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Read More Cervix Endometriosis Infertility Pelvic inflammatory disease (PID) Tubal ligation An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb (uterus). The baby (fetus) cannot survive, and often does not develop at all in this type of pregnancy. Causes An ectopic pregnancy occurs when a pregnancy starts outside the womb (uterus). The most common site for an ectopic pregnancy is within one of the tubes through which the egg passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix. An ectopic pregnancy is often caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the tube by hormonal factors and by other factors, such as smoking. Most cases of scarring are caused by:
• • •
Past ectopic pregnancy Past infection in the fallopian tubes Surgery of the fallopian tubes
Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of the fallopian tubes (salpingitis) or pelvic inflammatory disease (PID). Some ectopic pregnancies can be due to:
• • • •
Birth defects of the fallopian tubes Complications of a ruptured appendix Endometriosis Scarring caused by previous pelvic surgery
The following may also increase the risk of ectopic pregnancy:
• • •
Age over 35 Having had many sexual partners In vitro fertilization
Sometimes. They may include: • • • • Feeling faint or actually fainting Intense pressure in the rectum Pain that is felt in the shoulder area Severe. In the first year after sterilization. which may show tenderness in the pelvic area. Exams and Tests The health care provider will do a pelvic exam. symptoms may get worse. Symptoms • • • • • • • Abnormal vaginal bleeding Amenorrhea Breast tenderness Low back pain Mild cramping on one side of the pelvis Nausea Pain in the lower abdomen or pelvic area If the area of the abnormal pregnancy ruptures and bleeds.3 years after tubal sterilization will be ectopic. Tests that may be done include: • Culdocentesis Culdocentesis is a procedure that checks for abnormal fluid in the space just behind the vagina . Ectopic pregnancies are more likely to occur 2 or more years after the procedure. but most pregnancies that occur 2 . sharp. a woman will become pregnant after having her tubes tied (tubal sterilization). rather than right after it.In a few cases. only about 6% of pregnancies will be ectopic. and sudden pain in the lower abdomen Internal bleeding due to a rupture may lead to low blood pressure and fainting in around 1 out of 10 women. Ectopic pregnancy is also more likely in women who have: • • Had surgery to reverse tubal sterilization in order to become pregnant Had an intrauterine device (IUD) and became pregnant (very unlikely when IUDs are in place) Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies. the cause is unknown.
ovaries. It prepares the womb (uterus) for pregnancy and the breasts for milk production. The hematocrit is almost always ordered as part of a complete blood count • Pregnancy test A pregnancy test measures a hormone called human chorionic gonadotropin (HCG). It is also used to check the female pelvic organs during pregnancy. HCG is a hormone produced during pregnancy. HCG is a hormone produced during pregnancy. but it probably has no normal function except to help produce other steroid hormones. A pregnancy ultrasound is an imaging test that uses sound waves to see how a baby is developing in the womb. progesterone helps make the uterus ready for implantation of a fertilized egg. Men produce some amount of progesterone. After an egg is released by the ovaries (ovulation). In women. • Transvaginal ultrasound or pregnancy ultrasound Transvaginal ultrasound is a type of pelvic ultrasound. This measurement depends on the number of red blood cells and the size of red blood cells. progesterone plays a vital role in pregnancy. cervix. Transvaginal means across or through the vagina. It appears in the blood and urine of pregnant women as early as 10 days after conception. .• Hematocrit Hematocrit is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. and vagina. Progesterone is a hormone produced mainly in the ovaries. including the uterus. It is used to look at a woman's reproductive organs. • Serum progesterone level Serum progesterone is a test to measure the amount of progesterone in the blood. • Quantitative HCG blood test A quantitative human chorionic gonadotropin (HCG) test measures the specific level of HCG in the blood.
