Ectopic pregnancy

Definition

Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches itself to the lining of the uterus. With an ectopic pregnancy, the fertilized egg implants somewhere else.

An ectopic pregnancy nearly always occurs in one of the tubes that carry eggs from the ovaries to the uterus (fallopian tubes). This type of ectopic pregnancy is known as a tubal pregnancy. Rarely, an ectopic pregnancy occurs in the abdomen, ovary or neck of the uterus (cervix).

An ectopic pregnancy can't proceed normally. The fertilized egg can't survive, and the growing tissue may destroy various maternal structures. Left untreated, life-threatening blood loss is possible. Early treatment of an ectopic pregnancy can help preserve the chance for future healthy pregnancies.

Symptoms

In many cases, a woman with a developing ectopic pregnancy may not have any indication of being pregnant. Early signs and symptoms, if they occur, may be the same as those of any pregnancy — a missed period, breast tenderness, nausea and fatigue. If you suspect pregnancy and take a test, it will be positive.

But an ectopic pregnancy can't continue as normal. The first warning signs of an ectopic pregnancy often include:

• Light vaginal bleeding
• Lower abdominal pain
• Cramping on one side of the pelvis

If the fallopian tube ruptures, symptoms may include:

• Sharp, stabbing pain in the pelvis, abdomen, or even the shoulder and neck
• Dizziness
• Lightheadedness

When to see a doctor
Contact your obstetrics care provider if you have:

• Vaginal bleeding
• Abdominal pain

Call 911 or seek emergency medical help if you experience any signs or symptoms of an ectopic pregnancy, including:

• Severe abdominal pain
• Heavy vaginal bleeding
• Shoulder pain
• A strong urge to defecate without results
• Extreme lightheadedness, fainting or shock

Normal and ectopic pregnancy

Normal and ectopic pregnancy

In a healthy pregnancy, the fertilized egg attaches itself to the lining of the uterus. In an ectopic pregnancy, the egg usually attaches itself to the inside of the fallopian tube. ...

Causes

An ectopic pregnancy happens when a fertilized egg gets stuck on its way to the uterus — often because the fallopian tube is scarred, damaged or misshapen. Sometimes, the specific cause of an ectopic pregnancy remains a mystery.

Risk factors

Up to an estimated 20 in every 1,000 pregnancies are ectopic. Various factors are associated with ectopic pregnancy, including:

• Previous ectopic pregnancy. If you've had one ectopic pregnancy, you're more likely to have another.
• Inflammation or infection. The majority of women with ectopic pregnancies have had inflammation of the fallopian tube (salpingitis) or an infection of the uterus, fallopian tubes or ovaries (pelvic inflammatory disease). Gonorrhea or chlamydia can cause tubal problems that increase the risk of ectopic pregnancy. A condition that causes the tissue that normally lines the uterus to develop outside the uterus (endometriosis) also may slightly increase the risk of ectopic pregnancy.
• Fertility problems. Taking medication to stimulate ovulation increases the risk of ectopic pregnancy.
• Structural problems. An ectopic pregnancy is more likely if you have an unusually shaped fallopian tube or the fallopian tube was damaged, possibly during surgery. Even surgery to reconstruct the fallopian tube can increase the risk of ectopic pregnancy.
• Contraceptive choice. With proper use, pregnancy is rare when using birth control pills or an intrauterine device (IUD). If pregnancy occurs, however, it's more likely to be ectopic. The same goes for pregnancy after tubal ligation, a permanent method of birth control commonly known as "having your tubes tied." Although pregnancy is rare after tubal ligation, if it happens it's more likely to be ectopic.

Successful pregnancy after an ectopic pregnancy may still be possible. Even if one tube was injured or removed, an egg may be fertilized in the other fallopian tube before entering the uterus. If both tubes were injured or removed, in vitro fertilization may be an option. With this procedure, mature eggs are fertilized in the lab and then implanted into the uterus.

Complications

When you have an ectopic pregnancy, the stakes are high. Treatment may lead to loss of reproductive organs or infertility. Without treatment, the stakes are even higher. A ruptured fallopian tube may lead to life-threatening bleeding.

