An
ectopic pregnancy
is acomplication of pregnancyin which thefertilized ovumis
developed in any tissue other than theuterinewall. Most ectopic pregnancies occur in theFallopian tube(so-called
tubal pregnancies
), but implantation can also occur in thecervix,ovaries, andabdomen. The fetus produces enzymes that allow it to implant in
varied types of tissues, and thus an embryo implanted elsewhere than the uterus can causegreat tissue damage in its efforts to reach a sufficient supply of blood. An ectopic pregnancy is a medical emergency, and, if not treated properly, can lead to the death of the woman.
Overview
Oviduct with an ectopic pregnancy (tubal pregnancy) showing an embryo of approx. 6-7menstrual weeksAnother example of a tubal pregnancy (fetus is 8 weeks gestational age, 6 weeks fromconception)In a normal pregnancy,the fertilized egg enters theuterus and settles into theuterine
liningwhere it has plenty of room to divide and grow. About 1% of pregnancies are in anectopic location with implantation not occurring inside of the womb, and of these 98%occur in the Fallopian tubes.
In a typical ectopic pregnancy, theembryodoes not reach the uterus, but instead adheresto the lining of the Fallopian tube. The implanted embryo burrows actively into the tuballining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding (hematosalpinx
) expels the implantation out of the tubal end as a tubal abortion.Some women thinking they are having amiscarriageare actually having a tubal abortion.There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandinsreleased at the implantation site, and by free blood in the peritoneal cavity,
which is a local irritant. Sometimes the bleeding might be heavy enough to threaten thehealth or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it entersthe uterus), it may invade into the nearbySampson artery,causing heavy bleeding earlier
than usual.If left untreated, about half of ectopic pregnancies will resolve without treatment. Theseare the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has
reduced the need for surgery; however, surgical intervention is still required in caseswhere the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopicor through a larger incision, known as a laparotomy.
Causes
There are a number of risk factors for ectopic pregnancies. However, in as many as onethird
to one half
of ectopic pregnancies, no risk factors can be identified. Risk factorsinclude: pelvic inflammatory disease,infertility,those who have been exposed toDES,
tubal surgery,smoking, previous ectopic pregnancy, and tubal ligation.
Cilial damage and tube occlusion
Hair-likecilialocated on the internal surface of the Fallopian tubes carry the fertilizedegg to the uterus. Damage to the cilia or blockage of the Fallopian tubes is likely to leadto an ectopic pregnancy. Women with pelvic inflammatory disease(PID) have a high
occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the
Fallopian tubes, causing damage to cilia. If however both tubes were occluded by PID, pregnancy would not occur and this would be protective against ectopic pregnancy. Tubalsurgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy.Tubal ligationcan predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips areintrauterine. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubalclipping). A history of ectopic pregnancy increases the risk of future occurrences to about10%. This risk is not reduced by removing the affected tube, even if the other tubeappears normal. The best method for diagnosing this is to do an early ultrasound.
Other
Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has beennoted thatsmokingis associated with ectopic risk. Vaginal douching is thought by someto increase ectopic pregnancies; this is speculative. Women exposed todiethylstilbestrol (DES) in utero (aka "DES Daughters") also have an elevated risk of ectopic pregnancy,up to 3 times the risk of unexposed women.
Symptoms
Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancyoccurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to8 weeks. Later presentations are more common in communities deprived of moderndiagnostic ability.The early signs are:
•
Pain in the lower abdomen, and inflammation (Pain may be confused with astrong stomach pain, it may also feel like a strong cramp)
•
Pain while urinating
•
Pain and discomfort, usually mild. Acorpus luteum on the ovary in a normal
pregnancy may give very similar symptoms.
•
Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovarycause withdrawal bleeding. This can be indistinguishable from an earlymiscarriage or the 'implantation bleed' of a normal early pregnancy.
•
Pain while having a bowel movementPatients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologicmechanisms.
•
External bleeding is due to the falling progesterone levels.
•
Internal bleeding (hematoperitoneum
) is due to hemorrhage from the affectedtube.The differential diagnosis at this point is between miscarriage, ectopic pregnancy, andearly normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an activePelvic InflammatoryDisease (PID). The most common misdiagnosis assigned to early ectopic pregnancy isPID.More severe internal bleeding may cause:
•
•
Shoulder pain. This is caused by free blood tracking up the abdominal cavity andirritating the diaphragm, and is an ominous sign.
•
•
The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.
•
Ectopic pregnancy can mimic symptoms of other diseases such asappendicitis,
other gastrointestinal disorder, problems of the urinary system, as well as pelvicinflammatory diseaseand other gynaecologic problems.
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