An ectopic pregnancy is one in which the fertilised egg attaches itself in a place other than inside the uterus.
Almost all ectopic pregnancies occur in a fallopian tube; hence the term "tubal" pregnancy.
Rarely the egg may implant elsewhere, such as in the abdomen, ovary or cervix.
Because the narrow fallopian tubes are not designed to hold a growing embryo, the fertilised egg in a tubal pregnancy cannot develop normally.
Eventually, the thin walls of the tube stretch to the point of bursting. If this happens, a woman is in danger of life-threatening blood loss (hemorrhage).
During the 1980s the rate of ectopic pregnancy increased.
Ectopic pregnancy now occurs in about one of every 100 to 200 reported pregnancies in South Africa.
Even so, death from ectopic pregnancy is rare, occurring in fewer than one of every 2 500 cases.
This low rate is largely a result of new techniques to detect ectopic pregnancy at an early stage, when the risk to the pregnant woman is much lower.
Most cases of ectopic pregnancy are caused when the fertilised egg cannot move through the fallopian tube into the uterus.
This is often caused by an infection or inflammation of the tube, which has caused it to become partly or entirely blocked.
Endometriosis
Scar tissue left behind from a previous infection or an operation on the tube may also impede the egg's movement.
Previous surgery in the pelvic area or on the tubes can also cause adhesions (bands of tissue that bind together surfaces inside the abdomen or the tubes).
A condition called endometriosis, in which tissue like that normally lining the uterus is found outside the uterus, can also cause blockage of a fallopian tube.
Another possible cause is an abnormality in the shape of the tube, which may be caused by abnormal growths or a birth defect.
Major risk
Most ectopic pregnancies occur in women 35 to 44 years.
The major risk factor for ectopic pregnancy is pelvic inflammatory disease (PID).
This is an infection of the uterus, fallopian tubes, or ovaries.
The risk of ectopic pregnancy is also higher in women who have had any of the following:
* Previous ectopic pregnancy
* Surgery on a fallopian tube
* Several induced abortions
* Infertility problems or medication to stimulate ovulation
What are the symptoms? In many cases, a pregnant woman and her doctor may not at first have any reason to suspect an ectopic pregnancy.
The early signs of pregnancy, such as a missed period and other symptoms and signs, also occur in ectopic pregnancies.
Sharp and stabbing
Pain is usually the first sign of an ectopic pregnancy.
The pain may be in the pelvis, abdomen, or even the shoulder and neck (due to blood from a ruptured ectopic pregnancy building up under the diaphragm).
Pain from an ectopic pregnancy is usually described as sharp and stabbing.
It may come and go or vary in intensity.
Other warning signs of ectopic pregnancy include:
* Vaginal bleeding
* Gastrointestinal symptoms
* Dizziness or light-headedness
Although there may be other reasons for any of these symptoms, they should be reported to your doctor.
If your doctor suspects an ectopic pregnancy, he or she will probably first perform a pelvic exam to locate pain, tenderness, or a mass in the abdomen.
Lab tests may then be ordered.
Hormone testing
The most useful of these is the measurement of hCG.
In a normal pregnancy, the level of this hormone doubles about every two days during the first 10 weeks.
In an ectopic pregnancy, however, the rate of this increase is much slower.
An hCG level that is lower than what would be expected for the stage of the pregnancy is one reason to suspect an ectopic pregnancy.
The hCG level may be tested several times over a certain period to determine whether it is increasing at a normal rate.
Progesterone is another hormone that can be measured to help in the diagnosis of ectopic pregnancy.
Low levels of this hormone may indicate that a pregnancy is abnormal.
Ultrasound
Further tests are needed to confirm whether the pregnancy is ectopic and, if it is, where it is located.
Ultrasound exams may also be used to help determine whether a pregnancy is ectopic.
With this technique, a device called a transducer, which emits high-frequency sound waves, is moved over the abdomen or inserted into the vagina.
The sound waves bounce off internal organs and create an image that can be viewed on a TV-like screen.
Culdocentesis
With this procedure, your doctor may be able to see whether the uterus contains a developing foetus.
A procedure called culdocentesis is occasionally used to aid in diagnosing ectopic pregnancy.
This technique involves inserting a needle into the space at the very top of the vagina, behind the uterus and in front of the rectum.
The presence of blood in this area may indicate bleeding from a ruptured fallopian tube.
Treatment of ectopic pregnancy usually consists of surgery to remove the abnormal pregnancy.
Surgery is necessary
Surgery is generally scheduled soon after an ectopic pregnancy is diagnosed.
At one time, a major operation was needed for ectopic pregnancy.
General anesthesia was used, and the pelvic area was opened with a large incision.
Now, however, it is often possible to remove an ectopic pregnancy with a less extensive technique called laparoscopy.
In this procedure, a small incision is made in the lower abdomen, near or in the navel.
The surgeon then inserts a long, thin instrument, called a laparoscope, into the pelvic area.
This instrument is a hollow tube with a light on one end. Through it, the internal organs can be viewed and other instruments can be inserted.
Burst fallopian tube
Sometimes a second small incision is made in the lower abdomen, through which surgical instruments can be placed.
The laparoscope allows the surgeon to remove the ectopic pregnancy and repair or remove the affected fallopian tube.
Laparoscopy may be performed possibly with local anesthesia but more likely with regional or general anesthesia.
A fallopian tube that has ruptured from an ectopic pregnancy usually must be removed.
Less extensive surgery can be done if the ectopic pregnancy has been found early, before the tube has been stretched too much or has burst.
In these instances, it may be possible to remove the ectopic pregnancy and repair the tube, allowing it to continue to function.
Occasionally, a medication called methotrexate is used to dissolve an ectopic pregnancy.
This medication is used either with or without laparoscopy, depending on how far the pregnancy has developed.
Medical management
After treatment for an ectopic pregnancy, your doctor will check on a regular basis if your hCG level has reached zero.
An hCG level that remains high could indicate that the ectopic tissue was not entirely removed.
If this is the case, you may need additional surgery or medical management with methotrexate.
The outlook for future pregnancies after an ectopic pregnancy depends mainly on the extent of the surgery that was done.
Although the chances of having a successful pregnancy are lower if you've had an ectopic pregnancy, they are still good perhaps as high as 60 percent if the fallopian tube has been spared.
Plan your care
Even if one fallopian tube has been removed, an egg can be fertilised in the other tube.
The chances of having a successful pregnancy with one tube removed may be more than 40 percent.
If you've had one ectopic pregnancy, though, you're more likely to have another one.
And the risk increases with the number of ectopic pregnancies.
If you've had an ectopic pregnancy, talk to your doctor before becoming pregnant again so that you can plan your care together. - Staff doctor