Preparing for your appointment

Call 911 or seek emergency medical help if you develop any of the following emergency signs and symptoms of ectopic pregnancy:

• Severe vaginal bleeding
• Severe abdominal pain
• Extreme lightheadedness, fainting or shock

If you have less severe signs and symptoms of ectopic pregnancy, call your doctor. He or she may recommend immediate medical care. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Report the date of your last menstrual period if you can, and anything that was unusual about that bleeding episode.
• Tell your doctor right away if you've had a positive pregnancy test.
• List any symptoms you've been having, and for how long.
• Write down key medical information, including other medical problems for which you are being treated and the names of all medications, vitamins, supplements or other natural remedies you are taking.
• Take a family member or friend along, if possible. Someone who accompanies you can help soak up the information and provide support if you need immediate medical care.
• Write down questions to ask your doctor.

For ectopic pregnancy, important questions to ask your doctor include:

• What is the most likely cause of my signs and symptoms?
• Are there any other possible causes?
• If the pregnancy is not located in my uterus, where is it?
• Am I far enough along in this pregnancy to be sure?
• What kinds of tests do I need?
• What treatment approach do you recommend?
• Will the treatment you're recommending affect my ability to become pregnant again?
• What are my chances of having a normal pregnancy in the future?
• How long should I wait before trying to become pregnant again?
• Will I need to follow any special precautions if I become pregnant again?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time if you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them will help your doctor quickly determine next steps in making your diagnosis and starting care. Your doctor may ask:

• When was your last period, and was it normal?
• Are you pregnant that you know of?
• Are you having any pain?
• Have you been bleeding?
• How heavily are you bleeding?
• Are you experiencing any lightheadedness or dizziness?
• Have you been pregnant in the past? What was the outcome?
• Have you had any reproductive surgery, including any that involved your fallopian tubes?
• Have you been diagnosed with any sexually transmitted infections?
• Have you had in vitro fertilization?
• What form of birth control do you use, if any?
• Do you plan to become pregnant in the future?

Tests and diagnosis

If your health care provider suspects an ectopic pregnancy, he or she may do a pelvic exam to check for pain, tenderness, or a mass in the fallopian tube or ovary. A physical exam alone isn't enough to diagnose an ectopic pregnancy, however. The diagnosis is typically confirmed with blood tests and imaging studies, such as an ultrasound.

With a standard ultrasound, high-frequency sound waves are directed at the tissues in the abdominal area. During early pregnancy, however, the uterus and fallopian tubes are closer to the vagina than to the abdominal surface. The ultrasound will likely be done through a wand-like device placed in your vagina.

Sometimes it's too soon to detect a pregnancy through ultrasound. If the diagnosis is in question, your health care provider may monitor your condition with blood tests until the ectopic pregnancy can be confirmed or ruled out through ultrasound — usually by four to five weeks after conception.

In an emergency situation — if you're bleeding heavily, for example — an ectopic pregnancy may be diagnosed and treated surgically.

Treatments and drugs

A fertilized egg can't develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue must be removed.

Sometimes if the ectopic pregnancy is detected early, an injection of the drug methotrexate may be used to stop cell growth and dissolve existing cells. After the injection, your health care provider will monitor your blood for the pregnancy hormone human chorionic gonadotropin (HCG). If the HCG level remains high, you may need another injection of methotrexate.

If the ectopic pregnancy doesn't respond to medication or is too large, or you're unable to use methotrexate or return for monitoring, you may need laparoscopic surgery. In this procedure, the doctor makes a small incision in the abdomen, near or in the navel. Then he or she uses a thin tube equipped with a camera lens and light (laparoscope) to view the area. Other instruments can be inserted into the tube or through other small incisions to remove the ectopic tissue and repair the fallopian tube. If the fallopian tube is significantly damaged, it may need to be removed.

If the ectopic pregnancy is causing heavy bleeding or the fallopian tube has ruptured, you may need emergency surgery through an abdominal incision (laparotomy). In some cases, the fallopian tube can be repaired. Typically, however, the ruptured tube must be removed.

In a few cases, an injection of methotrexate is needed after surgery.

Prevention

You can't prevent an ectopic pregnancy, but you can decrease certain risk factors. For example, limit your number of sexual partners and use a condom when you have sex to help prevent sexually transmitted diseases and reduce the risk of pelvic inflammatory disease.

If you've had an ectopic pregnancy, talk to your health care provider before conceiving again. When you become pregnant, your health care provider will carefully monitor your condition.

Coping and support

Losing a pregnancy is devastating, even if you've only known about it for a few days. Recognize the loss, and give yourself time to grieve. Talk about your feelings and allow yourself to experience them fully. Rely on your partner, family and friends for support.

Many women who have ectopic pregnancies go on to have other, healthy pregnancies. If you choose to conceive again, seek your health care provider's advice. Early ultrasound imaging can offer reassurance that the pregnancy is developing normally.