An ectopic pregnancy is one that happens outside the uterus. The vast majority take place in a fallopian tube, where fertilization occurs, so the terms ectopic pregnancy and tubal pregnancy are often used interchangeably. An ectopic pregnancy can also occur, though rarely, in an ovary, the abdominal cavity, or the cervical canal. Ectopic pregnancy is a dangerous condition that must be dealt with, because the fallopian tube (or other site) cannot accommodate the growing embryo and sooner or later will tear or rupture. The internal bleeding that follows can be life threatening.

Before the days of ultrasound and quantitative blood pregnancy testing, ectopic pregnancy was one of the three most common causes of maternal mortality in the United States. Now we have sophisticated tests that can detect an ectopic pregnancy early on; we also have better ways to treat the condition.

How common is ectopic pregnancy?

In the United States the frequency of ectopic pregnancy is about one or two cases per hundred pregnancies. Some observers believe the rate is likely to rise because of the success of antibiotics in treating pelvic inflammatory disease. Before we had these drugs, women who had pelvic infections would often become totally infertile. With antibiotic treatment they may become pregnant, but their tubes may be scarred from infection and damaged, so that the fertilized egg remains stuck in the tube.

Who is at risk for an ectopic pregnancy?

Any woman who becomes pregnant has a 1-2 percent risk for an ectopic pregnancy. Beyond that basic level, the women at greatest risk are those who have had a previous ectopic pregnancy. Once you have had one ectopic pregnancy, your odds of having a second go from 1-2 percent to about 10 percent.

If you have had pelvic inflammatory disease, endometriosis, or tubal or pelvic surgery (anything from removal of the adhesions caused by endometriosis, to a ruptured appendix), you are at increased risk. The common factor is scarring or damage to the fallopian tubes, which prevents the fertilized egg from completing its journey to the uterus.

What are the symptoms of tubal pregnancy?

The classic symptoms are bleeding and pain. Usually, but not always, women know they are pregnant by the time they experience these symptoms, which frequently occur around six or seven weeks of gestational life.

The symptoms resemble those of a threatened miscarriage, but there may be differences. The pain of an ectopic pregnancy may be on one side rather than in the center of the abdomen, but since the ovaries or tubes are not far away from the uterus, it is difficult sometimes to pinpoint the precise location of the pain. Sometimes the pain is sharp and constant. Some women feel shoulder pain. The vaginal bleeding that accompanies an ectopic pregnancy is apt to be just spotting or staining.

If the pregnancy has ruptured a fallopian tube, the woman may pass out, because she has been hemorrhaging internally. This is a true emergency and must be treated immediately.

How is an ectopic pregnancy detected?

When someone comes in with pain and/or bleeding and we suspect an ectopic pregnancy, we use the same tests that evaluate the health of a pregnancy: ultrasound and quantitative blood pregnancy testing.

In an ectopic pregnancy, as with a miscarriage, the blood levels of human chorionic gonadotropin do not rise rapidly as they do in a healthy pregnancy. In order to differentiate between the two, we can do an ultrasound scan. Usually when a miscarriage is threatened, we will see something in the uterus — not necessarily a well-formed fetus, but perhaps a sac or a little placenta. With an ectopic pregnancy, there is nothing in the uterus, but occasionally something visible in the fallopian tube. Ultrasound tests in this case seldom show a fetal heartbeat; by the time the fetus is large enough to have a heart, the tube would probably have ruptured.

Sometimes it is not possible to tell with certainty that there is an ectopic pregnancy. Perhaps the ultrasound and blood pregnancy testing are not definitive. Perhaps no ultrasound technology is available, as in some small towns far from major medical centers. In that case a diagnostic laparoscopy can help. During this surgical procedure the laparoscope is inserted into the abdomen through a small incision. The doctor can then look around and try to determine whether the fallopian tube has a bump in it, which would suggest the presence of a tubal pregnancy.

When do the symptoms of an ectopic pregnancy occur?

