Ectopic Pregnancy – What to know?

Introduction 

Ectopic or tubal pregnancy occurs when a fertilised egg implants outside of the uterus, where it cannot continue its normal development. 

The egg is intended to pass via the fallopian tubes and embed itself in the uterine wall, where it can start to develop. The egg implants in one of the structures along the route during an ectopic pregnancy. 

Ectopic pregnancies make up about 2% of all pregnancies. Even though they can sometimes occur in the cervix, on an ovary, or in the abdomen, ectopic pregnancies mostly always happen in one of the fallopian tubes, accounting for more than 90% of all such pregnancies.

Also, a fertilised egg may implant on other abdominal organs. Compared to ectopic pregnancies in fallopian tubes, this one is more uncommon.

A fallopian tube may burst and cause severe bleeding if the ectopic pregnancy is left untreated and grows. 

Causes of Ectopic pregnancy 

Pelvic inflammatory disease 

When Pelvic Inflammatory Disease (PID) is left untreated and scar tissue forms in the fallopian tubes, an ectopic pregnancy may result. The fertilised egg cannot pass through the scar tissue in the fallopian tube to get implanted in the uterus. Eventually, the egg gets embedded in the fallopian tube itself.

Fertility treatment 

Fertility treatment includes in vitro fertilisation (IVF) and other reproductive treatments like surgery. Surgery can occasionally damage or scar the fallopian tubes, which increases the risk of an ectopic pregnancy. The chance of an ectopic pregnancy rises when women take medications to induce ovulation.

Previous Ectopic pregnancy 

The chances of getting another ectopic pregnancy are a little higher. There is a little increase in the risk that it will occur again because the person has already had one failed implantation of a fertilised egg on the uterus.

Fallopian tube surgery 

The most typical form of ectopic pregnancy, a tubal pregnancy, occurs when a fertilised egg becomes impaled on its way to the uterus, frequently as a result of fallopian tube damage from inflammation or malformation.

Getting pregnant while using contraception 

An ectopic pregnancy mostly develops in one of the fallopian tubes that transfer eggs from the ovaries to the uterus. There is a small increase in the chance of having an ectopic pregnancy if an individual becomes pregnant while taking a progestin-only birth control tablet, also referred to as the minipill.

Symptoms of Ectopic pregnancy 

Ectopic pregnancy shows the typical early signs and symptoms of pregnancy, such as missing the period, nausea (feeling sick to the stomach), and sore breasts. Few individuals can be pregnant and not even be aware of it since they have no symptoms or indicators.

On experiencing any ectopic pregnancy symptoms, contact a gynaecologist at once.

Vaginal bleeding 

Pregnancy vaginal bleeding typically differs slightly from ordinary menstrual bleeding. It may be watery and dark brown in colour.

Even though vaginal bleeding during pregnancy is usual and isn’t always an indication of a major issue, one should always seek medical help after experiencing it.

One-sided abdominal pain 

One-sided abdominal pain is primarily a pain on one side of the stomach. This can be severe and persistent.

Diarrhoea and Vomiting 

An ectopic pregnancy can produce symptoms that are similar to those of a digestive disorder and is frequently accompanied by diarrhoea and vomiting.

Shoulder tip pain 

Unusual pain at the point where the arm and shoulder joint is known as shoulder tip pain. Shoulder tip pain is a symptom of internal bleeding caused by ectopic pregnancy and typically happens while lying down, though its specific cause is unknown. 

The bleeding is believed to irritate the diaphragm’s phrenic nerve (the muscle used during breathing that separates the chest cavity from the abdomen). Persistent pain in the shoulder blade results from irritation of the phrenic nerve, which is pain that is felt elsewhere.

Risk factors for Ectopic pregnancy 

Certain Sexually Transmitted Diseases (STDs) 

When an embryo implants in the fallopian tube, it results in an ectopic pregnancy. According to a study, women who have had chlamydia (a sexually transmitted infection) are more likely to have a protein produced in their Fallopian tubes. This protein increases the likelihood of pregnancy developing outside the womb.

Smoking 

According to epidemiological research, smoking is a significant risk factor for tubal or ectopic pregnancy.

Age 

An NCBI article titled ‘Risk factors for ectopic pregnancy: A case-control study states that women aged 27 to 32 and women aged 33 to 38 each had an increased risk of EP of 3.9 and 4.3 times, respectively, whereas women aged 39 had an approximately 9-fold increased risk of EP.

Endometriosis 

Scar tissue and adhesions may develop as a result of endometriosis, which may hinder the ability of the fertilised egg to enter the uterus. An ectopic pregnancy is more likely to happen if the fallopian tubes have undergone surgery, such as tubal ligation. 

Complications of Ectopic pregnancy 

A fertilised egg can continue to grow in the fallopian tube and eventually burst if an ectopic pregnancy is not diagnosed early and treated. A fallopian tube that ruptures cannot later move a fertilised egg to the uterus. Also, if a rupture is left untreated, it can lead to severe internal bleeding.