White blood cells help fight infections. ovaries. including the fallopian tubes. small bowel. They are also called leukocytes. Women with high levels should have a vaginal ultrasound to identify a normal pregnancy. Curettage ("C") is the scraping of the walls of the uterus. uterus. Surgery that opens the abdomen is called a laparotomy. Laparotomy may also be done to treat certain health problems and conditions. large bowel. • Laparoscopy Diagnostic laparoscopy is a procedure that allows a health care provider to look directly at the contents of a patient's abdomen or pelvis. There are five major types of white blood cells: • • • • • Basophils Eosinophils Lymphocytes (T cells and B cells) Monocytes Neutrophils A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an ectopic pregnancy. Treatment . • Laparotomy Abdominal exploration is surgery to examine the contents of the abdomen. appendix. Other tests may be used to confirm the diagnosis.• White blood count A WBC count is a blood test to measure the number of white blood cells (WBCs). • • Dilatation ("D") is a widening of the cervix to allow instruments into the uterus. and gallbladder. liver. such as: • D and C D and C is a procedure to scrape and collect the tissue (endometrium) from inside the uterus.
.Ectopic pregnancies cannot continue to birth (term). you may be given a medicine called methotrexate and monitored. surgery (laparotomy) is done to stop blood loss. You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to shock. A minilaparotomy and laparoscopy are the most common surgical treatments for an ectopic pregnancy that has not ruptured. an emergency condition. Treatment for shock may include: • • • • • Blood transfusion Fluids given through a vein Keeping warm Oxygen Raising the legs If there is a rupture. If the doctor does not think a rupture will occur. Possible Complications The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. The developing cells must be removed to save the mother's life. You may have blood tests and liver function tests. A repeated ectopic pregnancy may occur in one-third of women. Some women do not become pregnant again. Outlook (Prognosis) One-third of women who have had one ectopic pregnancy are later able to have a baby. The likelihood of a successful pregnancy depends on: • • • The woman's age Whether she has already had children Why the first ectopic pregnancy occurred The rate of death due to an ectopic pregnancy in the United States has dropped in the last 30 years to less than 0. This surgery is also done to: • • • Confirm an ectopic pregnancy Remove the abnormal pregnancy Repair any tissue damage In some cases. the doctor may have to remove the fallopian tube.1%.
if not treated properly. With rare exceptions. they are dangerous for the mother. Prevention Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not preventable. but implantation can also occur in the cervix. call your health care provider. and abdomen. can lead to death. Furthermore.When to Contact a Medical Professional If you have symptoms of ectopic pregnancy (especially lower abdominal pain or abnormal vaginal bleeding). Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies). An ectopic pregnancy is a potential medical emergency. The following may reduce your risk: • • • • Avoiding risk factors for pelvic inflammatory disease (PID) such as having many sexual partners. . You can have an ectopic pregnancy if you are able to get pregnant (fertile) and are sexually active. is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. internal bleeding being a common complication. a tubal pregnancy (the most common type of ectopic pregnancy) may be prevented in some cases by avoiding conditions that might scar the fallopian tubes. and getting sexually transmitted diseases (STDs) Early diagnosis and treatment of STDs Early diagnosis and treatment of salpingitis and PID Stopping smoking Alternative Names Tubal pregnancy. or eccyesis. ectopic pregnancies are not viable. Abdominal pregnancy An ectopic pregnancy. and. ovaries. Cervical pregnancy. even if you use birth control. However. having sex without a condom.
3 Heterotopic pregnancy o 2.2 Other 5 Diagnosis 6 Treatment o 6.1 Cilial damage and tube occlusion o 4.4 Persistent ectopic pregnancy 3 Signs and symptoms 4 Causes o 4.Contents [hide] • • • • • • • • • • • • 1 Overview 2 Classification o 2.1 Medical o 6.1 Tubal pregnancy o 2.2 Nontubal ectopic pregnancy o 2.1 Future fertility 9 Cases with live birth 10 In other animals 11 References 12 External links  Overview Ruptured tubal pregnancy with approx 6-weeks-embryonic-age or 8-weeks-gestationalage embryo. with intact amniotic sac .2 Surgical 7 Complications 8 Prognosis o 8.
