Ectopic Pregnancy 

Definition:
It is when the developing embryo does not grow in the endometrial wall and attach itself on another place.

Ectopic pregnancy rate is 1% to 2% of live births, and assisted productive techniques may increase the risk.

95% of ectopic pregnancies happen in the fallopian tube.
In rare cases, the developing embryo will attach to the cervix, an ovary, abdominal wall or to a previous cesarean scar.

In ectopic pregnancy, the embryo is not able to grow normally, the organ where the embryo is attached can rupture leading to internal bleeding, shock or death in rare cases.

Risk factors:
1. Fallopian tubes abnormalities: due to previous surgery, infection, tumor or birth defect
2. History of ectopic pregnancies
3. Infertility, and Fertility drugs
4. History of genital infections such as chlamydia or gonorrhea
5. If pregnancy happens with IUD in place (Read more)
6. In vitro fertilization
7. After Tubal ligation
8. Smoking

Symptoms:
1. Slight vaginal bleeding
2. Early signs of pregnancy such as missed period, breast tenderness and nausea
3. Pain in the abdomen
4. Shoulder pain
5. Discomfort with urination or bowel movement
6. Severe pain and bleeding with dizziness and fainting in case of fallopian tube rupture.

Symptoms sometimes appear before the woman realizes that she is pregnant.

Diagnosis:
1. Transvaginal ultrasound to detect an embryo outside of the uterus.
2. If nothing was detected by ultrasound, blood test that measures pregnancy hormone (hCG):
a. If above 1500 to 2000 mIU/mL, ectopic pregnancy is suspected.
b. If below 1500 to 2000 mIU/mL, the ultrasound and hCG tests are repeated every few days either to confirm ectopic pregnancy or not.

Treatment:

Expectant management:
Indications:
a. Asymptomatic, or with mild symptoms.
b. Transvaginal ultrasound does not show any sac suspected to be ectopic pregnancy.
c. Mother is able to access medical support in case of emergency.
d. hCG level is low (≤200 mIU/mL) and decreasing.

Mother condition is monitored closely by: monitoring hCG level every two days making sure it is decreasing until it is undetectable.

Expectant management should be stopped in case of increase in abdominal pain, increase in hCG level or not decreasing as required.

1. Medical treatment:
Called methotrexate.
By stopping the growth of the embryo.
Used if:
– hCG ≤5000
– Ectopic mass size less than 3 to 4 cm.

– No fetal cardiac activity detected on transvaginal ultrasound.

It is an injection.
After the injection, hCG level is monitored.

Contraindication for this treatment:
a. Hematologic, renal, or hepatic abnormalities
b. Immunodeficiency
c. Active pulmonary disease or peptic ulcer disease
d. Breastfeeding
e. Hypersensitivity to methotrexate

2. Surgery:
It is recommended in case of:
a. Rupture
b. Failed methotrexate therapy

It can be done through:
a. Laparoscopy:
Through a few small incisions in abdomen, to remove the ectopic pregnancy.
The tube is either repaired or removed.
Less pain and faster recovery.

b. Abdominal (emergency):
In case of heavy bleeding.
through a single larger incision in the abdomen.

After surgery, hCG level may stay high, so the patient might be given a dose of methotrexate to lower it.

Fallopian tubes might be removed during surgery in case of:
1. Recurrent ectopic pregnancy in the same tube.
2. Severely damaged
3. Uncontrolled bleeding
4. Large tubal pregnancy (3 to 5 cm)

After Ectopic pregnancy:
Pregnancy is still possible if the other remaining tube is normal. Or if both tubes are removed or injured, IVF is still an option.

It is advised to wait for 3 months in case of treatment with methotrexate or by surgery before trying to get pregnant again.

Recurrent ectopic pregnancy rate is 15%.

Successful pregnancy after ectopic is 65% within year and a half.
85% over 2 years