Ectopic Pregnancy

Written by Suman Bijlani.

 

What is ectopic pregnancy?

A normal pregnancy grows inside the uterus. If the embryo implants outside the uterus, the pregnancy is known as ‘ectopic pregnancy’. The incidence of ectopic pregnancy is about 1-2% of all pregnancies.

Where exactly does an ectopic pregnancy occur outside the uterus?

The pregnancy may implant at any of the following sites:

          

    Inside the fallopian tube (tubal ectopic pregnancy)- commonest (98% cases) 

    Inside the ovary (ovarian ectopic pregnancy)Sites of ectopic pregnancy

        Inside the cervix (cervical ectopic pregnancy)

    Inside the abdominal cavity (abdominal ectopic pregnancy)

 

 

Since tubal pregnancy is by far the commonest type of ectopic pregnancy, the rest of the discussion will be limited to tubal ectopic pregnancy.

What happens if I have a tubal pregnancy? What happens to my baby? Will it be fine?

Unfortunately, the fetus cannot survive outside the uterus as it cannot get the nourishment and space to grow. Normally, the baby’s blood vessels grow deep into the muscles of the mother’s uterus to form the placenta which gives it blood supply. However, when the pregnancy is in the fallopian tube, the muscles of the tube are very thin and the blood vessels erode the wall of the tube, leading to bleeding, causing an emergency situation.

In an emergency situation, doctors have to operate and remove the pregnancy surgically.

Will I get any symptoms if I have ectopic pregnancy?

If you have ectopic pregnancy, you may experience the following symptoms:

  Missed periods

  Bleeding from vagina (mild, moderate or severe)

  Sometimes you may not even miss your period, but may get some bleeding at the time of your monthly cycle

  Lower abdominal pain (usually on one side or in the centre- may be mild, moderate or severe

  Giddiness

  Fainting (usually indicates internal bleeding)

Since most women undergo an early sonography in pregnancy, ectopic pregnancies are getting diagnosed very early before symptoms can develop.

Can ultrasound diagnose ectopic pregnancy?

Since the incidence of ectopic pregnancy is on the rise, it is advisable to undergo an early ultrasound examination (baseline check) at about 6 weeks pregnancy (2 weeks after a missed period) to confirm that the pregnancy is within the uterus. Transvaginal ultrasound (internal ultrasound) is the preferred method as it gives much better information at an early stage of pregnancy.

If the sonologist does not find the pregnancy inside the uterus, he/she will look for it in the tubes. It looks like an abnormal mass outside the uterus in the region of the tubes. But ectopic pregnancy may not always show up on sonography, especially in the early stages. In such cases, doctors will look for other signs suggestive of ectopic pregnancy such as free fluid inside the pelvis and abdomen (suggestive of internal bleeding). In very early cases, there may be no indication even on sonography.

What if ultrasonography does not diagnose ectopic pregnancy? Is there any other way?

If your gynaeocologist is suspicious, he/she will advise a blood test – beta HCG level. This level is higher in normal pregnancies than in ectopic pregnancy. Also, if you do HCG level twice (at 48-72 hours interval), the rate of rise of HCG hormone gives us a clue whether the pregnancy is ectopic or not.

So how can I be sure whether it is ectopic or not?

If sonography can clearly see the ectopic pregnancy, the diagnosis is easy. Otherwise, a simple indicator is this: If the beta HCG value is more than 1500 and no pregnancy is seen inside the uterus on INTERNAL sonography, it is diagnostic of an ectopic pregnancy. Sometimes you may need to undergo serial (repeated) beta HCG levels and sonographies to arrive at a diagnosis.

I have been bleeding heavily since 2 days. Does that mean that the ectopic pregnancy has been thrown out of my system? Or that it has ruptured?

No. The ectopic pregnancy is located inside the abdominal cavity. It cannot bleed outside. If you are having vaginal bleeding, it means that the inner lining of the uterus is shedding. That can happen due to low hormonal levels. 

If I have a tubal ectopic pregnancy, is it necessary that I have to undergo surgery? Can I take medicine to dissolve the pregnancy?

Fortunately, there are treatments available which can avoid surgery.

The commonest and time-tested treatment is giving Inj Methotrexate (an anti-cancer drug) to dissolve the pregnancy. It is given in a small dose and thus, it harms only the growing embryo and is quite safe for the mother. This regimen is about 80% effective for well-selected cases.