legal abortions and ectopic pregnancies]. the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb. Between 1970 and 1992.5 to 19.  .Oviduct with an ectopic pregnancy (tubal pregnancy) showing an embryo of approx.7 per 1000 reported pregnacies [including live birth. In other words it can be said that in an ectopic pregnancy the embryonic implantation occurs outside the uterus. 6 weeks from conception) In a normal pregnancy. It poses serious threat to the general and reproductive health of the mother. the rate of ectopic pregnancy increased from 4. 6-7 menstrual weeks Another example of a tubal pregnancy (fetus is 8 weeks gestational age. most commonly in the fallopian tubes but at times also in the extra tubal locations. Ectopic pregnancy comprises 2% of all pregnancies reported to the Centre for Disease Control and Prevention [CDC]. and of these 98% occur in the Fallopian tubes. It has been noted that ectopic pregnancy is steadily and persistently rising since 1970.
The pain is caused by prostaglandins released at the implantation site. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur. The implanted embryo burrows actively into the tubal lining. especially if the implantation is in the proximal tube (just before it enters the uterus). This intervention may be laparoscopic or through a larger incision. it may invade into the nearby Sampson artery.  Classification  Tubal pregnancy The vast majority of ectopic pregnancies implant in the Fallopian tube. surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. Most commonly this invades vessels and will cause bleeding.   Nontubal ectopic pregnancy Two percent of ectopic pregnancies occur in the ovary. known as a laparotomy. . Usually this degree of bleeding is due to delay in diagnosis. which is a local irritant. about half of ectopic pregnancies will resolve without treatment. There is no inflammation of the tube in ectopic pregnancy. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery. the ampullary section (80%). Pregnancies can grow in the fimbrial end (5% of all ectopics). causing heavy bleeding earlier than usual. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria. Some women thinking they are having a miscarriage are actually having a tubal abortion. or are intraabdominal. In a typical ectopic pregnancy. but instead adheres to the lining of the Fallopian tube.Detection of ectopic pregnancy in early gestation has been achieved mainly due to enhanced diagnostic capability. cervix. and by free blood in the peritoneal cavity. but sometimes. Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. If left untreated. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. however. and the cornual and interstitial part of the tube (2%). Despite all these notable successes in diagnostics and detection techniques ectopic pregnancy remains a source of serious maternal morbidity and mortality all over the world. These are the tubal abortions. the embryo does not reach the uterus. the isthmus (12%). This intratubal bleeding (hematosalpinx) expels the implantation out of the tubal end as a tubal abortion.
Such a fetus would have to be delivered by laparotomy. there is the chance that a pregnancy inside the uterus is still viable. such as the renal (kidney). Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of hemorrhage. a live baby has been delivered from an abdominal pregnancy. but some trophoblastic tissue perhaps deeply embedded has escaped removal and continues to growth. also methotrexate can be given at the time of surgery prophyllactically. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy. This is called a heterotopic pregnancy. liver or hepatic (liver) artery or even aorta have been described. For this reason hCG levels may have to be monitored after removal of an ectopic to assure their decline. very rarely. However. there may be two fertilized eggs. This is generally bowel or mesentery. such as a section of bowel. Successful pregnancies have been reported from ruptured tubal pregnancy continuing by the placenta implanting on abdominal organs or on the outside of the uterus. then the placenta should be removed together with that organ. in about 15-20% the major portion of the ectopic may have been removed. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports. If the organ to which the placenta is attached is removable. mainly because of the painful emergency nature of ectopic pregnancies. but other sites. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%. Often the intrauterine pregnancy is discovered later than the ectopic. one outside the uterus and the other inside.  Persistent ectopic pregnancy A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. This is normally discovered through an ultrasound. . but even in third world countries. Although rare. the diagnosis is most commonly made at 16 to 20 weeks gestation. generating a new rise in hCG levels.  Heterotopic pregnancy In rare cases of ectopic pregnancy. an ultrasound may not find the additional pregnancy inside the uterus. heterotopic pregnancies are becoming more common. When hCG levels continue to rise after the removal of the ectopic pregnancy.While a fetus of ectopic pregnancy is typically not viable. Support to near viability has occasionally been described. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy. After weeks this may lead to new clinical symptoms including bleeding.
