Of all women that get pregnant, around 2% of them will develop an ectopic pregnancy. It can be a life threatening condition that needs to be diagnosed as soon as possible. What is it, why does it happen and how can it be treated? Let’s find out!
Ectopic pregnancy is a pregnancy that develops outside the uterine cavity. The word ectopic comes from the Greek terminology “ektopos” and means out of place. A normal pregnancy develops in the uterus, therefore an extrauterine one is not normal nor healthy. Don’t know how a normal pregnancy happens? Read our previous post.
In an ectopic pregnancy the fertilised egg becomes an embryo and is implanted outside of the uterus. Most cases of extrauterine pregnancies happen in the fallopian tube (98%) but the embryo can fix itself on the cervix, ovary, abdomen, liver, spleen or caesarean section scar as well. As the embryo is implanted outside the uterus, it does not have the suitable environment for growing and developing, therefore the process of transforming into a fetus stops.
Ectopic pregnancy is a common cause of sickness and death in fertile women in the first trimester of pregnancy. In developed countries around 1-2% of pregnancies are ectopic, while in developing ones it is supposed to be a higher percent. In the developing world 1 in 10 patients with ectopic pregnancy ultimately dies from this condition because of the lack of proper medical services, leading to late diagnosis. Therefore, 10% of women diagnosed with ectopic pregnancy end up dying because of it. The most frequent causes of death related to ectopic pregnancy are hemorrhage, infection and anesthetic complications.
Symptoms of an ectopic pregnancy are usually pelvic pain and vaginal bleeding in the gestational period of 6 to 10 weeks. Unfortunately, these are also normal symptoms during pregnancy so it is hard to diagnose based only on these signs. Other symptoms include: shoulder tip pain, syncope (fainting) or abdominal tenderness (pain when pressing on the abdomen).
One third of patients have no clinical signs (signs observed by the doctor) and 9% of them have no symptoms (patients feel good). Some cases of ectopic pregnancies can even mimic other conditions such as appendicitis, gastrointestinal or urinary tract diseases, urinary tract infection or misscariage, making the diagnosys very difficult.
The exact cause of ectopic pregnancies is not completely elucidated, but in the last decades the incidence of ectopic pregnancies has risen, due to several factors: an increase in risk factors, the increased use of ART (assisted reproductive technology) and increased awareness, as a result of medicine evolving. Unfortunately, around 50% of women with this condition do not have an identifiable risk.
The major risks that can cause ectopic pregnancy are: damage of the fallopian tube as a result of surgery or infection with Chlamydia trachomatis, smoking or IVF (in vitro fertilization).
Damage of the fallopian tube
Previous pelvic or abdominal surgery
Previous pelvic infection: infection with Chlamydia trachomatis has been linked with 30-50% of all ectopic pregnancies. The mechanism is still unknown, but it is claimed that the infection and recurrent infections cause tubal inflammation and tubal damage over time. Another infection that can cause ectopic pregnancy is caused by Neisseria gonorrhoeae.
Assisted reproduction technology (ART): in vitro fertilisation has an 2-5% chance of developing into an ectopic pregnancy. The first IVF pregnancy, that was unsuccessful, was an ectopic one. The risk of developing an ectopic pregnancy increases with the number of embryos transferred during IVF treatment. Women who undergo IVF because of infertility related to fallopian tube damage, are more prone to developing ectopic pregnancies than women that approach this method because of male infertility.
Contraceptive failure: progesterone-only contraception and IUDs (intrauterine devices with progesterone; the one with copper is safer) can cause ectopic pregnancies as a failure of contraceptive action.
Cigarette smoking: present and past exposure. One third of ectopic pregnancy are linked to smoking. The effect of smoking is dose dependent (correlated with the amount of cigarettes smoking - more than 20/day). Studies suggest that smoking affects the pregnancy by delaying the ovulation process, by altering the tubal and uterine motility (ability to transport the embryo) or altering the immunity. Smokers have higher risk (around 3.5 times more) than non smokers to develop ectopic pregnancy.
Age over 35: the risk of ectopic pregnancy increases with age. The highest incidence is between the age of 35 and 44. The increased age is correlated with this condition due to a longer period of time of accumulating other factors.
Previous ectopic pregnancy: the risk of developing ectopic pregnancy increases with the experience of having one (up to 20% risk) or more in the past (up to 32% risk).
Previous spontaneous missscariage or induced abortion.
In case of a healthy intrauterine pregnancy, the identification of the embryo with transvaginal ultrasonography should be possible with an almost 100% accuracy at a gestational age of around 6 weeks. Sometimes, the transvaginal ultrasonography can’t identify the location of a pregnancy accurately so patients are diagnosed with “pregnancy of unknown location” (PUL). In case of a PUL diagnostic, further investigation is imperious.
When an intravaginal sonogram is inconclusive, a diagnostic laparoscopic procedure (a narrow device with a camera and light that goes through a small cut in the abdomen in order to look at the reproductive system) is approached. The laparoscopy is considered to be the “gold standard” in diagnosing ectopic pregnancies.
A transvaginal ultrasonography can be inconclusive when a heterotopic pregnancy occurs. It is a very rare (1 in 400000) situation when both extravaginal and intravaginal pregnancies develop at the same time. Usually, they are more common after an IVF treatment and they are hard to diagnose.
Measurement of hormone levels
The beta-human chorionic gonadotropin hormone (β-hCG) is a hormone that is secreted during pregnancy and the levels usually increase by 66% every 2 days. In the case of an ectopic pregnancy or a misscariage, the levels of β-hCG decrease by 35% over 2 days.
CT and MRI
Pregnant women should not undergo radioactive diagnostic methods, but young women that complain of abdominal pain and bleeding can undergo CT (computed tomography) and MRI (magnetic resonance imaging) in order to rule out ectopic pregnancy.
Management of ectopic pregnancy
Surgery is imperious in case of an ectopic pregnancy that provoked tubal damage or rupture, or for patients that have contraindications to medical treatment or the medication didn’t work in the past.
There are two types of surgery:
Salpingectomy: procedure where the entire fallopian tube, or the segment that is affected by the ectopic pregnancy is removed. In this case future fertility may be compromised.
Salpingostomy: procedure that makes an opening on the fallopian tube in order to remove the ectopic pregnancy, maintaining fertility.
For patients without damaged fallopian tubes, the most suitable treatment is a single dose of Methotrexate. Methotrexate is a substance that targets cells that are growing fast, stops the growing process and inverts it.
Some ectopic pregnancies can resolve by themselves through regression or tubal abortion without causing any harm to the patient. This approach needs to be observed carefully by the doctor in order to assess the resolving spontaneity of the pregnancy without any intervention.
As medicine developed and the awareness about ectopic pregnancy spreaded, now it is a condition that can be treated if diagnosed in time.
If you have one of the symptoms presented, consult with your doctor and never take treatment by yourself!
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