because sunburn can occur very easily. Rare complications include pneumonia and inhibition of platelet production, resulting in bleeding problems within the first two weeks after methotrexate treatment. Patients may complain of abdominal pain, lasting for a day or two, which is often due to resorption of the ectopic pregnancy. Women should report these symptoms to their doctors.

When being treated with methotrexate, women should not drink alcohol or take vitamins containing folic acid, which is found in most prenatal vitamins.

Methotrexate does not always work. It is most likely to fail when an ectopic pregnancy is large. If treatment is successful, hCG levels should decline to zero over the next two to six weeks. If hCG levels do not fall, methotrexate treatment may be repeated or the pregnancy may be removed surgically.

OUTCOME

There is an increased chance of being infertile after an ectopic pregnancy. In addition, the chance of having another ectopic pregnancy is increased. Fortunately, over half of women who experience an ectopic pregnancy will have healthy baby sometime in the future. It is often recommended that women wait three to six months after treatment of an ectopic before attempting pregnancy. Since an ectopic pregnancy is often due to pre-existing tubal disease and these patients are at an increased risk for infertility, many physicians may consider further evaluation in those women who want a future pregnancy. Physicians may recommend that women who have had multiple recurrent ectopic pregnancies undergo in vitro fertilization (IVF). While IVF reduces the risk of ectopic pregnancies for these women, there is still approximately a 5 percent chance of a tubal pregnancy.

Emotional Aspects

Ectopic pregnancy is a physically and emotionally traumatic experience. In addition to experience the loss of a pregnancy, women may fear the loss of future fertility. Feeling of grief and loss are normal. Sadness, anger, self-blame, guilt, and depression are part of the grieving process and need to be acknowledged and expressed. Time is necessary for both physical and emotional healing before attempting another pregnancy.

SUMMARY

Ectopic pregnancy refers to any pregnancy implanted outside of the uterus, usually in the fallopian tube. Early diagnosis is facilitated by the use of sensitive hormonal tests, ultrasound exams, laparoscopy, or D&C. Modern surgical and medical treatments frequently allow for avoidance of extensive surgery and preservation of the involved fallopian tube. Although the risk of having another ectopic pregnancy is increased, many women will successfully conceive and have children in the future, either naturally or with the aid of an assisted reproductive technology such as IVF.