and is often getting worse. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms: • • External bleeding is due to the falling progesterone levels. it may also feel like a strong cramp) Pain while urinating Pain and discomfort. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID).2 weeks after the last normal menstrual period. Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube. Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis. Pain while having a bowel movement Patients with a late ectopic pregnancy typically experience pain and bleeding. and early normal pregnancy. usually mild. and is an ominous sign. More severe internal bleeding may cause: • • • • Lower back. The differential diagnosis at this point is between miscarriage. There may be cramping or even tenderness on one side of the pelvis. other gastrointestinal disorder. The pain is of recent onset. Clinical presentation of ectopic pregnancy occurs at a mean of 7. problems of the urinary system. . with a range of 5 to 8 weeks. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. as well as pelvic inflammatory disease and other gynaecologic problems. and inflammation (Pain may be confused with a strong stomach pain. meaning it must be differentiated from cyclical pelvic pain. Early signs include: • • • • • Pain in the lower abdomen. Vaginal bleeding. Signs and symptoms Early symptoms are either absent or subtle. or pelvic pain. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. ectopic pregnancy. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm. abdominal. The most common misdiagnosis assigned to early ectopic pregnancy is PID. usually mild. Shoulder pain. Later presentations are more common in communities deprived of modern diagnostic ability.
 Women exposed to diethylstilbestrol (DES) in utero (aka "DES Daughters") also have an elevated risk of ectopic pregnancy. so that sperm and egg were physically unable to meet. Causes There are a number of risk factors for ectopic pregnancies. However.  Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. then fertilization of the egg would naturally be impossible. partial removal of the tubes) have been used than less destructive methods (tubal clipping). Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. Vaginal douching is thought by some to increase ectopic pregnancies. This is higher if more destructive methods of tubal ligation (tubal cautery.  Other Patients are at higher risk for ectopic pregnancy with advancing age. and tubal ligation. and neither normal pregnancy nor ectopic pregnancy could occur. up to 3 times the risk of unexposed women. Seventy percent of pregnancies after tubal cautery are ectopic. This risk is not reduced by removing the affected tube. Also. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. The best method for diagnosing this is to do an early ultrasound. use of an intrauterine device (IUD). while 70% of pregnancies after tubal clips are intrauterine . it has been noted that smoking is associated with ectopic risk. The threshold of discrimination of intrauterine pregnancy is around . If however both tubes were completely blocked. even if the other tube appears normal. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. in as many as one third to one half of ectopic pregnancies. those who have been exposed to DES. A history of a tubal pregnancy increases the risk of future occurrences to about 10%.  Diagnosis An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. Risk factors include: pelvic inflammatory disease. Tubal ligation can predispose to ectopic pregnancy. tubal surgery. leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy. no risk factors can be identified. smoking. causing damage to cilia. This results from the build-up of scar tissue in the Fallopian tubes. infertility. An abnormal rise in blood β-human chorionic gonadotropin (β-hCG) levels may indicate an ectopic pregnancy. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy. previous ectopic pregnancy.
it may be necessary to wait a few days and repeat the blood work. A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883. . this strongly suggests a spontaneous abortion or rupture.  Treatment  Medical Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment since at least 1993. it is difficult to find the pregnancy tissue. Culdocentesis. is a less commonly performed test that may be used to look for internal bleeding. whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. If the β-hCG falls on repeat examination. this may cause an abortion. In this test. or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. This can be done by measuring the β-hCG level approximately 48hrs later and repeating the ultrasound. transvaginal ultrasound showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for β-hCG has been reached. If the diagnosis is uncertain.  Surgical If hemorrhage has already occurred. behind the uterus and in front of the rectum. Often if a tubal abortion or tubal rupture has occurred. surgical intervention may be necessary.1500 IU/ml of β-hCG. a needle is inserted into the space at the very top of the vagina. in which fluid is retrieved from the space separating the vagina and rectum. A high resolution. Cullen's sign can indicate a ruptured ectopic pregnancy. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy. However. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy. methotrexate terminates the growth of the developing embryo. but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If administered early in the pregnancy.
