Ectopic Pregnancy

What is ectopic pregnancy is a common question among many couples trying to conceive. For pregnancy to be successfully taking place, the egg should be fertilized and then attach itself to the uterus lining. But, not every conception leads to a successful pregnancy as the egg doesn’t always attach itself to the lining of the uterus. Such pregnancies are called ectopic pregnancies which may turn into a horrifying ride. These can prove to be very harmful and even fatal for pregnant women who are faced with this hardship. 

What is Ectopic Pregnancy?

It is the term used for the pregnancy in which the fertilized egg implants on regions other than at the lining of the uterus i.e., womb, like in the case of a usual pregnancy. In 95% of ectopic pregnancies, the egg implants itself on the fallopian tubes. Such pregnancy is called a tubal pregnancy.

Types of Ectopic Pregnancy:

The classification of ectopic pregnancy is done on the basis of the place where the fertilized egg gets implanted. 

Tubal Pregnancy: A pregnancy where the fertilized egg implants in the Fallopian tube instead of continuing its journey to the uterus, like in a normal pregnancy. This is the most commonly found type of all the ectopic pregnancies. Based on the exact location of the implanted egg, the tubal pregnancies can be further classified. 

• In 80% of the cases, the egg gets implanted in the ampullary region
• In nearly 5% of the tubal pregnancies, gets implanted in the fimbrial end of the fallopian tube
• In 12% cases, it gets implanted in the isthmus region of the fallopian tube. Such cases are very dangerous as the increased vasculature in this area means an invitation to hemorrhage which ultimately leads to death/ mortality.
• In rest 2% of cases, the egg grows in the cornual and interstitial part of the fallopian tube. Such cases can also lead to mortality due to increased vasculature.

Non-tubal Pregnancy:  In around 2% of the ectopic pregnancies, the egg gets implanted in the cervix, ovaries, or abdominal region. Such pregnancies are called non-tubal pregnancies.

Heterotopic Pregnancy: There are very rare cases in which one fertilized egg gets implanted in the uterus and another gets implanted outside of its structure.  The pregnancy in the ectopic region is mostly discovered first, because of its painful nature and the normal (intrauterine pregnancy) one is detected later. Such pregnancy can be removed in such cases and if the HCG levels still rise after the removal, the normal pregnancy can still be possible.

Causes of Ectopic Pregnancy

The reason for ectopic pregnancy is not always so crystal clear as one would presume. However, certain conditions can be directly linked with it:

• If there is any Inflammation of the fallopian tube.
• Presence of scarring/ adhesions in the fallopian tubes
• Hormonal issues of the women
• Any Genetic defects
• If there are any birth defects

Risk Factors of Ectopic Pregnancy:

• Tubal Damage: 

There are hair like structures called cilia present on the internal surface of the fallopian tubes responsible for transporting the egg to the uterus for the implantation to happen. If the cilia are less in number, it would be impossible for the egg to get transported to the uterus and hence, it gets implanted in the fallopian tube instead. Hence, the ectopic pregnancy in which the fertilized egg gets implanted in the fallopian tube, instead of the uterus is called Tubal Pregnancy. This reduced number of cilia leading to the ectopic pregnancy in the fallopian tube is mostly seen in women who smoke as smoking leads to risk factors of damaging and killing cilia. Because of the reduced number of cilia, the time taken to transport the fertilized egg to the uterus gets extended/ increased. Hence, the egg layer which is supposed to degenerate in the uterus for the implantation to happen, degenerates in the fallopian tube leading to tubal pregnancy. 

• Age:

Although, ectopic pregnancy can occur at any age until the woman is ovulating and who has an active sex life. However, women aged 35-44 years are more prone to this condition because of the greatest chances of cilia loss and adhesions to be found in these years.

• Prior History of Ectopic pregnancy:

In women with prior history of ectopic pregnancy, there is a really high chance of occurrence of ectopic pregnancy. 

• Previous surgeries: 

In case of women who have undergone previous surgeries of the fallopian tubes like tubal sterilization or any other reconstructive surgeries, scarring and disruption of the normal shape and structure of the fallopian tubes can occur increasing the threat of an ectopic pregnancy. 

• Infections:

Pelvic infections caused by sexually transmitted organisms can lead to ectopic pregnancy. In cases of women with Chlamydia, gonorrhea, or pelvic inflammatory disease also, there are really high chances of the occurrence of ectopic pregnancies because of the scar tissue in the fallopian tubes, destroying the cilia. In women with blockages of the fallopian tubes, the sperm and egg would be unable to meet, then no pregnancy could occur. 

1. Multiple sex partners: 

Women having sex with multiple sex partners have high chances of ectopic pregnancy as sex with multiple partners increases the risk of any pelvic infections.

