Ectopic pregnancy

An ectopic pregnancy occurs when a fertilized egg implants itself outside the uterus.


General information
At the beginning of pregnancy, the fertilized egg passes through the fallopian tube on its way to the uterus. In more than 95 percent of ectopic pregnancies, the egg implants itself in one of the fallopian tubes before reaching the uterus.
A fertilized egg can also attach itself on the outside of an ovary (a gland that produces female sex hormones and eggs for reproduction), inside the abdominal cavity or even on the cervix (the neck of the uterus). If the displaced egg is left to grow, it can eventually cause serious bleeding and damage to the structures around it. For example, in the fallopian tube, the egg usually develops to about the size of a walnut before the tube ruptures and serious bleeding occurs. In the United States, ectopic pregnancy is the leading cause of maternal death during the first trimester.


Causes/associated factors
About two of every 100 pregnancies in the United States are ectopic. The most important risk factor for developing an ectopic pregnancy is a prior bout with pelvic inflammatory disease (PID), an infection of the female reproductive organs -- the uterus, fallopian tubes or the ovaries. This risk is even more important if the cause of the PID was the sexually transmitted infection chlamydia.
Other factors that may increase your likelihood of having an ectopic pregnancy include:


a previous ectopic pregnancy (up to 15 percent of women diagnosed with ectopic pregnancy have a subsequent ectopic pregnancy)
previous tubal surgeries or diagnosed tubal abnormalities
tubal ligation (commonly known as having your tubes tied)
exposure to diethylstilbestrol (DES) while in your mother's womb (DES is a synthetic estrogen that was used for certain medical conditions in pregnant women from 1938 to the early 1970s in the United States. It has been associated with tubal abnormalities.)
adhesions (scar tissue) in or around the fallopian tubes, often related to endometriosis (when the tissue that lines the uterus grows outside the uterus) or appendicitis (inflammation of the appendix, a small organ located at the point where the large and small intestines join) or infection following childbirth or abortion
using an intrauterine device (IUD) or progestin-only minipills for contraception
pregnancy from assisted reproduction (in vitro fertilization or ovulation induction, for example)
previous infections with sexually transmitted diseases
having multiple sexual partners
smoking cigarettes
Sometimes, the cause of an ectopic pregnancy is unknown.


Signs/symptoms
Early symptoms of an ectopic pregnancy may include:
missed menstrual period
scanty, dark-brown vaginal bleeding or light bleeding (Any vaginal bleeding or spotting usually precedes abdominal pain and cramping. However, there may be no spotting or bleeding at all.)
abdominal tenderness or cramping (usually in the lower abdomen that is one-sided initially, and then radiates through the abdomen)
Symptoms of a rupture may include:

sudden, severe abdominal pain that may be sharp, stabbing or tearing
for some women, shoulder, neck or chest pain that is worse when breathing in (referred pain from the diaphragm, which has been irritated by blood that has accumulated in the abdomen)
bleeding
dizziness or weakness
for some women, sensation of rectal pressure
for 25 to 50 percent of women, nausea or vomiting
shock (weak pulse, clammy skin and fainting)

Diagnosis
Early diagnosis of ectopic pregnancy is essential in preventing serious tubal damage, major surgery or even death. If you're at risk for an ectopic pregnancy, it's possible to detect the condition as early as 4½ weeks gestation, before symptoms even appear. When the fetus is very small, it may take several days from the time testing begins until a final diagnosis of ectopic pregnancy is made, however.
The doctor will begin by asking questions about your medical history and do a pelvic exam. You may also need one or more of the following tests:


a blood test to measure progesterone (a hormone produced by the ovaries early in pregnancy) and human chorionic gonadotropin (hCG, a hormone produced by the placenta)
an ultrasound (using sound waves to create an image of internal body parts)
a laparoscopy (a surgical procedure that allows the doctor to directly view organs in the abdominal cavity with a laparoscope, a thin tube equipped with a camera lens and light)

Treatment
To preserve your health, the ectopic pregnancy must be terminated. How this is done depends on the age, size and location of the fetus. Whenever possible, the doctor will try to preserve as much of the fallopian tube as possible.
The medication methotrexate can sometimes be used to treat an ectopic pregnancy if the pregnancy is diagnosed early, before rupture or bleeding has occurred. Methotrexate stops cell growth and dissolves existing cells. One or more injections of the medication are given, and you'll be monitored closely for side effects, possible tubal rupture and signs that the pregnancy has ended. With successful treatment, the hormone hCG will gradually disappear from your blood. You'll also need several weeks of blood tests to ensure complete resolution of the ectopic pregnancy. If the pregnancy continues despite treatment, more medication or surgery may be necessary.

If the fallopian tube has ruptured and you're bleeding, you may need emergency surgery through a laparotomy (an abdominal incision). The ruptured fallopian tube must often be removed, but repair may be possible if the tube is only slightly damaged. If emergency surgery is not necessary, the doctor may be able to surgically remove the fetus from the tube during a laparoscopy. Recovery is usually faster with laparoscopic surgery. After treatment, your blood will be monitored for the hormone hCG. If the pregnancy has not successfully ended, you may need additional surgery or treatment with medication.

Thanks to earlier diagnosis and treatment, survival rates for ectopic pregnancies have increased, as has the chance for future healthy pregnancies. Grief following an ectopic pregnancy is normal, however. It's important for you and your partner to talk about your feelings with someone who understands and can provide the support you need. You may find it helpful to talk to your doctor, a counselor or someone who has experienced a similar loss.


Complications
Complications of an ectopic pregnancy may include infection after surgery, loss of reproductive organs and, for 30 to 35 percent of women, infertility. A ruptured fallopian tube may lead to hemorrhage or shock. In some cases, a ruptured fallopian tube can be fatal. (Again, symptoms include a sudden onset of severe abdominal pain or a significant increase in abdominal pain, heavy vaginal bleeding, dizziness and fainting.)

Prevention
Ectopic pregnancies cannot be directly prevented. However, you may be able to decrease some of your risk factors. Consult your doctor for details.