Ectopic Pregnancy
When a pregnancy implants in any place of the
body other than the uterus it is an ectopic pregnancy. These pregnancies can be life
threatening if left untreated. Maternal morbidity and mortality result from rupture of the
fallopian tube with resultant internal bleeding. Often times the patient has delayed
seeking medical treatment or been misdiagnosed with an intestinal disorder, pelvic
infection or even as a normal pregnancy.
Women at risk for an ectopic pregnancy include
those women with a history of pelvic inflammatory disease (PID) or other prior pelvic
infection, prior tubal surgery and assisted reproductive techniques such as in-vitro
fertilization (IVF) or gamete intrafallopian transfer (GIFT). However it is important to
remember that in half the cases of an ectopic pregnancy no risk factors will be
identified. A prior ectopic pregnancy even if the fallopian tube was removed carries an
increased risk for reoccurrence. A positive pregnancy test in a women who has had her
tubes tied is an ectopic pregnancy until proven otherwise. The diagnosis of PID in the
presence of a positive pregnancy test should only be entertained when an intrauterine
pregnancy has been documented. (intrauterine or within the uterus)
Following a positive pregnancy test any
bleeding in the first twelve weeks should be evaluated for a possible ectopic pregnancy.
Other more likely causes for bleeding during this period are normal implantation related
bleeding or miscarriage; none of which carry the potential danger inherent in an ectopic
pregnancy. Tubal pregnancies do not suddenly appear and rupture but often herald their
presence with pain or bleeding. . In fact the major symptom experienced by women is pain
followed by spotting or bleeding. These symptoms together with a known positive pregnancy
test should raise a high index of suspicion.
The most common site of ectopic implantation
is the fallopian tube, which accounts for the vast majority of ectopic pregnancies. The
rarer sites include the ovary, abdomen, cervix and interstitial portion of the tube. The
interstitial portion of the tube or cornual portion of the uterus is the area of the
uterus where the fallopian tube attaches and opens up into the uterus. Here an
implantation is especially dangerous because of the major blood vessels that meet in this
area and the fact that these pregnancies present much later than the typical five to six
weeks. This means they are more developed and larger. A ruptured ectopic in this area can
be catastrophic.
If your doctor is at all suspicious of an
ectopic pregnancy an ultrasound will be performed and a measurement of beta Human
Chorionic Gonadotropin (betaHCG) will be measured. If the pregnancy is very early your
caretaker may follow the betaHCG level. Normally this pregnancy hormone doubles within
forty-eight to seventy-two hours in normal intrauterine pregnancies. An abnormal doubling
is suspicious for an ectopic pregnancy. This is especially true if the level of hormone
should allow visualization of a developing pregnancy by ultrasound and nothing is
visualized in the uterus.
Ectopic pregnancies are managed by both
medical and surgical interventions. Laparoscopy has revolutionized the surgical treatment
and allowed shorter recovery periods as well as tubal conservation. Depending on the
extent of damage at the time of surgery the tube may be opened with removal of the
pregnancy (see picture) and the tube conserved and allowed to heal on its own. Other times
the fallopian tube will need to be removed especially in cases where it is ruptured. When
an ectopic pregnancy has ruptured and there is obvious internal bleeding an incision is
often the swiftest route to stopping the emergency.
Medical treatment presently centers on
Methotrexate therapy, a drug used in chemotherapy. Single dose regiments require careful
follow-up and multiple blood draws to follow and assure a descending betaHCG level. On
occasion a second dose is necessary if levels do not appear to be dropping or they drop
then plateau. It is well tolerated by most women. Blood type must always be checked and
RHOGAM given if appropriate.
The following pictures were photographs taken
during laparoscopic removal of an ectopic pregnancy with conservation of the fallopian
tube. These photographs are shown with permission of the patient who is presently twenty
weeks pregnant.
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Left Tubal Pregnancy |
Removal Of Pregnancy From Left Tube |
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