• Gynecological conditions:

There are other conditions like endometriosis, the presence of fibroids, or scars/adhesions in the pelvic region of the uterus which can cause ectopic pregnancy as they cause narrowing of the fallopian tubes and hence create hindrances in the transportation of the egg. 

• Use of IUD:

50% of the women who use IUDs (Intra Uterine Devices) face the problem of ectopic pregnancy. This number seems less in quantity because the number of women who use IUDs is extremely low.

• Cigarette Smoking:

There are many instances where smoking cigarettes near the time of conception have increased the risk of an ectopic pregnancy. This risk depends on the amount of smoking one has been doing i.e., the risk increases with the number of cigarettes smoked by the individual woman. 

• Infertility:

If there is a history of infertility in a woman for two or more years, there is an increased risk of an ectopic pregnancy.

Ectopic Pregnancy Symptoms

In most cases, such pregnancy might not even be suspected as one may think that the symptoms are of a normal pregnancy. Although, there are certain symptoms associated with an early ectopic pregnancy that can differentiate it from a normal one. A few of the common early symptoms experienced by most women having an ectopic pregnancy are tenderness of the breast/breasts, missing a period, and nausea. In other cases, the following symptoms can also be experienced:

• Vaginal bleeding
• Pelvic pain
• Vomiting and uncomfortable stomach 
• Sharp occurrences of pain in the abdominal, pelvic, shoulder, rectum, or neck region.
• Dizziness 
• Weakness
• Low Blood Pressure

As the egg keeps on growing, it becomes hard for the fallopian tube (or other parts like the ovary, cervix, etc.) to bear the pressure, and ultimately, rupture/ burst occurs of that area. If that happens, ectopic pregnancy signs like heavy vaginal bleeding, fainting, or serious abdominal pain can occur requiring immediate medical attention.

Diagnosis

Diagnosis for Ectopic Pregnancy is done in the first-trimester stage of the pregnancy. The doctor interviews and examines the individual. Depending on the possibility of a rupture, there can be differences in the physical findings of a pregnancy. There can be a substantial amount of pain and tenderness in case of an intraperitoneal rupture. Although, pelvic pain and/or vaginal bleeding can be found in cases where the rupture hasn’t taken place. 

After this, a qualitative test for pregnancy and a quantitative test for hormone levels is done.

If the doctor feels a tender mass while examination of the pelvis. If there is a suspicion of an ectopic pregnancy, tests like blood hormone tests and ultrasonography are carried out to be sure about the diagnosis. Out of both these tests, transvaginal ultrasound is of most effective and useful as it delivers the proper visualized report. To carry out this test, an ultrasound probe is used which is inserted into the vagina and the visual data (images) is seen on the monitor. It helps by revealing the gestational sac(initial baby) to us which helps us to know if the pregnancy is a normal or an ectopic one. In a few cases, the findings are not that conclusive as the examination may sometimes reveal a mass in the fallopian tubes or other areas instead of a gestational sac that may be indicative of an ectopic pregnancy. Even in cases where there is an absence of pregnancy also, ultrasound can help us.

Pregnancy tests detect/examine specific hormones i.e., beta HCG hormone in the blood. If the levels of beta HCG hormone are greater than the normal levels, it is an indication of pregnancy. If the pattern in the rise of this hormone is abnormal, then it can be a clue that the pregnancy is of ectopic type. Rarely a laparoscopy can be required to confirm that the pregnancy is of the ectopic kind. 

Laparoscopy is a technique in which viewing instruments are inserted into the abdomen and pelvis through small incisions made on the abdominal wall by a doctor.

Ectopic Pregnancy Treatment

It is not possible in case of an ectopic pregnancy to save the baby (growing embryo). Treatment is usually required to remove the embryo before it can prove fatal for the pregnant woman.

There are three major treatment options:

Management: The condition of the woman having an ectopic pregnancy is kept under monitoring to see if there is a requirement for treatment.

• If the embryo is very small and the symptoms are mild or if there are  no symptoms,  only close monitoring may be required to do as there are good chances of the pregnancy dissolving by itself.
• This is referred to as expectant management.

Routine blood tests are done in order to check for the HCG hormone to ensure the levels are going down. If the level doesn’t show a decline, further treatment would be required. Some vaginal bleeding can still be there so tampons should be used for a proper hygienic environment until the bleeding stops. Some abdominal pain can be there so paracetamol is suggested by the doctor. 

Advantages: No chances of side effects of treatment as the body is taking over the treatment for itself, we are just suppressing the pain.

Disadvantages: Minor chances of the fallopian tube getting ruptured in a few cases hence, demanding further treatment.

