Ectopic Pregnancy

An ectopic pregnancy is one that occurs anywhere outside the uterus. The most common place for ectopic pregnancy is the Fallopian tubes. An ectopic pregnancy occurs in about 1 in 100 pregnancies. A doctor should be seen urgently if an ectopic pregnancy is suspected
Understanding normal early pregnancy
An egg (ovum) is released from an ovary into a Fallopian tube. This is called ovulation and usually occurs once a month about halfway between periods. Sperm can survive in the Fallopian tubes for up to five days after having sex. A sperm may then combine with the ovum (fertilisation) to make an embryo. The tiny embryo is swept along a Fallopian tube to the womb (uterus) by tiny hairs (cilia). It normally attaches to the inside lining of the uterus and develops into a baby.

Where does an ectopic pregnancy develop?
Most ectopic pregnancies occur when a fertilised egg attaches to the inside lining of a Fallopian tube (a tubal ectopic pregnancy). Rarely, an ectopic pregnancy occurs in other places such as in the ovary or inside the tummy (abdomen). The rest of this leaflet article deals only with tubal ectopic pregnancy.
Problems of an ectopic pregnancy.
A tubal ectopic pregnancy never survives. Possible outcomes include the following:
• The pregnancy often dies after a few days. Sometimes there is slight pain and
some vaginal bleeding like a miscarriage. Nothing further needs to be done if
this occurs.
• The pregnancy may grow for a while in the narrow Fallopian tube. This can
stretch the tube and cause symptoms. This is when an ectopic pregnancy is
commonly diagnosed.
• The narrow Fallopian tube can only stretch a little. If the pregnancy grows
further it will normally split (rupture) the Fallopian tube. This can cause
heavy internal bleeding and pain. This is a medical emergency.
What are the symptoms of an ectopic pregnancy?
Symptoms typically develop around the sixth week of pregnancy. This is about two weeks after a missed period in case of regular periods. However, symptoms may develop at any time between 4 and 10 weeks of pregnancy. A woman may not be aware that she is pregnant. Symptoms can also start about the time a period is due. One may often think the symptoms are just a late period.
Symptoms include one or more of the following.
• Pain on one side of the lower tummy (abdomen). It can become severe.
• Vaginal bleeding often occurs, but not always. It is often different to the
bleeding of a period. The blood may look darker.
• Diarrhoea, feeling faint, or pain on passing faeces.
• Shoulder-tip pain may develop. This is due to some blood leaking into the abdomen
and irritating the diaphragm (the muscle used to breathe).
• If the Fallopian tube ruptures and causes internal bleeding, severe pain may
develop and the woman may ‘collapse’. This is an emergency as the bleeding is
heavy.
• Sometimes there are no warning symptoms (such as pain) before the tube ruptures.
Therefore, collapse due to sudden heavy internal bleeding is sometimes the first
sign of an ectopic pregnancy.
Who gets ectopic pregnancy?
Ectopic pregnancies are common. The chance is higher than average in the following at-risk groups:
• If a woman has already had an ectopic pregnancy she has a slightly higher chance
that a future pregnancy will be ectopic.
• If there is kinking, scarring, damage, or other abnormality of a Fallopian tube.
This is because a fertilised egg (ovum) may become stuck in the tube more
easily.
This may occur due to a previous infection of the womb (uterus) or Fallopian
tube.
This is most commonly due to either chlamydia or gonorrhoea.
• Previous sterilisation operation. Although sterilisation is a very effective
method of contraception, if a pregnancy does occur, about 1 in 20 is ectopic.
• Any previous surgery to a Fallopian tube or nearby structures.
• If one has endometriosis(see page xx).
• If a coil is used as an intrauterine contraceptive device. Pregnancy is rare as
this is a very effective method of contraception.
• The risk of ectopic pregnancy increases in women over the age of 35 years and
also in smokers.
However, around one third of women with an ectopic pregnancy do not have any of these risk factors.
How is ectopic pregnancy confirmed?
If a woman has symptoms that may indicate an ectopic pregnancy she should be taken to her doctor immediately.
• A urine test can confirm pregnancy.
• An ultrasound scan may confirm an ectopic pregnancy. This is usually an internal
(transvaginal) scan which is not painful and shows good views of the Fallopian
tubes. However, the scan may not be clear if the pregnancy is very early. If
this is the case, then a repeat scan a few days later is often done.
• Blood tests that show changes in the pregnancy hormones – human chorionic
gonadotrophin (hCG) – are also usually done.
What are the treatment options for ectopic pregnancy?
Ruptured ectopic pregnancy
Emergency surgery is needed if a Fallopian tube ruptures with heavy bleeding. The main aim is to stop the bleeding. The ruptured Fallopian tube and remnant of the early pregnancy are then removed. The operation is often life-saving.
Early ectopic pregnancy – before rupture
Ectopic pregnancy is most often diagnosed before rupture. The doctor will discuss the treatment options with the patient and, in many cases, help decide which treatment is best. These may include the following:
• Surgery. Removal of the tube (either the whole tube or part of it) and the
ectopic pregnancy is most commonly performed by
keyhole surgery (a laparoscopic operation). Removal of the Fallopian tube
containing the ectopic pregnancy is usually performed
if the other tube is healthy. Removal of only a section of the tube with the
ectopic pregnancy in it is usually performed if the
other tube is unhealthy; for example, scarred from a previous infection.
However, many women with an ectopic pregnancy do not
need to have an operation.
• Medical treatment. Medical treatment of ectopic pregnancies is now more common
and avoids the need for surgery. A medicine
called methotrexate is often given, usually as an injection. It works by killing
the cells of the pregnancy growing in the
Fallopian tube. It is normally only advised if the pregnancy is very early. The
advantage is that an operation is not needed.
The disadvantage is that close observation for several weeks with repeated blood
tests and scans are needed. Methotrexate can
cause side-effects which include nausea and vomiting in some women.
• ‘Wait and see’ (expectancy). Not all ectopic pregnancies are life-threatening or
lead to a risk to the mother. In many cases the
ectopic pregnancy resolves by itself with no future problems. The pregnancy
often dies in a way similar to a miscarriage. A woman would need to be closely
observed by her gynaecologist and repeated scans and blood tests to check on how
things are developing.
A common question is – ‘What is the chance of having a future normal pregnancy after an ectopic pregnancy?’ Even if one Fallopian tube is removed, there is a 7 in 10 chance of having a future normal pregnancy. (The other Fallopian tube will still usually work.) However, 1 in 10 future pregnancies may lead to another ectopic pregnancy. It is therefore important that if one has had an ectopic pregnancy in the past to should go to see the doctor early in future pregnancies.
It is common to feel anxious or depressed for a while after treatment. Worries about possible future ectopic pregnancy, the effect on fertility, and sadness over the loss of the pregnancy are normal. A patient who has had an ectopic pregnancy should talk with her doctor about these and any other concerns following treatment.

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