Ectopic Pregnancy

CONDITION

What is an ectopic pregnancy?

An ectopic pregnancy is characterised by the implantation of a fertilised egg (embryo) in a region other than the uterus. Since it occurs most often in the fallopian tube, it is sometimes referred to as a tubal pregnancy. The uterus is the only organ designed to hold and nurture a growing embryo; hence, the attachment of the embryo in any other place needs to be treated.

What are the common names for ectopic pregnancy?

Since ectopic pregnancy occurs most often in the fallopian tube, it is sometimes referred to as a tubal pregnancy.

Ectopic Pregnancy

Ectopic Pregnancy

What is the percentage of population affected by ectopic pregnancy?

An ectopic pregnancy can occur in 1 out of 50 pregnancies.

How does ectopic pregnancy affect you?

The organ/tissue other than the uterus will not support the growing embryo and will lead to serious complications if left untreated.

Which part of the body is affected?

The normal process of reproduction involves a chain of events. The woman releases an egg from one of her ovaries (ovulation). The egg travels through a fallopian tube toward her uterus (womb). A man’s sperm is introduced into the vagina through intercourse and travels up the uterus and into the fallopian tube to join with (fertilise) the egg at the fallopian tube. The fertilised egg then attaches to the inside of the uterus, initiating pregnancy.

What are the causes of ectopic pregnancy?

Ectopic pregnancy can be caused by a damaged fallopian tube. Some of the factors that can lead to an ectopic pregnancy can include:

  • Blockage of the fallopian tube due to an infection or inflammation
  • Scar tissue formed from an infection or previous surgery on the tube
  • Adhesions caused by previous surgery in the fallopian tubes or pelvic area
  • Birth defects or abnormal growths can lead to an abnormally shaped tube

These may impede the movement of the fertilised egg past the tubal defect into the womb, and cause it to implant in the fallopian tube.

Who is at risk of ectopic pregnancy?

Your risk of an ectopic pregnancy increases with the following factors:

  • Older than 35-44 years of age
  • Previous history of ectopic pregnancy
  • Pelvic inflammatory disease (PID)
  • Several previous induced abortions
  • Attained pregnancy after an unsuccessful tubal ligation or tubal ligation reversal, or while using an IUD
  • Endometriosis
  • Taking fertility medication or undergoing fertility treatments
  • Smoking

What are the signs and symptoms of ectopic pregnancy?

You may sometimes experience symptoms of a normal pregnancy such as

  • A missed period
  • Tender breasts
  • Tiredness
  • Nausea
  • Frequent urination

Sometimes, you may not show any symptoms. If you do have symptoms, they may show up at the 4th to 12th week of pregnancy and may include:

  • Abnormal vaginal bleeding – either heavier or lighter than usual
  • Stabbing pain in the abdomen, pelvis, shoulder or neck
  • Painful intercourse or pelvic examination
  • Fainting, weakness or dizziness
  • Nausea or vomiting

What are the related disorders that occur with ectopic pregnancy?

Ectopic pregnancy may be associated with endometriosis or pelvic inflammatory disease.

How is an ectopic pregnancy diagnosed?

When you visit the clinic with signs of an ectopic pregnancy, your doctor will review your medical history and previous instances of an ectopic pregnancy, and perform a thorough pelvic exam. A transvaginal ultrasound scan may be ordered to ascertain the presence of a developing foetus. hCG and progesterone levels are also tested through a blood test. If the presence of an ectopic pregnancy is still not clear, a laparoscopic procedure may be carried out, where a narrow lighted tube with a camera is inserted through a small abdominal incision to directly examine the fallopian tube and uterus.

TREATMENT

What are the consequences of not treating ectopic pregnancy?

Left untreated, ectopic pregnancy can result in the rupture of the fallopian tube and severe loss of blood.

When should I consider watchful waiting of ectopic pregnancy?

When you are diagnosed with ectopic pregnancy, your doctor may consider watchful waiting or expectant management instead of immediate treatment in order to consider the least invasive form of treatment first.

How does expectant management help manage my condition?

You will be closely monitored with blood tests at regular intervals to ensure that your hCG levels are dropping, until levels less than 5<mIU/mL have been achieved. Expectant management is only considered in the following cases:

  • Low beta hCG (pregnancy hormone) levels
  • Stable overall health
  • Acceptable pain levels
  • Small ectopic pregnancy with no threat of bleeding

Most often, ectopic pregnancy will resolve on its own (aborting) without the need for any kind of treatment. You can help by avoiding heavy lifting, engaging in strenuous exercises and sexual activity. You are also advised to stop taking folic acid and other vitamins and minerals that support a pregnancy.

What are the treatment options for ectopic pregnancy?

If your pregnancy does not resolve as indicated by the blood tests, you will be advised other forms of treatment, which may include:

  • Medication: You will be given an injection to abort the growth of the foetus
  • Surgery: A surgical procedure may be performed to remove the ectopic tissue, repair the fallopian tubes and stop bleeding.

When is medication or surgery indicated?

Medication is indicated in the following cases:

  • Pregnancy is at its early stages and has not progressed too far
  • Embryo has still not developed a heartbeat
  • hCG levels are less than 5,000

Surgery is indicated in the following cases:

  • Severe symptoms
  • Bleeding
  • High hCG levels
  • Signs of fallopian tube rupture

How is surgery performed?