Medication:

If the diagnosis for ectopic pregnancy is performed early but active monitoring doesn’t seem suitable for the case, “methotrexate” named medicine can be prescribed that ceases the growth of the pregnancy. This is given in the form of injection. Although, there is no requirement to stay at the hospital after the methotrexate treatment. Blood tests will still be carried out until the HCG levels fall to the normal values. Reliable contraception should be used for at least 3 months after treatment because the methotrexate can cause harm to the baby if you get pregnant with it being in your system. Alcohol drinking should also be stopped as methotrexate can damage the liver with alcohol.

There can be other side effects of methotrexate like;

• Abdominal pain
• Feeling dizzy
• Being sick
• diarrhea

Surgery: The final treatment for this would be ectopic pregnancy surgery in which the pregnancy(embryo) is removed from the body. Sometimes, the affected fallopian tube is also removed along with it. This is carried out using laparoscopy in which the doctor injects general anesthesia to the patient, small incisions are made in the abdomen through which a laparoscope is inserted along with small surgical instruments. Then, the whole fallopian tube is removed (if affected) from the body. It is the most effective treatment. This surgery is not that intensive as women who have undergone this surgery can leave the hospital in a few days after the procedure. Full recovery may take up to 6 weeks.

Each of these options has its respective pros and cons. Your doctor will help you in finding the best one for you depending on the following factors ;

• Your symptoms
• Size of the fetus
• Level of HCG hormone present in your blood

Conclusion:

When ectopic pregnancy symptoms start, one should not be careless and presume it to be a normal pregnancy. Rather, she should observe each discomfort that feels like too much as it is not always easy to differentiate between a normal and ectopic pregnancy. There can be an occurrence of this without bleeding also. Bleeding is not a symptom that will be seen in every case. If there is pelvic pain that feels like too much for a pregnancy, go to your doctor and have a proper diagnosis. If there is an ectopic pregnancy and it is diagnosed at right time, you can save your life and increase the chances of your future baby as in some cases fallopian tube also has to be removed along with the embryo. There are many women who get depressed if they encounter an ectopic pregnancy, even worse for the women trying to get pregnant for a while and then facing an ectopic pregnancy. They should know that there is hope. There’s a quote by Jodi Sky Rogers that fits for such scenarios,

“Something profound happens when you wake up in a calm green pasture on the other side of the treacherous storm that you thought would end you. You discover who you are beyond the unimaginable. You discover what you are made of. Suddenly, the thing that may have broken you becomes the very thing that empowers and emboldens you.”

Patient Testimonial

I am Reena Duggal from Chandigarh. I was eight weeks pregnant through IVF when I started noticing brown discharge and little red spots. I waited for a week but the discharge didn’t stop. When I had my ultrasound, we discovered we had an ectopic pregnancy. It was an emotional rollercoaster that I felt at that moment. I still can’t talk about it much. I had not much discomfort except the sharp cramps. Thank god I was saved as the doctors told me that it could have been dangerous if any rupture had taken place. I feel sad sometimes about the baby being removed from my body but I am thankful that I am alive today as my husband would not be able to live with himself if I had died.

FAQs

How early can ectopic pregnancy be detected by ultrasound?

It usually takes about 5 to 6 weeks for an ectopic pregnancy to be detected by the ultrasound as the symptoms/discomfort appear as the embryo grows in the ectopic site.

How to prevent Ectopic Pregnancy? 

Limit your sexual partners and use condoms to avoid getting any sexually transmitted diseases like PID, Chlamydia, etc. Quit smoking and doing drugs as they can destroy the cilia thereby, leading to an ectopic pregnancy.

How do I know if I’m having an ectopic pregnancy? 

You’ll know it when the symptoms start to occur. The most common early symptoms are a pain in the abdominal or pelvic area and vaginal bleeding. 

Can a baby survive an ectopic pregnancy? 

The fetus in an ectopic pregnancy can’t be saved. The focus should be on saving the woman having an ectopic pregnancy as it can be fatal for her if the ectopic pregnancy causes rupture. 

How long can an ectopic pregnancy go unnoticed? 

The symptoms start appearing in the first 4 weeks as the growing egg puts pressure on the fallopian tube leading to vaginal/pelvic pain and bleeding. It is noticed in cases of extreme pain or bleeding. 

What is ectopic pregnancy pain like? 

The pain in ectopic pregnancy comes and goes like a sudden wave of stabbing pain which is not like the mild cramping in the usual normal pregnancy.

What are the chances of having an ectopic pregnancy twice?

If it was because of any serious reasons like PID, then there are high chances of you having an ectopic pregnancy twice. Otherwise, there are only 10-15% chances of it being a possibility.

References

https://www.nejm.org/doi/full/10.1056/NEJMcp0810384

https://pubmed.ncbi.nlm.nih.gov/7823895/

https://www.cmaj.ca/content/173/8/905.short

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000324.pub2/abstract