Ectopic pregnancy is derived from the Greek word ektops, meaning out of place, and it refers to the implantation of a fertilized egg in a location outside of the cavity of the uterus, such as the fallopian tube, the cervix , ovary, cornual region of the uterus and the abdominal cavity. This abnormally implanted pregnancy attaches to surrounding tissue, grows and draws its blood supply from the area of attachment. As the pregnancy enlarges it creates the risk of bleeding and tissue / organ rupture because only the uterus is designed to expand, grow and accommodate the the growth of the fetus. Ectopic pregnancy can lead to severe bleeding, infertility and death.

CAUSES OF ECTOPIC PREGNANCY

Pelvic Inflammatory Disease ( PID ) – inflammation of the pelvis may cause adhesions or partial blockage of the fallopian tubes. The fertilized egg can not travel to the uterus and becomes lodged in the fallopian tube, ovary or abdominal cavity, then attaches itself and starts to grow in an abnormal area. The most common cause of PID is Chlamydia trachomatis, and patients may have a mild infection of the cervix to moderate to severely infected fallopian tubes. More than 50% of women with a past PID  infection are unaware of the infection. Gonorrhea and other organisms can also cause PID. A history of salpingitis, or infected fallopian tubes, increases the risk of ectopic pregnancy 4 – fold because the incidence of tubal damage increases after each episode of PID ( i.e. -  13% after one episode,   % after 2 episodes and 75% after 3 episodes).

 Previous Ectopic Pregnancy – there is a 10 – 13 fold increase in the likelihood of another ectopic pregnancy, if there has been a prior ectopic pregnancy. The patient with a previous ectopic pregnancy  has a 50 – 80% chance of having a subsequent intrauterine pregnancy, and a 10 – 25% chance of having a future tubal pregnancy.

Tubal Ligation or Tubal Surgery – pregnancy after a previous tubal ligation increases a woman’s risk of an ectopic pregnancy.  Up to 50% of women who become pregnant after a tubal ligation are reported to have an ectopic pregnancy.

Intrauterine Device Use  - IUD use is associated with an approximate 4% increased  risk of ectopic pregnancy.

Increased Maternal Age – the highest rate of ectopic pregnancy occurs in women 35 – 44 years old.

Smoking – women who smoke cigarettes have up to a 3 fold increased risk of ectopic pregnancy. No good explanations to explain this observation.

SYMPTOMS  AND SIGNS OF ECTOPIC PREGNANCY

Pelvic Pain, Absence of a period ( Amenorrhea) and Vaginal Bleeding are the classic symptoms of an ectopic pregnancy. Only 50% of women will present with all three classic symptoms. Most patients will present with nausea, breast fullness, fatigue, lower stomach pain, cramping, pain with intercourse and occasional shoulder pain.  

 On physical examination only 50% of patients will have a pelvic mass able to felt on pelvic exam, and only 40 – 50% will have vaginal bleeding. Signs of severe blood loss occurs in about 20% of patients ( i.e.- low blood pressure, low blood count, fast heart rate, and weak pulse)

DIAGNOSIS  OF  ECTOPIC PREGNANCY

Levels of Beta Human Chorionic Gonadotropin

          Cells of fertilized eggs grow to produce an embryo. Cells of normal embyro’s produce the pregnancy hormone called  beta -HCG, or beta human chorionic gonadotropin. This hormone can be measured in early pregnancy; in normal pregnancies it almost doubles( 66% increase ) every 48 hours.  An increase in B-HCG less than 66%  is associated with an abnormal intrauterine or ectopic pregnancy. Women suspected of having an abnormal pregnancy will have two B-HCG levels drawn 48 hours apart and evaluated. Most normal pregnancies with B-HCG levels over 6500 can be detected by  transvaginal ultrasound. If B-HCG levels are greater than 6500 and no intrauterine pregnancy is seen on transvaginal ultrasound, the pregnancy is generally considered to be ectopic.

Transvaginal ultrasound

Transvaginal ultrasound is the most important tool in diagnosing an ectopic pregnancy. It can visualize an intrauterine pregnancy in about 38 days after the last menstrual period. The yolk sac is normally visualized at 5 weeks after the last period. The fetal cardiac motion is seen around 5.5 – 6 weeks after the last period.

Laparoscopy

Laparoscopy is the primary means of direct diagnosis of an ectopic pregnancy. It involves placing a telescope through the belly button and looking into the abdominal cavity to see the anatomy of the pelvis and the entire cavity. Ectopic pregnancies can be seen in the fallopian tubes, ovaries, and abdominal cavity.  

TREATMENT OF ECTOPIC PREGNANCY

Medical Therapy

           Methotrexate is a chemotherapeutic agent used to disrupt cell multiplication and thus gradually causes the pregnancy to dissolve away. Best results are noted when the B-HCG level is below 5,000 IU/L. This treatment is preferred when the pregnancy is located in the cervix, ovary, or the cornual portion of the tube. Good subsequent pregnancies have been reported after this therapy.

Surgical Therapy

          Laparoscopy is the primary form of treatment in most cases of ectopic pregnancy. Removal of the ectopic pregnancy while leaving the tube is often possible. If severe bleeding is noted removal of the entire tube may be necessary.

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                               KENNETH GOODRICH, M.D.  -  OBSTETRICIAN- GYNECOLOGIST  
     
                                           Certified by the American Board of Obstetrics and Gynecology

           Specializing in General Obstetrics and Gynecology, Minimally Invasive Gynecological Surgery- Hysterectomies
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