Surgery to treat ectopic pregnancy can be performed through two approaches:

Laparoscopy

Surgery may be performed through a minimally invasive approach using a narrow lighted tube with a camera called a laparoscope. Through small incisions, the laparoscope and small surgical instruments are inserted to view and perform the surgery. Your surgeon will attempt to remove the entire fallopian tube with the ectopic tissue if the other tube is healthy or the ectopic pregnancy alone, leaving the tube intact.

Laparotomy

Laparotomy is performed as an emergency procedure in case of rupture and bleeding. A single large incision is made on your abdomen. Bleeding is stopped and the fallopian tube is carefully repaired.

What can I expect after ectopic pregnancy treatment?

Following surgery, you are usually able to go home on the same day or next. You may experience abdominal discomfort, and neck and shoulder pain for a few days due to the gas pumped into your abdomen. This will eventually resolve. You will be prescribed pain medication to keep you comfortable.

If your treatment involves the administration of medication this would be done as an outpatient procedure, but you will have to visit the clinic regularly for blood tests to confirm on the treatment outcome.

What are the advantages of the different types of treatment?

The advantages of the different types of ectopic pregnancy treatment are briefed on below.

Expectant management

You will not experience any complications or side effects from waiting, but due to the risk of rupture, you may eventually require surgical treatment.

Medication

This is a simple conservative treatment for ectopic pregnancy.

Surgery

Surgical removal of the fallopian tube is the most effective form of treatment. Laparoscopic surgery has additional advantages of:

  • Shorter hospital stay
  • Faster recovery
  • Less pain and post-surgery complications
  • Minimal scar formation

Describe the stages of recovery and care plan

Following the administration of ectopic pregnancy medication, you will be instructed to have protected intercourse for at least three months as the medication can be harmful for a foetus, should you conceive during this time. You are also advised to avoid alcohol after the injection as the combination of alcohol and medication can damage your liver. Since there is still a chance of the fallopian tube rupturing, your doctor will inform you on the signs that you need to look out for. Consult your doctor immediately if you experience:

  • Fever
  • Vaginal bleeding
  • Severe abdominal pain
  • Nausea and vomiting

After surgery, you will need anti-D rhesus prophylaxis if your blood type is RhD negative. This is an injection that prevents the occurrence of rhesus disease in future pregnancies. You are instructed not to lift heavy objects for 3 weeks. You can resume sexual activities once your bleeding stops or after 3 months, if a hysterectomy is performed.

What are the outcomes of ectopic pregnancy treatment?

While medication can destroy the ectopic pregnancy, there is still a risk of fallopian tube rupture. Surgery, on the other hand, is an effective treatment that removes the pregnancy along with the diseased/damaged fallopian tube. However, this may make it difficult for you to get pregnant.

What are the potential complications of ectopic pregnancy treatment?

As with most drugs, the medication injected to stop the pregnancy from growing may be associated with certain side effects such as:

  • Stomach pain
  • Diarrhoea
  • Dizziness
  • Feeling sick

As with all surgeries, ectopic pregnancy surgery may be associated with certain complications such as:

  • Infection
  • Bleeding
  • Blood clots
  • Heart problems
  • Breathing problems
  • Damage to nearby organs

What is the downtime of ectopic pregnancy surgery?

You should be able to resume your normal activities in 1 or 2 days after surgery.

What is the prognosis of ectopic pregnancy surgery?

Your chances of having a normal pregnancy is 60% if both the fallopian tubes are retained. If both tubes are removed, you can still become pregnant with the help of in vitro fertilisation, where a fertilised egg is directly implanted into your uterus.

What is the cost of ectopic pregnancy surgery?

Any costs involved will be discussed with you prior to your surgery.

What is the likelihood of ectopic pregnancy recurrence? How can it be managed?

Scar formation after surgery and incomplete removal can increase your risk of ectopic pregnancy recurrence. If you are a high risk recurrence, your doctor may inject a drug to destroy any traces of the pregnancy.

How can ectopic pregnancy be prevented? What are the lifestyle recommendations to manage the condition?

Although ectopic pregnancy cannot be prevented in all cases, you can reduce your risk by maintaining good reproductive health. By limiting your sex partners and practicing safe sex, you can prevent sexually transmitted diseases that can cause inflammation of your fallopian tubes. Quitting smoking is also a positive step in the prevention of ectopic pregnancy.

What is the current research regarding ectopic pregnancy?

Extensive research is being done to find better treatment options for ectopic pregnancy. Some of the recent studies are listed below:

  • Egger E. Recurrent Interstitial Pregnancy: a Review of the Literature. Geburtshilfe Frauenheilkd. 2017 Apr;77(4):335-339.
  • NeamŢu SD, DiŢescu D, ForŢofoiu M, et al. Correlation of clinical and biological evidence – a dominant therapeutic element of succeeding in ectopic pregnancy. Rom J Morphol Embryol. 2017;58(1):167-174.
  • Farahani L, Sinha A, Lloyd J, Islam M, Ross JA. Negative histology with surgically treated tubal ectopic pregnancies – A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol. 2017 Jun;213:98-101.