She should not have any contraindications to the use of methotrexate. 2008 an Australian woman. The treatment choice. Rate of fertility may be better following salpingostomy than salpingectomy. The baby was delivered by a laparotomy at 28 weeks gestation. She had no problems or complications during the 38week pregnancy. On 19 April 2008 an English woman. the fatty covering of her large bowel. Complications The most common complication is rupture with internal bleeding that leads to shock. Furthermore.15% of women who have had an ectopic pregnancy.  Cases with live birth There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by laparotomy. For example. which should not exceed 3. Durga. Another factor is size of the gestation. Death from rupture is rare in women who have access to modern medical facilities. The intrauterine twins were taken out first. The patient must be hemodynamically stable. Infertility occurs in 10 . Medical therapy Medical therapy involving methotrexate may be indicated in certain patients. and able to return for follow-up. compliant. Mary and Ronan had an extrauterine fetus (Ronan) and intrauterine twins. the most important of which is a prior history of infertility. gave birth. and both mother and baby survived. gave birth to a healthy full term 6 pound 3 ounce (2. who had an ectopic pregnancy in the ovary. whether surgical or nonsurgical. The case of Olivia. On May 29. All three survived. Jayne Jones (age 37) who had an ectopic pregnancy attached to the omentum. via Caesarean section. Surgical therapy . the first of its kind to be performed in the UK. also plays a role. with no signs or symptoms of active bleeding or hemoperitoneum.  Prognosis  Future fertility Fertility following ectopic pregnancy depends upon several factors. Meera Thangarajah (age 34). was successful.5 cm at its greatest dimension on ultrasound (US) measurement. The surgery. the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.8 kg) baby girl. she must be reliable. A number of factors must be considered.
and free fluid in the culde-sac on US (presumably representing tubal rupture) are contraindications to medical therapy with methotrexate. peptic ulcer disease. total salpingectomy is the procedure of choice. In cases involving uncontrolled bleeding and hemodynamic instability. Furthermore. Surgical therapy Surgical treatment in cases in which the pregnancy is located on the cervix. conservative treatment methods are avoided in favor of radical surgery. Laparotomy is usually reserved for patients who are hemodynamically unstable or patients with cornual ectopic pregnancies. breastfeeding. In these cases. Contraindications Medical therapy A bhCG level of greater than 15. leukopenia. such as declining bhCG levels. and renal. Relevant Anatomy See Pathophysiology. Other contraindications to the use of methotrexate include documented hypersensitivity to methotrexate. In a patient who has completed childbearing and no longer desires fertility. . obesity or massive hemoperitoneum). or in a patient with severely damaged tubes. or hematologic dysfunction. They must be fully compliant and must be willing to accept the potential risks of tubal rupture.Within the last 2 decades. Expectant management Candidates for successful expectant management are asymptomatic and have no evidence of rupture or hemodynamic instability. or in the interstitial or the cornual portion of the tube is often associated with increased risk of hemorrhage. immunodeficiency. a more conservative surgical approach to unruptured ectopic pregnancy using minimally invasive surgery has been advocated to preserve tubal function (see Surgical Therapy). ovary. blood dyscrasias. alcoholism. thrombocytopenia. anemia. treatment with methotrexate is an especially attractive option.000 IU/L. in a patient with a history of an ectopic pregnancy in the same tube. alcoholic liver disease or any liver disease. fetal cardiac activity. secondary to the presence of multiple dense adhesions. It also is a preferred method for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is difficult (eg. Laparoscopy has become the recommended approach in most cases. hepatic. active pulmonary disease. often resulting in hysterectomy or oophorectomy. they should portray objective evidence of resolution.
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