Symptoms of an ectopic pregnancy usually make themselves known quite early in the pregnancy. The fallopian tube is narrow and as the embryo distends it, pain begins. Often symptoms begin at six to seven weeks of gestational life. When women call in because they are two days late for their period and feel abdominal pain, an ectopic pregnancy is probably not the reason for their discomfort. While it is not at all unusual for women to feel cramping when they are pregnant, it is rare to start having symptoms of an ectopic pregnancy that early.

Can an ectopic pregnancy be replanted in the uterus?

The current state of technological advancement does not allow this; perhaps sometime in the future it maybe possible.

Is it possible to tell whether an ectopic pregnancy has ruptured?

Most tubal pregnancies are diagnosed early and treated before rupture is a threat. However, there is a procedure called a culdocentesis, which can be used to determine whether the pregnancy has ruptured. A needle is inserted behind the cervix into a pouch called the cul-de-sac, which lies between the back of the vagina and the rectum. Fluid is withdrawn from the abdominal cavity through the needle and examined to see whether blood is present. If there is blood, we know the pregnancy has ruptured and we treat the patient accordingly. Culdocentesis is painful and fortunately is not needed very often.

What is the treatment for an ectopic pregnancy?

Basically the approach is to remove the fetus either surgically or medically. Since the laparoscope has become available as a surgical aid, it is often possible to make a small incision in the tube and lift out the embryo, scrape out the tube, and stop any bleeding. The tube will usually heal by itself, so stitches are not necessary. The procedure is called a salpingostomy.

Twenty-five years ago the standard procedure was to remove the entire fallopian tube through an abdominal incision. Nowadays we take out the whole tube only when we are unable to stop the bleeding. If a fallopian tube has ruptured, it may be better, for example, to make a small abdominal incision and remove the ectopic pregnancy that way, rather than to work through the laparoscope.

A recent nonsurgical approach uses methotrexate, a drug used for cancer therapy. Methotrexate kills cells that are dividing rapidly, whether they are in a cancerous tumor or an ectopic pregnancy.

The tissue in the ectopic pregnancy dies and is passed out the end of the fallopian tube into the peritoneal cavity, where it is reabsorbed. Methotrexate therapy has a high rate of success, though it must be used early in the pregnancy before the situation becomes acute. If someone is having severe pain and bleeding, she cannot wait for the methotrexate to work and is a candidate for immediate surgery.

Interestingly enough, Chinese herbal medicine has long used a similar technique. One of my colleagues visiting China more than fifteen years ago was shown fifty women who had had documented ectopic pregnancies and had been treated with herbal medicines. Only two eventually needed surgery. The success of the Chinese technique is not surprising, especially since many of our chemotherapeutic medications come from plants. Vincristine, for example, which is used to kill rapidly dividing cancer cells, is obtained from the common flowering herb periwinkle (Vinca rosed).

Does treatment with methotrexate have serious side effects?

Methotrexate for ectopic pregnancy is given in a single injection, in a much smaller amount than that used in chemotherapy, so the side effects are not severe. Women do not lose their hair or suffer severe nausea.

If you’ve had an ectopic pregnancy, will you have trouble conceiving again?

As long as the underlying cause is not tubal disease, you will probably have no trouble. When you do conceive, however, ask your doctor about having early ultrasound to rule out ectopic pregnancy.

If your tubes have been damaged by ectopic pregnancies, can you ever have children?

Women who have had tubal pregnancies are excellent candidates for in vitro fertilization, in which egg and sperm are mixed outside the woman’s body and then implanted in the uterus. All that is needed is an ovary and a uterus.

Dana, an art teacher, had an ectopic pregnancy, which we were able to treat conservatively, saving the fallopian tube. Later she had another ectopic in that same tube, and that time we did have to remove the tube. She went on to have a third ectopic pregnancy in her other tube. Since that time she has had two healthy children by in vitro fertilization.

 

Selections from the book: “The Yale Guide to Women`s Reproductive Health: From Menarche to Menopause”, 2003.

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