These risks can be avoided with early diagnosis, treatment or surgery, so always be sure to inform the doctor immediately while experiencing any ectopic pregnancy symptoms.

Diagnosis of Ectopic pregnancy 

Ultrasound 

An ultrasound is an imaging test that uses sound waves to provide an image of the internal organs in the body. The use of ultrasound during pregnancy is common. This test will be used by the doctor to determine where the fertilised egg has been implanted.

A treatment plan will be developed when the doctor has confirmed the pregnancy and identified the location of the implantation. Treatment for ectopic pregnancy is crucial because it is a medical emergency.

Blood test 

A blood test is done to determine the level of the hormone human chorionic gonadotropin (hCG) in the body. This hormone is produced during pregnancy, which is commonly referred to as serum beta-hCG level.

Urine test 

To perform a urine test, one must either urinate into a cup, where a test strip will then be dipped into the urine sample, or urinate on a test strip (usually shaped like a stick). 

Standard urine hCG test can diagnose ß hCG at concentrations as low as 20 mIU/mL. This case study detects even low ß hCG levels that are below the cutoff point, signifying that an ectopic pregnancy can exist and be large enough to rupture.

Pelvic exam 

A doctor may find areas of pain, soreness or a lump in the ovary or fallopian tube by performing a pelvic exam. On the other hand, a physical examination alone cannot reveal an ectopic pregnancy and requires blood tests and an ultrasound for diagnosis.

Treatment for Ectopic pregnancy 

Medication 

Methotrexate is frequently used to treat small ectopic pregnancies, in which there is no foetal heartbeat and no fallopian tube rupture. Since the medication prevents cell growth, the pregnancy terminates and is reabsorbed by the body over a period of four to six weeks.

The patient will have crucial follow-up blood tests after receiving a dose of this drug to make sure hCG levels are declining appropriately. A second dose is necessary if the hCG level does not decrease by at least 15% between the fourth and seventh day following therapy.

Avoiding alcohol, folic acid and ibuprofen, as well as strenuous activity and sex, will help the drug perform as intended (for at least two weeks). 

It’s crucial to keep regular doctor’s appointments and adhere to any follow-up care instructions since the ectopic pregnancy still has a chance to rupture during the treatment procedure.

Expectant management 

Expectant management is the act of not intervening and letting the pregnancy end naturally via miscarriage. This is possible only very early in the pregnancy when the patient has few or no symptoms.

The doctor will need to monitor the hCG levels every few days until they return to normal. This is done to make certain that the pregnancy is terminated.

Laparoscopy

A laparoscopy may occasionally be required to confirm the diagnosis of an ectopic pregnancy. Laparoscopy can occasionally be used to treat ectopic pregnancies as well. 

An outpatient surgical procedure called a laparoscopy requires general anaesthesia. A laparoscope—a small telescope—is inserted into the abdominal cavity through a small incision or cut at the navel. 

In most cases, the doctor can remove the ectopic pregnancy by inserting specialised equipment through the laparoscope or through tiny incisions above the pubic area. 

Surgery 

The ectopic pregnancy must be removed through surgery. Either a laparoscopy or a laparotomy will be performed during the procedure (open surgery). In the case of open surgery, the recovery may take longer.

The fallopian tube might be removed through a procedure known as salpingectomy. As a result, there will be a lower chance of future ectopic pregnancies.

It is advisable to have a salpingectomy (a surgical procedure involving removal of one or both fallopian tubes) if the patient has only one tube or if the other tube does not appear to be healthy. The pregnancy will be terminated through this procedure without the tube being cut out. 

The woman will still be able to conceive naturally despite having an increased risk of another ectopic pregnancy.

Prevention of Ectopic pregnancy 

There are a few techniques to lower the chance of an ectopic pregnancy, even though some circumstances are beyond our control.

• Avoid smoking
• Use condoms to reduce the risk of getting an STI while not actively attempting to get pregnant.
• If one is sure to have an STI, get tested to begin treatment right away.
• If a patient has endometriosis, speak with the doctor about potential treatments.
• Of course, the best approach to keeping healthy while trying to conceive is to exercise, eat a nutritious diet, and remember to take a daily prenatal vitamin.

Conclusion 

Ectopic pregnancies happen when foetal tissue implants outside of the uterus or connects to an aberrant or scarred area of the uterus. This typically occurs in the fallopian tube. 

Ectopic pregnancies have a high risk of morbidity and mortality if they are not identified and treated early. Ectopic pregnancy symptoms can include pain, vaginal bleeding or less specific complaints like nausea and vomiting.

Sensitive hormone tests, ultrasounds, laparoscopies or D&C procedures are frequently used to make an early diagnosis. Modern surgical and medical procedures allow women to forego significant surgery and maintain their fallopian tubes. 

Although there is a higher chance of experiencing another ectopic pregnancy, many women will conceive and give birth to children successfully in the future, either naturally or with the use of assisted reproductive techniques.

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