Sometimes your doctor may choose to inject this drug directly into the pregnancy under sonographic guidance. That also works well for most women.

How can I decide whether to undergo surgery or to take the injection? What would be best for me?

This is a technical issue and should be decided by your doctor. However, there are certain indicators which can guide you. Inj Methotrexate should be used under the following conditions:

 You are not bleeding internally

 Your tube has not ruptured

 Your ectopic pregnancy is less than 3 cm in size and the embryo does not show heart beat

  Your beta HCG level is low (preferably less than 5000 IU/ml)

If the mass is big or HCG is high or you have begun to bleed internally, the risk of rupture of the fallopian tube is high. Therefore it is better to undergo surgery.

If I am given injections, am I assured that the ectopic pregnancy will dissolve? And I will be cured?

If you are given Inj Methotrexate (single dose in the muscle), you would need to be under observation, preferably in the hospital. You may experience the following symptoms: Abdominal pain (mostly cramp-like) usually happens about 3 days after the injection; occasionally, you may get nausea, vomiting, loose motions or ulcers in the mouth. The doctor will do your beta HCG on the 4th and 7th day after the injection. The levels should drop by 15% of the initial value on 7th day. That indicates good response to the injection. The fourth day Beta HCG may rise. Do not panic.

There is a chance that your tube might rupture inspite of methotrexate injection and that would require immediate surgery.

How do I know if my tube has ruptured? Is it dangerous?

When your tube ruptures, you get intense pain in the lower abdomen. You may even faint or feel giddy or may vomit. This happens because of sudden bleeding inside the abdomen. This is a critical situation because blood loss may be sudden and massive. You should be transferred to a hospital immediately and operated upon. You may need blood transfusions to save your life (depending on the amount of blood loss).

What kind of surgery do I need to undergo?

There are many options for surgery. Today most of the surgeries are done laparoscopically. Salpingectomy

The commonest operation is salpingectomy – removal of the affected tube. At other times, when you wish to and it is possible to retain the tube, the gynaecologist may perform salpingostomy (making an incision on the tube, removing the ectopic sac and cleaning the tube) or may try to push the ectopic tissue out from the fimbrial end (milking of the tube)so that the entire tube may be saved. This is not always possible or successful though.

If your tube has ruptured and you are bleeding profusely, you may need to undergo laparotomy (open surgery).

I would like to save my tube – I mean I would prefer to undergo salpingostomy/milking of the tube and not salpingectomy. Is that advisable?

In all cases, it may not be feasible or advisable to save the tube. For example, if your tube has ruptured or is diseased or you have a second-time ectopic pregnancy in the same tube or you don’t desire more children.

If, on the other hand, you have a small, unruptured ectopic pregnancy Salpingostomywith no bleeding and the tube is otherwise healthy and you wish to have children, the gynaecologist may try to milk the tube or perform salpingostomy. Rarely, if you preserve the tube, some amount of ectopic tissue may be left behind which may grow later or cause symptoms and may need medical (injection) or surgical treatment.

Why does one get ectopic pregnancy?

Ectopic pregnancy occurs more commonly in the following group of women:

$      Women with diseased fallopian tubes. This may be due to infection (pelvic inflammatory disease) endometriosis or post-operative adhesions

$      Women undergoing fertility treatments

        Women who have had ectopic pregnancy in the past

$      Women with IUD in place and women who have undergone tubal sterilisation or tubal repair surgery may rarely find themselves with pregnant inside the tubes

    Smokers may have a slightly increased risk depending on the number of cigarettes per day smoked

I have had ectopic pregnancy in the past. Will I get it again?

The risk of getting a repeat ectopic pregnancy on the same side or the opposite side is 15% after one episode of ectopic pregnancy and 30% after two episodes of ectopic pregnancy.

What precautions should I take for the future?

If you have taken Injection Methotrexate, you should wait for about 3months before you try to conceive again. Methotrexate reduces your folic acid levels and that can increase your risk of birth defects if you conceive soon. During this 3 month waiting period and till you conceive, you should be on folic acid supplementation to restore your folic acid levels.

If you are a smoker, it would be worth your while to try and get over the habit.

 

 

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