An ectopic pregnancy is one which developes outside the uterus. Most ectopics are found in the fallopian tube and these are called ‘tubal pregnancies’. However, they can also occur at other pelvic sites which include the ovary, the abdomen, and the cervix.
Fertilization normally occurs in the outer half of the fallopian tube which is called the ampulla. The embryo is then propelled along the fallopian tube, by the coordinated beating of the cilia which line the tube, towards the uterus. An ectopic pregnancy occurs when the embryo gets stuck in the fallopian tube and is implanted here, instead of moving on to the uterus.
Ectopic pregnancy occurs once in every one hundred pregnancies.
The commonest cause of a tubal pregnancy is tubal damage, which most often occurs due to pelvic inflammatory diseases. If tubal damage is severe, the tube gets totally blocked, as a result of which the patient becomes infertile. However, in the case of less severe infection, the tube remains open, but the tubal lining gets damaged, as a result of which the cilia can no longer function effectively. Other reasons for tubal damage include tubal surgery, infection following IUCD insertion, and previous tubal pregnancy.
Infertile patients face an increased risk of having an ectopic pregnancy, but the reasons for this are still unclear. Perhaps the cause of their infertility is subtle tubal damage. There is also an increased risk of tubal pregnancy after IVF, since the embryo may sometimes migrate after embryo transfer from the uterine cavity to the fallopian tube. The risk of ectopics after GIFT is greater than after IVF.
Initially, an ectopic pregnancy may appear just as a normal pregnancy, with a missed menstrual period and symptoms such as sore breasts and nausea. However, there is often abnormal vagina bleeding which may occur at the time of (or a little later than) the expected period. Often, this bleeding is mistaken for a period. Pain of the side of the ectopic occurs commonly and may be associated with a feeling of light-headedness. Making the diagnosis on clinical examination is difficult and the only suspicious finding may be pain on internal examination. If the tube ruptures, the patient experiences severe abdominal pain, fainting and shock.
A tubal pregnancy used to be considered a catastrophe. Diagnosis was usually made only after the tube had ruptured, and emergency surgery was required to stop the bleeding and save the patient’s life. Often, this meant removing the whole tube, which was often completely damaged. Consequently, the chances of a patient’s conceiving after such surgery was markedly reduced.
Today, an ectopic pregnancy can be diagnosed very early using blood tests for HCG and through vaginal ultrasound. Both these tests need to be done simultaneously in order to interpret the results correctly. The beta-HCG test is a very specific ‘marker’ for pregnancy. This blood test is very sensitive and, if negative, virtually excludes any risk of a significant ectopic pregnancy. A positive HCG level confirms that the patient is pregnant, but does not provide information about the site of the pregnancy. A vaginal ultrasound allows the doctor to locate the gestational sac of the early pregnancy. Occasionally, the sac may be seen outside the uterus, making a positive diagnosis of the ectopic pregnancy on sonography. Often, however, the sac cannot be seen clearly in ectopic pregnancies, especially if it is in an early stage. Then, both the scan and HCG levels need to be studied.
Another blood test which can be helpful is the determination of the serum progesterone level, which is low in patients with ectopic pregnancies, as compared to normal pregnancies.
Sometimes, differentiating between an ectopic pregnancy and an early miscarriage can be difficult. In these cases, if a curettage shows that there is no pregnancy tissue in the uterus (as tested by histopathologic examination), then an ecotopic pregnancy is suspected. The diagnosis can be confirmed by laparoscopy, if needed, which shows that the pregnancy is in the bus, where it appears as a dark bluish bulge.
The major benefit of early diagnosis is that early treatment can be started, making it possible to save the tube and thus preserving fertility and increasing the chances of a normal pregnancy in the future. If the ectopic pregnancy is very early and the HCG levels low, one can choose to simply wait and watch and monitor the patient carefully with serial HCG levels. Often, the HCG levels will fall, meaning that the pregnancy is being reabsorbed by the body units own and no treatment is needed. Medical treatment is also possible. Such treatment involves the use of the anti-cancer drugs, methotrexate, which acts on the rapidly dividing cells of the tubal pregnancy and kills them, thus diminishing the pregnancy from growing further.
Ultrasound-guided treatment can also be useful for treating tubal pregnancies which have not ruptured. This treatment involves the injection of toxic chemicals into the tubal pregnancy under ultrasound guidance. These chemicals kill the pregnancy, allowing the body of reabosorb it.
Surgical treatment for early tubal pregnancies can be done through the laparoscope as well; with salpingotomy, the pregnancy can be selectively removed and the tube saved.
If the tube has ruptured, and blood has collected in the abdomen, then emergency surgery is needed. In such cases, the tube is often so badly damaged, that it has to be removed entirely. When this occurs, a couple not only mourns the loss of a pregnancy, but also the possible loss or reduction in their fertility. This sense of loss is accompanied by the discomfort and anxiety of the wife having to undergo an emergency operation.
What about the chances of getting pregnant after an ectopic pregnancy? Because tubal disease usually damages both the fallopian tubes, the chances of being infertile are increased. Also, the risks of having a repeat ectopic pregnancy are increased even if the other tube seems normal. However, about 60% of women who have had a tubal pregnancy the first time will have a normal pregnancy the next time without further treatment. Early testing during pregnancy to rule out a repeat ectopic pregnancy is absolutely essential!
If pregnancy does not occur within about a year of trying, then treatment is needed. Treatment options for fertility will depend upon the kind of surgery done for the ectopic pregnancy and upon the condition of the other tube. Often, a second-look laparoscopy is required in order to assess tubal status. Options may include the following : ovulation induction; tubal surgery; laparoscopic surgery; and even IVF.
Having faced an unsuccessful outcome the first time makes getting pregnant very stressful, especially if the tubal pregnancy ended in a rupture. However, with the right treatment, the chances of having a baby are quite good—after all, the fact that a pregnancy occurred (even though it was an ectopic) means that the eggs and sperm are in good working order.
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